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Key learning points on sexual dysfunction



Key questions: Erectile dysfunction

+ ED occurs on average three years before the onset of coronary symptoms and five years before the coronary event.

+ Oral therapy produces a mean improvement of six to seven points on the Sexual Health Inventory for Men.

+ Antidepressants, antipsychotics, and antihypertensives are the drugs most likely to cause ED.

+ Diagnosing and treating low testosterone with gels, long-acting injection and patches is within the scope of most GPs.

+ Depression in a population with ED is 25%, compared to 13% in an age-matched sample.

+ All men with ED should be investigated by lipid profile, fasting glucose and morning testosterone.

+ Oral therapies are effective in around 75% of patients.

+ But oral therapies are only effective in about 55% of men with diabetes and 30% of men who have undergone a radical prostatectomy.

+ Tadalafil at 5mg daily has potential benefits in improving endothelial function.

Ten top tips on psychosexual therapy

+ PDE5 inhibitors require sexual stimulation to be effective.

+ Addressing sex as a standard part of history-taking will ‘normalise' the consultation.

+ There are particular disease areas, such as cancer, that can have an impact on sexuality.

+ Altered body image after surgery may need to be discussed rather than the subject avoided.

+ Encourage couples to bathe or shower together, as this allows intimate touch and the opportunity to experience different sensations.

+ Illness, especially when associated with stomas or dressings, may alter the smell of a partner and be off-putting.

+ If there are limited psychosexual services locally, GPs can try referring through Relate.

Peyronie's disease

+ 40-50% of cases of Peyronie's disease are complicated by ED.

+ Penile plaques are most commonly found dorsally – occurring in 66% of cases.

+ The active phase of the disease occurs between one and six months from disease onset.

+ The quiescent phase of disease starts nine to 12 months after onset.

+ About 12-13% of patients will spontaneously improve over time.

+ Doppler ultrasound can be used to assess vascular abnormalities.

+ Penile implants can be used for severe deformities with ED.

Orgasmic disorders in men

+ There are four premature ejaculation syndromes: lifelong PE, acquired PE, naturally variable PE and inconsistent PE.

+ The only currently available medical treatments are the off-label use of SSRIs and the tricyclic antidepressant clomipramine.

+ A failure of ejaculation often presents as inhibited ejaculation or retarded ejaculation.

+ If a man can masturbate and ejaculate or ejaculate with oral stimulation or in specific positions, it would suggest the problem is psychological.

+ Men with no ejaculation should be referred for urological assessment.

+ For men who reach orgasm with no ejaculation, arrange for the first urine sample after sex to be analysed for presence of sperm.

+ Indomethacin and diltiazem may be helpful for orgasmic headache.

Dyspareunia

+ Up to 90% of women attending with gynaecological complaints have a sexual issue.

+ Dyspareunia is commonly divided into superficial and deep pain.

+ Vulval pain syndrome has a prevalence of 2-10%.

+ Vaginal infections can cause pain that develops into a chronic pain cycle.

+ An ultrasound scan can identify those needing diagnostic laparoscopy.

+ Triple swabs – high vaginal, endocervical and endocervical chlamydia swabs – are standard in sexually active women with deep dyspareunia.

+ Local anaesthetic gels used 20-30 minutes before penetration help some women.

+ Skin disorders such as lichen sclerosis are rapidly resolved with steroid creams but are often recurrent.

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