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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