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Measurement of Male and Female Sexual Dysfunction Raymond C Measurement of Male and Female Sexual Dysfunction Raymond C. Rosen, PhD Address disorders are less well understood presently, efforts are Department of Psychiatry, UMDNJ-Robert Wood Johnson underway to refine the diagnosis and classification of these Medical School, 675 Hoes Lane, Piscataway, NJ 08854, USA. disorders [5]. An important contributing factor to this E-mail: [email protected] field has been the development of validated instruments for Current Psychiatry Reports 2001, 3:182–187 the assessment of sexual function. These instruments have Current Science Inc. ISSN 1523-3782 Copyright © 2001 by Current Science Inc. been used as primary endpoints in clinical trials, as well as for clinical screening and diagnostic purposes. Not surpris- ingly, most attention thus far has been directed towards Measurement approaches for male and female sexual development of validated instruments for assessment of ED. dysfunction have proliferated in recent years, spurred in Sexual dysfunctions in men and women are classified large part by the development of new treatments for male according to the four-phase model of Masters and Johnson and female dysfunction. In the past, physiologic measures [6] and Kaplan [7]. This is briefly as follows: of penile tumescence and rigidity in males, and vaginal Sexual desire, the first phase, consists of the motiva- blood flow in females, played an important role in clinical tional or appetitive aspects of sexual response. Sexual and research studies. More recently, a variety of brief, urges, fantasies, and wishes are included in this phase. self-report measures have been developed for assessing Sexual excitement refers to a subjective feeling of male and female function across a variety of sexual sexual pleasure and accompanying physiologic changes. domains (eg, desire, arousal, orgasm, satisfaction). These This phase includes penile erection in men and vaginal self-report measures have been shown to have a high lubrication in women. degree of reliability and validity, and are sensitive to Orgasm, or climax, is defined as the peak of sexual treatment interventions. Accordingly, they are widely pleasure, with rhythmic contractions of the genital employed in clinical trials. Daily diary or sexual event musculature in both men and women, as well as ejacu- logs have similarly been developed for this purpose. Self- lation in men. report measures have been used for clinical screening The final phase is resolution, during which a general purposes and for diagnostic assessment of sexual function sense of relaxation and well-being is experienced. In men, in a number of studies. Finally, several disease-specific a refractory period for erection and ejaculation usually quality of life and treatment satisfaction measures have occurs during this phase. The sexual dysfunctions can been developed, which are currently in widespread use be considered as alterations in one or more phases of the in clinical trials of sexual dysfunction. sexual response cycle, and this four-stage model forms the basis for diagnosis and classification of the sexual dysfunc- tions in DSM-IV (Diagnostic and Statistical Manual of Mental Introduction Disorders, Fourth Edition) [8]. Sexual dysfunctions are highly prevalent, affecting about Measurement instruments for sexual dysfunction focus 43% of women and 31% of men overall [1,2]. In addition to on assessing changes or disruption in one or more of these their widespread prevalence, sexual dysfunctions have phases. Physiologic measures are generally directed at been found to impact significantly on interpersonal assessing arousal responses, including penile tumescence functioning and overall quality of life in both men and and rigidity in men [9•10] or vaginal vasocongestion in women. Although less prevalent overall than sexual desire women [11], in response to endogenous events (eg, noctur- difficulties, sexual arousal difficulties in men and women nal penile erection) or exogenous stimulation (eg, visual have received special attention in recent years. A broad range sexual stimulation). These measures are currently used of organic and psychologic risk factors, including more often for research than clinical purposes. In contrast, diabetes, cardiovascular disease, smoking, and depression self-report or questionnaire measures are typically multi- have been associated with arousal disorders in both sexes dimensional instruments that assess sexual functioning [3•]. Effective treatment of erectile dysfunction (ED) has in across a number of domains, including desire, arousal, turn been associated with marked improvements in mood orgasm, and satisfaction. Several new questionnaire state and quality of life [4]. Although female sexual instruments have been developed in recent years, which Measurement of Male and Female Sexual Dysfunction • Rosen 183 have played an important role in clinical trials of male and diagnostic classification [14]. Additional limitations of female sexual dysfunction. Clinical trials have also the device include lack of adequate standardization of included daily diaries or sexual event logs for measurement normal values, limited time sampling of tumescence and of daily sexual activities. Finally, several instruments have rigidity, and potential intrusiveness of the device for some been developed for assessment of life satisfaction or patients. Despite these limitations, Rigiscan assessment quality of life changes associated with sexual dysfunction of penile tumescence and rigidity continues to play an in men and women. important role as an objective and quantifiable measure of erectile response. Other physiologic measures of penile tumescence and Physiologic Measures rigidity include volumetric and strain-gauge plethysmo- As noted above, several objective or physiologic measures graphy [15], and the erectiometer [16]. Volumetric plethys- are available for assessment of sexual arousal responses in mography provides a highly sensitive measure of penile males and females. These have typically focused on the engorgement, which has been used extensively in studies assessment of penile erection and rigidity in men, and of sexual preference or paraphilias [17–19]. However, the vaginal blood flow or vasocongestion in women. Although measurement apparatus is obtrusive and inconvenient studies of nocturnal erection were used extensively in the to use, and provides no information on penile rigidity. 1980s and 1990s for diagnostic assessment of organic Similarly, mercury-in-rubber and electromechanical strain- erectile dysfunction, this technique has declined in use gauges provide sensitive measures of penile circumference since the availability of sildenafil. Currently, physiologic change and have been widely used in laboratory studies of assessment methods are used predominantly for research sexual arousal [20–22]. in clinical trials of male and female sexual dysfunction. Finally, the erectiometer provides a crude measure of Among the methods for physiologic assessment of both rigidity and tumescence (circumference change). This penile rigidity and engorgement [9•,10], the most widely device consists of a 2-cm wide felt band with a sliding used is the Rigiscan system (Timm Medical Systems, Eden collar fastened to one end. The felt band expands with Prairie, MN). This method was first described by Bradley tumescence, but requires a force of about 250 grams to and Timm [9•], who recommended use of the device in initiate expansion. In this way, the device provides a the home setting for monitoring of nocturnal penile combined assessment of both circumference and rigidity tumescence and rigidity (NPTR). The device is attached to changes [16]. It has been used to differentiate response the patient's inner thigh, with two loops placed around the patterns in clinical studies with normal and sexually base and tip of the penis proximal to the coronal sulcus. dysfunctional men [23,24], although the erectiometer Measures of radial rigidity are obtained by application of a provides less sensitivity and reliability than either the predetermined force to each loop every 3 minutes initially, Rigiscan or mercury strain gauge devices [24]. and at 30-second intervals when an increase of more than In women, the most widely used method for assessing 10 mm at the base is detected. Penile rigidity is expressed sexual arousal is the vaginal photoplethysmograph as a function of displacement when the loop is tightened [11,25•]. This device consists of a light-emitting diode and around the penis, and rigidity is defined in terms of penile sensitive photocell detector enclosed in a tampon-sized, stiffness as determined by cross-sectional response to clear acrylic probe. The signal obtained reflects changes in radial compression [9•]. Although the technique was the amount of light back-scattered to the photocell from developed originally for home monitoring of NPTR, the surrounding vasculature, and provides a sensitive, Rigiscan recording has recently been used for in-clinic albeit indirect, measure of vaginal vasoengorgement. assessment of penile tumescence and rigidity in response Depending upon the mode of recording, measures of to pharmacologic or visual sexual stimulation (VSS). vaginal blood volume or vaginal pulse amplitude (VPA) Several potential limitations have been identified, the can be obtained. VPA is regarded as the more sensitive and most significant of which is the assumption of equivalence reliable measure [25•], and is more often used in studies of between radial and axial rigidity. Although
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