Sexual Dysfunction

When sexual complaints exist

What is the exact nature of the problem? In which phase(s) of the sexual response cycle does the problem occur?

• Desire: lack of sexual desire or libido; desire discrepancy with partner; aversion to sexual activity
• Arousal: difficulties with physical and/or subjective sexual arousal; difficulties or inability to achieve or sustain an erection of sufficient rigidity for sexual intercourse (men); i.e. erectile dysfunction; lack or impaired nocturnal erections (men); difficulties lubricating (women); difficulties sustaining arousal
• Orgasm: difficulties experiencing orgasm
• Pain: pain with sexual activity; difficulties with vaginal/anal penetration–anxiety, muscle tension; lack of sexual satisfaction and pleasure

Self-assessment of sexual function (questionnaires):

• Men: International Index of Erectile Function, see https://qxmd.com/calculate/calculator_377/international-index-of-erectile-function-iief-5
  
• Women: Female Sexual Function Index (FSFI), see https://www.fertstert.org/article/S0015-0282%2809%2902741-1/fulltext
  
  

Check for endocrine causes

• Signs of hypogonadism
• Men
  • Look for signs of testosterone insufficiency (main: decreased or absent nocturnal erections, decrease in testes size, decreased volume of ejaculate, hot flushes, sweats, reduction of body hair and beard; others: reduced sexual arousal and libido, decreased frequency of sexual thoughts and fantasies, decreased genital sensitivity, erectile dysfunction, loss of vitality; fatigue; loss of muscle mass and muscle strength)
  • If signs or symptoms of hypogonadism are present ask for hormonal assessment: lutropin hormone (LH), follicle stimulating hormone (FSH), total testosterone; sex hormone-binding globulin evaluation to calculate free testosterone, see http://www.issam.ch/freetesto.htm
  • Action: If hypogonadism is present (total testosterone < 300 ng/dL or calculated free testosterone below normal): refer to endocrinologist or andrologist
  • Action: If hypogonadism is not present: check for other causes
• Women
  • Look for signs of estradiol insufficiency/menopause (amenorrhoea or missed menstrual periods, vaginal dryness, hot flashes, night sweats, sleep disturbances, emotional lability, fatigue, recurrent urogenital infections) 
  • If symptoms of menopause are present ask for hormonal assessment: LH, FSH, estradiol
  • Action: If symptoms of menopause are present: refer to endocrinologist or gynaecologist
  • Action: If hypogonadism is not present: check for other causes
    
    

Check for other causes

• Psychological or sociological problems:
• Stigma, body image alteration, depression, fear of infecting an HIV-negative partner, anxiety, awareness of a chronic disease, condom use.
• Action: Refer to clinical psychologist

• Infections:
• Men: Urogenital infections (note: if complete sexual response possible, e.g. with another partner, with masturbation or nocturnal erections, then no major somatic factors are involved).
  • Action: Refer to urologist, andrologist, cardiologist
• Women: Urogenital infections.
  • Action: Refer to gynaecologist

• Relevant medicines, recreational drugs, alcohol, smoking and other lifestyle factors:
• Drugs associated with sexual dysfunction:
  
  • Psychotropics: Men and Women (antidepressants, antiepileptics, antipsychotics, benzodiazepines)
  • Lipid-lowering drugs: Men (statins, fibrates)
  • Antihypertensives: Men (ACE-inhibitors, beta blockers, alpha blockers)
  • Others: Men and Women (omeprazole, spironolactone, metoclopramide, finasteride, cimetidine)
  • Men and Women - contribution from ART is controversial and benefit from switch studies is not proven
  • Action: Consider therapy changes