Sexual dysfunction
Sexual dysfunction spans desire, arousal, orgasmic, and pain disorders in men and women, most often from a mix of vascular, neurologic, hormonal, medication, and psychological causes. Diagnosis rests on a structured sexual history plus screening for diabetes, cardiovascular disease, and androgen deficiency. First-line treatment is an oral phosphodiesterase type 5 inhibitor for erectile dysfunction, an SSRI for premature ejaculation, and flibanserin or bremelanotide for female sexual interest and arousal disorder, alongside treatment of the underlying cause.
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What this article covers
- Overview
Definition: a persistent, distressing disturbance of desire, arousal, orgasm, or pain that interferes with intercourse, in a man or a woman, with a cardinal presentation of erectile trouble, lost…
- Epidemiology
Overall burden: sexual dysfunction affects roughly 30% of adults, about one-third of cases attributable to biologic causes, one-third to psychological causes, the remainder mixed.
- Risk factors
Vascular disease and diabetes: atherosclerosis, hypertension, and peripheral artery disease limit genital blood flow, and diabetes adds autonomic neuropathic injury, together the leading organic cause of ED.
- Pathophysiology
Erection: parasympathetic input releases nitric oxide in the corpora cavernosa, raising cyclic guanosine monophosphate and relaxing cavernosal smooth muscle so the sinusoids fill and the…
- Clinical features
Desire disorders: diminished or absent interest in sexual activity or fantasies; marked distress from this is termed hypoactive sexual desire disorder (HSDD).
- Differential diagnosis
Isolated erectile dysfunction: arousal-phase impairment with desire and ejaculation intact; unlike global sexual dysfunction, testosterone and mood are usually normal and the deficit is confined to erection.
- Diagnosis
The diagnosis is clinical: established by a structured sexual history meeting the duration and distress criteria above; no single test confirms sexual dysfunction, evaluation instead identifies a treatable underlying cause.
- Management
First, treat the reversible cause: stop or substitute an offending medication, if an SSRI switch to bupropion sustained-release 150 mg PO once daily, and treat underlying depression, uncontrolled…
- Complications
Priapism: an erection persisting beyond 4 hours after intracavernosal alprostadil, or rarely a PDE5 inhibitor, is a urologic emergency needing prompt aspiration to prevent permanent erectile loss.
- Prognosis
Erectile dysfunction: most men respond to a PDE5 inhibitor, and treating the underlying cause adds further benefit; psychogenic ED responds best to psychotherapy.
- Prevention
Cardiovascular risk reduction: control blood pressure, target hemoglobin A1c below 7% in diabetes, and manage LDL cholesterol to limit the vascular disease driving organic sexual dysfunction.
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Related articles
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Erectile dysfunction is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance for at least 6 months, most often from vascular, neurologic, medication, endocrine, or psychological causes, and is a significant marker of coronary risk. Diagnosis is clinical from history and exam with targeted labs, and first-line treatment is an oral phosphodiesterase-5 inhibitor unless the patient takes nitrates.
- Premature ejaculation
Premature ejaculation is ejaculation with minimal stimulation that occurs earlier than desired, most objectively measured by an intravaginal ejaculatory latency time under 1 minute causing psychological distress. Diagnosis is made entirely by history, and first-line treatment is a daily SSRI (paroxetine), a topical lidocaine-prilocaine anesthetic, or their combination with a PDE5 inhibitor.
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