Guidelines for Diagnosis and Treatment of Sexual Dysfunction

Even though more than two out of five adult women and one out of five adult men experience sexual dysfunction in their lifetime, underdiagnosis occurs frequently. To increase recognition and care, multidisciplinary teams of experts recently published diagnostic algorithms and treatment guidelines.

The recommendations emanated from the 2nd International Consultation on Sexual Medicine held in Paris from June 28 to July 1, 2003, in collaboration with major urology and sexual medicine associations. Psychiatrists were among the 200 experts from 60 countries who prepared reports on such topics as revised definitions of women's sexual dysfunction, disorders of orgasm and ejaculation in men, and epidemiology and risk factors of sexual dysfunction. Several committees' summary findings and recommendations were published recently in the International Society for Sexual and Impotence Research's inaugural issue of the Journal of Sexual Medicine. Full text of the committees' reports is in Second International Consultation on Sexual Medicine: Sexual Medicine, Sexual Dysfunctions in Men and Women (Lue et al., 2004a).

"The First [International] Consultation in 1999 was restricted to the topic of erectile dysfunction. The second consultation broadened the focus widely to include all of the male and female sexual dysfunctions. The conference was truly multidisciplinary in orientation and patient-centered in its approach to treatment," Raymond Rosen, Ph.D., a vice chair of the international meeting, told Psychiatric Times. Rosen is also associate professor of psychiatry and medicine and director of the Human Sexuality Program at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School.

"Sexual problems are highly prevalent in men and women, yet frequently under-recognized and under-diagnosed in clinical practice," even among clinicians who acknowledge the relevance of addressing sexual issues, reported the Clinical Evaluation and Management Strategies Committee (Hatzichristou et al., 2004).

Dysfunctions and Prevalence

Statistics gathered by the Epidemiology/Risk Factors Committee revealed that 40% to 45% of adult women and 20% to 30% of adult men have at least one manifest sexual dysfunction (Lewis et al., 2004). These estimates are similar to those found in a U.S. study (Laumann et al., 1999). In a national probability sample of 1,749 women and 1,410 men ages 18 to 59, among individuals who were sexually active, the prevalence of sexual dysfunction was 43% for women and 31% for men.

Sexual dysfunction in women can include persistent or recurrent disorders of sexual interest/desire, disorders of subjective and genital arousal, orgasmic disorder, and pain and difficulty with attempted or completed intercourse. At the meeting, the International Definitions Committee recommended several modifications to the existing definitions of female sexual disorders (Basson et al., 2004b). The changes include a new definition of sexual desire/interest disorder, division of arousal disorders into subtypes, proposal of a new arousal disorder (persistent genital arousal disorder), and the addition of descriptors indicating contextual factors and degree of distress.

Rosemary Basson, M.D., vice chair of the international meeting and clinical professor in the departments of psychiatry and obstetrics and gynecology at the University of British Columbia, told PT that the revised definitions have been published in the Journal of Psychosomatic Obstetrics and Gynecology (Basson et al., 2003) and are in press in the Journal of Menopause..

Some of the revised definitions are "based on theoretical constructs that we have yet to prove," said Anita Clayton, M.D. Clayton is David C. Wilson professor of psychiatric medicine at the University of Virginia and was a participant in the Clinical Evaluation and Management Strategies Committee. "We need to study these in order to see if they are really going to help us better define sexual dysfunction in women, and therefore be better able to help women seeking treatment."

For women, the prevalence of manifest low levels of sexual interest varies with age (Lewis et al., 2004). Approximately 10% of women up to age 49 have a low level of desire, but the percentage climbs to 47% among 66- to 74-year-olds. Manifest lubrication disability is prevalent in 8% to 15% of women, although three studies reported prevalence of 21% to 28% in sexually active women. Manifest orgasmic dysfunction is prevalent in one-fourth of women ages 18 to 74, based on studies in the United States, Australia, England and Sweden. Vaginismus is prevalent in 6% of women, as reported in studies of two widely divergent cultures: Morocco and Sweden. The prevalence of manifest dyspareunia, according to different studies, ranges from 2% in elderly women to 20% in adult women generally (Lewis et al., 2004).

Disorders of sexual function in men include erectile dysfunction (ED), orgasm/ejaculation disorders, priapism and Peyronie's disease (Lue et al., 2004b). The prevalence of ED increases with age. In men age 40 and younger, the prevalence of ED is 1% to 9% (Lewis et al., 2004). The prevalence climbs to 20% to 40% in most men ages 60 to 69 and is 50% to 75% in men in their 70s and 80s. Prevalence rates for ejaculatory disturbances range from 9% to 31%.

Comprehensive Assessmentss

Evaluation and treatment of sexual dysfunction problems in men and women need to include patient-physician dialogue, history taking (sexual, medical and psychosocial), focused physical examination, specific laboratory tests (as needed), specialist consultation and referral (as needed), shared decision making and treatment planning, and follow-up (Hatzichristou et al., 2004).

They warned, "Careful attention should always be paid to the presence of significant comorbidities or underlying etiologies." Potential etiologies for sexual dysfunction include a wide range of organic/medical factors, such as cardiovascular disease, hyperlipidemia, diabetes, and hypogonadism and/or psychiatric disorders, such as anxiety and depression. Additionally, organic and psychogenic factors may coexist. In some disorders, such as ED, diagnostic tests and procedures can be used to separate organically based cases from psychogenic cases. Medications that can cause problems in sexual functioning include antidepressants, conventional antipsychotics, benzodiazepines, antihypertensive drugs and even some medications for treating stomach acid and ulcers, Clayton noted.

When treating patients with psychiatric disorders, Clayton said clinicians should also consider the presence of sexual dysfunction.

"If you look at depression, the most common complaint is a diminished libido associated with other symptoms of depression," she said. "Sometimes people have arousal problems as well. Orgasmic dysfunction with depression is usually related to the medications, not to the condition itself."

Among patients with psychotic disorders, men in particular may experience significant sexual dysfunction, according to Clayton. They are less likely than women with psychotic conditions to be involved in sexual activity with another person, and they have problems throughout the phases of the sexual response cycle.

Individuals with anxiety disorders can have problems with arousal and orgasm, Clayton said. "If you don't get arousal, it is hard to have an orgasm. And then as a result, you start to see decreased desire--mostly avoidance, performance anxiety or concerns that it is not going to work right," she added.

Patients with substance use disorders, such as alcoholism, may also experience sexual dysfunction.

Psychosocial assessments should be an integral part of patient evaluations, several committees emphasized. For example, Hatzichristou et al. (2004) wrote:

The physician should carefully assess past and present partner relationships. Sexual dysfunction may affect the patient's self-esteem and coping ability, as well as his or her social relationships and occupational performance.

They added "the physician should not assume that every patient is involved in a monogamous, heterosexual relationship."

advertisement

More in-depth guidance on the psychosocial assessment was provided by the Committee on Sexual Dysfunctions in Men (Lue et al., 2004b). They presented a new screening tool for male sexual function (Male Scale) that includes psychosocial and sexual function assessments as well as a medical assessment. The psychosocial assessment asks the male patient, for example, whether he has sexual fears or inhibitions; problems finding partners; uncertainty about his sexual identity; a history of emotional or sexual abuse; significant relationship problems with family members; occupational and social stresses; and a history of depression, anxiety or emotional problems. Another critical aspect of assessment "is the identification of patient needs, expectations, priorities and treatment preferences, which may be significantly influenced by cultural, social, ethnic and religious perspectives" (Lue et al., 2004b).

continue

Last updated: 11/05

top ~ pages 1 2 ~ send page to friend