Gab Kovacs1 and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
Sexual Pain Disorders: Vaginismus and Dyspareunia
Definition
Incidence
Aetilogy and Pathogenesis
Clinical Asessment
Treatment
Complications
Prognosis
Loss of Desire
Definition
Incidence
Aetiology and Pathogenesis
Clinical Assessment
Treatment
Complications
Prognosis
Anorgasmia
Definition
Incidence
Aetiology and Pathogenesis
Clinical Assessment
Treatment
Complications
Prognosis
Male Sexual Problems: Loss of Libido, Erectile Dysfunction and Ejaculatory Problems
Loss of Libido
Erectile Dysfunction (ED)
Ejaculatory Problems
Sexual Pain Disorders: Vaginismus and Dyspareunia
Theses two symptoms are often interrelated, as dyspareunia can cause vaginismus.
Definition
The inability to have penetrative sex due to spasm of the vaginal muscles. Primary is when it has been present from coitarche, secondary is when it develops where sex has previously been pain free.
Incidence
It is a relatively uncommon problem, but is a relatively frequent presentation.
Aetilogy and Pathogenesis
The vagina is a fibro-muscular structure lined by epithelium. The surface area is composed of ridges called rugae. The walls of the vagina are usually in apposition, but have the ability to be distended during sex and childbirth. The lower third of the vagina is under control of voluntary muscles – these muscles can be contracted consciously.
Possible causes of vaginismus include:
· Congenital- an anatomical abnormality such vaginal stenosis.
· Traumatic- a previous bad experience can result in contraction of the voluntary muscles as a defense mechanism.
· Inflammatory/Infective – Any cause of vaginitis, such as chronic thrush can cause painful sexual intercourse and consequent vaginismus.
· Denegenerative – lack of oestrogen during the menopause can cause atrophic changes in the vagina. The mucosa becomes less elastic.
· Neoplastic
· Benign –Precancerous changes of the vulva and/or vagina can result in dyspareunia and possible vaginismus.
· Psychogenic – This is usually primary, and should be considered if no physical cause is identified.
· Iatrogenic – Vaginal atrophy as a result of radiotherapy
Clinical Asessment
History
Women who have avoided using tampons or having sex may have vaginismus.
Examination
Speculum examination is often not possible.
Investigations
Not necessarily helpful.
Treatment
Medical
· Hormonal – If the problem is associated with menopause, HRT may improve it, particularly local oestrogen.
· Other medical – vaginal lubricants can be recommended.
· Psychosexual counselling is sometimes recommended, particularly where no physical abnormality is found.
Surgical
· Minor- If vaginal stenosis is diagnosed, the introitus can be enlarged by a reverse posterior repair, where the posterior perineum is incised and repaired longitudinally (Fenton’s operation).
If vaginal adhesions have developed eg. in association with erosive lichen planus, division of adhesions followed by treatment using vaginal dilators may be appropriate.
Complications
Inability to have penetrative sex may result in frustration and relationship difficulties.
Prognosis
Many women with dyspareunia/vaginismus will improve with treatment.
Loss of Desire
Definition
This is a lack of interest in sex.
Incidence
This is not uncommon, particularly as women age.
Aetiology and Pathogenesis
Hormonal
Lack of oestrogen and testosterone in post-menopausal women may be relevant.
Psychogenic
Sexual desire varies during the course of life. Many factors can inhibit or enhance sexual desire such as tiredness, ill health, depressed mood, stress, as well as situational factors, such as economic hardship, or lack of privacy.
Clinical Assessment
History
A full medical, social, relationship and psychological history is required.
Examination
The only associated physical abnormality is atrophic vaginitis.
Investigations
Of little value. Measuring hormone levels is of no benefit.
Treatment
Medical
· Hormonal – If the problem is associated with menopause, HRT may improve it.
The administration of testosterone by implant or gel may resolve loss of desire.
· Other medical – If there is clinical depression, anti-depressants may be helpful.
Psychosexual/Relationship Counselling
Psychosexual/relationship counselling enables the woman/couple to understand any potential underlying problem.
Complications
Lack of sexual intercourse may result in relationship difficulties, which initially may have been the cause of loss of desire- vicious circle.
Prognosis
Counseling and understanding the underlying problem may help.
Anorgasmia
Definition
The inability to achieve orgasm.
Incidence
This is not uncommon.
Aetiology and Pathogenesis
Physical
Lack of direct stimulation of the clitoris.
Psychological
Negative association with sexual intercourse.
Clinical Assessment
History
A full medical, social, relationship and psychological history is required.
Examination
Unhelpful.
Investigations
Of little value. Measuring hormone levels is of no benefit.
Treatment
· Education of the woman regarding clitoral stimulation.
· Psychosexual/relationship counselling to facilitate the couples shared understanding.
Complications
None
Prognosis
Women may have a fulfilling sex life without necessarily achieving orgasm. However, with minimal intervention, achievement of orgasm may improve satisfaction.
Male Sexual Problems: Loss of Libido, Erectile Dysfunction and Ejaculatory Problems
Loss of Libido
As in females, there can be many causes for this. Libido may be affected by tiredness, ill health, depressed mood, stress, and situational factors, such as economic hardship, or lack of privacy. Testosterone deficiency is usually associated with a decrease in sexual desire. Whilst it is more common with advancing age, a direct correlation with hormone levels has not been demonstrated.
Treatment
· Hormonal – the administration of testosterone by gel, injection or implant may assist with resolution of the problem.
· Other medical – If there is clinical depression, anti-depressants may be helpful.
· Psychosexual counselling
Erectile Dysfunction (ED)
This occurs in 30 % of men between 40 and 70 years of age and becomes more prevalent with advancing years. ED can be precipitated by certain medications used for treating hypertension or depression. However, it can be purely organic, for example in association with diabetic neuropathy. Treatment depends on the cause of the problem but generally use of a PD5 inhibitor is effective for both physical or psychological problems. Psychosexual counselling may be helpful.
Ejaculatory Problems
Premature ejaculation occurs when a man ejaculates and loses his erection before he or his partner is sexually satisfied. It is more likely to be due to a psychosexual cause than a physical cause, and psychosexual counselling may help. Antidepressants of the SSRI group may also be helpful.
Delayed ejaculation is less common, and its mechanism is poorly understood. It is often situational, and psychosexual counselling may help.