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J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from , Part I: Classific~tion, Etiology, And Pathogenesis john G. Halvorsen, M.D., M.S., andMichaelE. Metz, Ph.D.

Abstraet: Bllellgroun4: The sexual dysfunctions are extremely common but are rarely recognized by primary care physicians. They represent inhibitions in the appetitive or psychophysiologic c:haoges that characterize the complete adult sexual response and are classifted into four major categories: (1) sexual disorders (hypoactive , sexual aversion disorder), (2) sexual disorders (female disorder, male erectile dysfunc:tion), (3) orgasmic disorders (inhibited male or female , premature ejacu1ation), and (4) sexual disorders (, wginiSJDUS). Metbotls: Artic:les about the sexual dysfunctions were obtained from a search of MEDUNE mes from 1966 to the present using the categories as key words, along with the general key word "sexual dysfunc:tion." Additional artic:les came from the reference Usts of dysfunc:tion-speclflc reviews. Re",lts """ COIIelflSlmu: Cause and pathogenesis span a continuum from organic to psychogenic and most often inc:lude a mosaic of factors. Organic factors inc:lude chronic illness, , pharmacologic agents, endoc:rine alterations, and a host of other medic:a1, surgic:a1, and traumatic: factors. Psychogenic factors inc:lude an array of individual factors (e.g., , , fear, frustradon, guUt, hypochondria, intrapsychic contlict), interpersonal and relationship factors (e.g., poor communic:ation, relationship conflict, diminished , fear of intimacy, poor relationship models, family system conflict), psychosexual factors (e.g., negative learning and attitudes, performance anxiety, prior sexual trauma, restric:tive religiosity, intellec:tua1 defenses), and sexual enactment factors (e.g., skill and knowiedge deficits, unrealistic performance expectations). Understanding the cause and pathophysiology of sexual disorders will help primary care physicians diagnose these problems accurately and manage them eft'ec:tively. (J Am Board Pam Prac:t 1992; 5:51-61.)

Sexual dysfunctions are exceptionally common satisfaction and found that 63 percent of the but infrequendy recognized. The classic "Con­ women and 40 percent of the men experi­ tent of Family Practice" study from the Depart­ enced a specific sexual dysfunction, and an even http://www.jabfm.org/ ment of Family Practice, Medical College of Vir­ higher percentage (77 percent of the women and ginia 1 recorded sexual dysfunctions rarely. Other 50 percent of the men) reported general "sexual investigators, however, have reported that sexual difficulties. " problems can occur in 50 percent of all marriages2 Because many sexual problems are hidden, pri­ and that they are present in 75 percent of couples mary care physicians need to help discover them. who seek marital .3,4 Moore and Gold­ Once discovered, to manage these disorders on 1 October 2021 by guest. Protected copyright. steins found that 56 percent of patients in a family effectively, physicians must understand their practice reported one or more sexual problems, cause and pathogenesis; evaluate them thor­ but these problems were recorded in only 22 oughly by history, physical examination, and percent of the cases. In one of the most cited laboratory testing; initiate management; and prevalence studies, Frank and colleagues6 sur­ refer to other appropriate professionals when veyed well-adjusted couples with high marital necessary.

Classification of Sexual Dysfunctions Submitted, revised, 9 August 1991. Inhibitions in the appetitive or psychophysiologic From the Department of Family Practice and Community changes that characterize the complete adult sex­ , University of Minnesota, Minneapolis. Address reprint ual response are at the heart of the sexual dysfunc­ requests to John G. Halvorsen, M.D., M.S., University of Min­ nesota, 3-100 Phillips-Wangensteen Bldg., 516 Delaware St. tions. They are not usually diagnosed, however, if S.E., Box 381 UMHC, Minneapolis, MN 55455. they occur exclusively during the course of an-

Sexual Dysfunction 51 J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from other psychiauic disorder, such as a major dept cs' sion or an obsessive compulsive disorder The complete sexual response cycle consists of four phase3~ appetitive, excitement (arousal), or­ gasmic, and resoluQon. The appetitive phase in volve5 sexual falluisies and a deSIre for iiexual ac­ tivity_ Dmmg the excitement phase, in addition w a subjecave .ie:use of sexual pleasure, men ex­ pel·ie.lc.;; penile tIltu..:;;:,ccnc.:: and , md .;eCl-etions appear from the bulbourethral glands. Sexual DysfunctionS Women experience pelvic vasoconge:ition, vagi· .I' r" .{.;S~ Phase ~ hy~ ~b"d Q :wIIihJ OIl"tIlliL6 .. c. ~,jllOlttf':: ,)~.~: 2.' ~nirf Sexw: :, ·rxJ..'\B~ Otg.iioflI nallubi.·tcarion, swelling of the external genitalia, C'!:".,t~r, ren. ,~...o, narrowing of dIe outer third of the ,8\,':'I:-.io- by increased pubococcygeal muscle tension and vasocongesnon, vasocongesrion of the Fipu 1 'Ibe sexualleSponse cycle, with several DOnna! minora, , and lengthening patklGS and the oommOD dysfunctions classltled by the and widemng of the inner two-thirds of the phaw: that they affect. vagma. Sexual pleasure peaks during the orgas~ mic phase and IS accompamed byche release of sexual tension and rhythmic contraction of sen.,c;: of sexual excttelllent and pleasure during the perineal ano pelVIC reproductive organs. In sexual activity. men, a sensation of ejaculacory inevitability pte· Orgasm disordels lllclude (1) inhibited male cedes the contraCtions m the , sefllinal and female O1gasm, characterized by delayed or vesicles, and that results in seminal ernis absent Olgasm following a normal sexual excite­ sion. In women, contractions occur in the outeI ment phebe that is adequate in focus, intensity, thtrd of the vaginal walt During resolution, and duration, and (2) premature , de­ both men and women feel relaxed and free fined as ejaculation with mirumal sexual stimula­ from muscular tension. Men are tempOlarily rt;­ tion or beforc; upon, 01 shortly after penetration fractory to further en::ction and mgasm, but and befure the man wishes it. women can respond almost immediately co ad&· Sexual pain disorders include (1) dysparewlia, tional stmlUlation. characterized by genital pain in either sex be­ http://www.jabfm.org/ Inhibitions m me ::;exual response cycle can fore, during, or after that is occur at one or more of these phases, although not caused exclusively by lack of lubrication or only the first three are of primary clinical slgnifi ; and (2) vaginismus, defined as in­ cance. The major dysfunctions are classified and voluntary spasm of the musculature of the defined as follows7; outer third of the vagina that interferes with Sexual desire disordel's include (1) hypoactive COItUS .. sexual desire disorder, characterized by deficient Figure 1 sUlllmarizes these sexual dysfunctions on 1 October 2021 by guest. Protected copyright. or :lbsent sexual fantasies and desire fot sexual acwlding to the phase of the sexual response activity; and (2) sexual av~rsion disorder, defined cycle that they affect. It also depicts several nor­ as extreme aversion to and avoidance of genital mal response patterns. contact with a sexual parmer. Sexual arousal disorders include (1) female i:iex·· Cause and Pathophysiology uai arousal disorder, characterized by failure to rhe sexual dysfunctions have both organic and attain or mamwn the lubncation-·swcHing re· psychogenic causes A specific dysfunction can be sponse of sexual eXCItement until completion of mosdy psychogemc, mosdy organic, or mixed. the sexual actIvity or by lack of a subJt:ctive sense Dysfunctions C-all be lifelong (primary) or ac­ of sexual excitement and pleasure during 8exual qwred (secondary), generalized (o<.curring in any actiVIty; and (2) male ereCtile disorder, marked by situatton or with any parOler) or situational failure 'i:C attain or maimain erection until com· (lirruted to ct:rtain situations or partners), and pietion of sexual activity or by lack of a subjective co.cnplete or partial in severity.

52 JABFP Jan. Ft.b.1992 VoL; I-Jo, 1 J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from GeItertII CaflSllHve FMtors Drugs that sedate and depress the central nerv­ Organic Factors ous system adversely affect sexual functioning by Organic problems affect all phases of the sexual decreasing and altering potency, perhaps by response cycle. According to current estimates, increasing brain and decreasing dopa­ the cause of at least 50 percent of erectile dysfunc­ mine levels. 15,17-19 Depressants include alcohol, tion cases is primarily organic,8 with some esti­ , barbiturates, and benzodiazepines, as mates ranging as high as 75 to 85 percent.9Thirty well as antihypertensive and medi­ percent of surgical procedures on the female cations that have sedating properties. genital tract result in temporary dyspareunia, and Increased levels reduce the respon­ 30 to 40 percent of the women seen in siveness of the male gonads to leutinizing hor­ clinics for dyspareunia have pathologic pelvic mone, thereby inhibiting produc­ conditions.9,lo The common general organic fac­ tion.1S,19-23 Some drugs can cause increased tors that affect sexual function include chronic prolactin release through antago­ illness, pregnancy, pharmacologic agents, endo­ nism (e.g., phenothiazines, thioxanthenes, buty­ crine alterations, and chemical abuse. A variety of rophenones). Other drugs, such as other medical, surgical, and traumatic factors can and , increase prolactin levels through be implicated in specific dysfunctions. mechanisms that are incompletely defined. Some The degree to which chronic illness interferes drugs have effects. 1S,24-26 The aldo­ with sexual function depends on the type of sterone antagonist causes es­ chronic illness, the age of onset with regard to trogenlike side effects with decreased libido, im­ sexual maturation, and whether the illness was potence, and in men and painful recognized before the current relationship. I I breast enlargement and menstrual irregularity in Congenital illnesses and illnesses that begin be­ women. It likely causes these effects by inhibiting fore or during have a greater impact on binding to its cytosol protein the course of sexual development. The more visi­ receptor. Alcohol also decreases testosterone lev­ ble the problem, the more it will interfere with els, perhaps by peripheral suppression of testos­ sexual development. Relationships that begin be­ terone production in the testes. Oral contracep­ fore the onset of a chronic illness are more af­ tives can decrease libido in women by decreasing fected by the illness because they require a greater levels. is thought to sup­ number of difficult adjustments. I I press sexual activity in some women because of an

Pregnancy affects sexual desire in different antiandrogen effect. http://www.jabfm.org/ ways.12,13 In the first trimester, nausea, , Anticholinergic agents, or drugs with and the fear of miscarriage interfere with sexual atropinelike actions, can cause sexual problems desire. In the last trimester, increasing size and a (chiefly arousal difficulties) secondary to their of decreasing attractiveness, along parasympatholytic activity.1S,27-29 These agents with a focus on the well-being of the infant and on include antiparkinsonian drugs, tricyclic anti­ enduring labor and delivery, decrease sexual de­ depressants, many agents, antihista­ sire. During the middle trimester, increasing pel­ mines, antiemetics, antivertigo drugs, and the on 1 October 2021 by guest. Protected copyright. vic and an overall feeling of well­ antiarrhythmic disopyramide. being facilitate sexual responsiveness. Various mechanisms are proposed to explain Pharmacologic agents interfere with sexual the sexual dysfunction associated with drugs that functioning through several mechanisms.14 Some do not appear to fit the other categories.lS,19,30-38 cause adrenergic inhibition.15,16 Drugs that alter Examples include decreasing receptor sensitivity the by block­ to or a decrease in its intraneuronal ing a-adrenergic receptors, by depleting nor­ turnover (lithium) and peripheral vasoconstric­ epinephrine stores, or by blocking norepineph­ tion or sympathetic blockade (propranolol). rine release can cause sexual dysfunction by The specific drugs that are associated with sex­ altering emission or ejaculation. Adrenergic an­ ual dysfunction and the dysfunctions associated tagonists include such drugs as , re­ with each are listed in Table 1. The particular serpine, , , prazosin, and effect of any drug on a patient will vary depend­ phenoxybenzamine. ing on such factors as age, absorption, body

Sexual Dysfunction 53 1ab1e 1. JIIIaanaKolOPC AFt .. AIIodated with Sexual Dylfaacdoo. * 'DIble 1. Continued. J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from Phase of Sexual Response Cycle Phase of Sexual Response Cycle Affected (+) or Not Affected (-) Affected (+) or Not Affected (-) Arousal Orgasm Arousal Orgasm DruB: Desire (erection) (ejaculation) DruB: Desire (erection) (ejaculation) A"tilmxiety A"giotmsive comJerting enzyme ~razolam + inhibitor orazepate + + Captopril + + + Enalapril + + + Lisino ril + + A"ticholinergic CilIa_ cta1l1lt1 bl«lcw Atropine + Diltiazem + Benztropine + Nifedipine + Glycopyrrolate + Verapamil + Mepenzolate + A,,#microbial Methantheline + Ethionamide + Propantheline + K.etoconazole + Scopolamine + A"~chotic 1liIiexyphenidyi + orpromazine + + + A"tico1lvulstmt Chlorprothixene + Carbamazipine + Fl~henazine + + Phenytoin + + H operidol +,- + + + + Mesoridazine + A"tidepressant Perphenazine + HtterocyclK Pimozide + + + + + + Thioridazine + + + Amoxapme + + + Thiothixene + + Oomipramine + + + Trifluoperazine + Desmethylimipramine + + + Hz-rrceptor antagonist Doxepin + + + Cimetidine + + Imipramine + + Famotidine + + + + Ranitidine + + N orttiptyline + + + HIIt7III)M + + + Danazol + Hy~rogesterone + M01IOfI1lIme oxidase inhibitor Norethindrone + + Carboxazid + + Oral contraceptives + + + Progesterone + + Pargyline + + + + Codeine + + + Tranylcypromine + + + + + A"tibistamine Meperidine + + + + + + + + + + Morphine + + +,- HydroxyZine + + Propoxyphene + + + A"tihypertensive Sedative-r°tic Diuretic Alcoho +,- + + Amiloride + + Barbiturates +,- + + http://www.jabfm.org/ Furosemide + Chloral hydrate + + + Indapamide + + Ethchlo~ol + + + Spironolactone + + Methaq one + + + +,- + +,- Otberagmts CmtraJJy acting sympatholytic Acetazolamide + + Alpha-methyldopa + + + Aminocaproic acid + Oonidine + + + Amiodarone + Guanfacine + + Am~etamines + + Reserpine + + + Ba ofen + + a-AtlmJergic bMw Cannabis + +

Guanabenz + + + on 1 October 2021 by guest. Protected copyright. Guanadrel + + + Oofibrate + + Pheno~nzamine +,- + Digitalis +,- + Phento amine +,- + Dis~de + I3-AtlmJerr bMw Dis m + + Labetalo + + + + + +,- Interferon + + + Levodopa + Propranolol + + Lithium + + + Mazindol + + ~Iilmic bMw Methandrostenolone + ecamylamine + + Methazolamide + + Trimethaphan + + Metoclopramide + + ~pathttic neurfKjfeaor agmt Metyrosine + + uanethidine +,- + + Mexiletine + + N~ vasodi14tor Naltrexone + + Hydralazme +,- + N.t;roxen + + Prazosin +,- +,- L- ryptophan + +

CoDdnued

54 JABFP Jan.-Feb. 1992 Vol. 5 No.1 J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from weight, dosage, duration of use, rates of metabo­ minants, relationship issues, and psychosexual lism and excretion, presence of other drugs, factors. underlying disorders, patient compliance, and Empirical studies have linked many individual suggestibility. psychological factors with sexual dysfunction. 51 Based on current research, it is unlikely that Depression52 and anxieo/,53,54 are most common. hormonal fluctuations during the Diminished self-esteem,55 , , hy­ a significant role in sexual dysfunction.ll,39 pochondria, sexual fear, hostility or ,54,56 un­ The combination of somatic and emotional realistic expectations or perfectionism,57 intrapsy­ symptoms that some women experience during chic conflicts (such as grief, unresolved sex menses, however, can result in sexual disinterest orientation, concerns about paraphilic arousal and arousal difficulty. Furthermore, patterns54), and serious psychopathologic disor­ can affect sexual function because of religious ders also contribute. Depression and anxiety are teachings, , sexual ignorance, fears of dis­ considered generic causes of sexual dysfunction, pleasing one's , or simple esthetics but they also commonly occur as consequences of rather than because of physiologic factors. 11 sexual dysfunction58; therefore, determining cau­ A number of commonly abused chemical sality can be challenging. As a general rule, severe agents also cause sexual dysfunction. Alcohol is depression or anxiety is more likely causative; associated with decreased libido and erectile diffi­ mild forms more commonly represent the impact CUlty.14,15,40 Marijuana also can decrease libido and of sexual failure. cause erectile difficulty.l4,15 Phencyclidine hydro­ Sexual and relationship factors can interact in chloride (PCP) can cause erectile and ejaculatory several ways. 59 Relationship problems can cause failure. l4,41 Cocaine is associated with sexual in­ sexual dysfunction, organic sexual dysfunction difference, , aggressiveness, situational can precipitate relationship distress, or the two impotency, and . 14,42 Heroin users also factors can exist independendy. Recognizing that experience reduced sexual desire, erectile dys­ sometimes there is no clear relation between sex function, and anorgasmia.l4,43 Methadone and and marital problems is important. Some couples reportedly decrease sexual per­ with serious marital dysfunction appear to have a formance. 14,44,45 Tobacco abuse results in sexual satisfactory sexual relationship. The reverse is dysfunction primarily through its adverse effects also true. The most common relationship factor on the vascular system.l4 that causes sexual dysfunction, however, remains play an important role in the libido marital dissatisfaction60 involving relationship http://www.jabfm.org/ of both men and women. deficiency problems that generate , fatigue, or dyspho­ can result from panhypopituitarism,46 combined ria. Dissatisfaction can focus on poor communica­ bilateral adrenalectomy and ovariectomy in tion,53,54 unrealistic marital expectations,61 failure women, or castration in men. Hyperprolactine­ to resolve relationship conflict,53,61,62 diminished mia caused by a prolactin-secreting pituitary trust, 54 fears of intimacy or romantic success,54,63 tumor has been associated with sexual dysfunc­ a history of poor relationship modeling that is tion.47 The mechanism responsible is not clearly transferred to the , family system distress on 1 October 2021 by guest. Protected copyright. defined but may relate'to second­ (such as caring for an elderly relative or preschool ary to prolactin-induced hypogonadotropism. and school-age children), sex role conflicts, diver­ Both and can gent sexual preferences or sex values, career prob­ also cause sexual dysfunction.8,48 lems, and legal troubles. The most common psychosexual factors caus­ Psychosexual Factors ing sexual dysfunction are prior sexual failure Sexual dysfunctions are invariably multideter­ (often at first intercourse), chronic sexual per­ mined; a single cause is rare.49,50 Even when an formance inconsistency, negative learning and organic factor is present, it is essential to treat the attitudes about sex,2,64 and prior sexual trauma.2,54 principal psychological factors that can compli­ Other identified factors include and cate the organic problem or that could have re­ shame,65,66 unrealistic expectations about sexual sulted from it. Three areas of psychological focus performance,67 restrictive religiosity,2 sexual per­ are important: individual psychological deter- formance anxiety generated by fears of failure or

Sexual Dysfunction 55 perceived performance demands from a partner,2 primary dysphoria, sexual orienta­ J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from interpersonal insensitivity,58 intellectual defenses tion. conflict, negative sexual learning, and sexual (such as denying sexual arousal and detachment trauma. from sensual pleasure),54 sexual identity conflict,68 Learning conflicts about sex create an emo­ issues, and a parent-child rela­ tional double bind for some patients with a tionship history filled with conflict. hypoactive sex drive. Mixed messages about sex Other sexual disorders sometimes underlie sex­ often originate with parents, religious instruction, ual dysfunctions, especially in men. For example, and in general. Young people are praised or (e.g., , for appearing sexually attractive but chastised for , ) in some cases manifests as behaving sexually. Negative sexual experiences or inhibited orgasm. Current can create feelings of disregard, avoidance, or evidence suggests that these factors are more even repugnance, and avoidance behavior can re­ common than previously thought. 69 sult from fears of sex related to problems of infec­ In some cases, sexual dysfunction is caused by tious , exploitation, and control. "Anti­ deficient skill and knowledge about sexual physi­ fantasies, "54 a focus on negative aspects of sex, are ology and or by unrealistic per­ common also. formance expectations. For example, a potential Loss of sexual interest commonly blunts rela­ cause of erectile dysfunction can be inadequate tionship affect, often generalizes to other feelings, physical stimulation to the . Female dyspa­ and can signal important marital distress. The reunia can be caused by insufficient to most common relationship issues in sexual desire cause arousal, overly aggressive digital or penile disorders are unresolved conflict and disappoint­ penetration, or an unfavorable pelvic position for ment that lead to subsequent anger, hidden re­ intercourse. sentment, and unconscious alienation. Covert re­ sentment in overly conventionalized, attractive, Dysfulldlon-SpeclJk Ftlelim adaptive couples can manifest itself in lost "pas­ Sexual Desire Disorders sion" or desire. In other couples, sex is withheld Hypoactive sexual desire disorder is common (40 or used to exploit, control, or manage the partner percent) for both men and women, complicated to negotiate other . Anger, fear of intimacy, in its origin, and difficult to treat.50,70,71 Common commitment, or sexual success (with resultant organic problems associated with loss of desire shame), and emotional fatigue are other relation­ include chronic illness, disorders, disfig­ ship factors that decrease desire. uring trauma, congenital disfigurement, and pitu­ Research documents that men and women with http://www.jabfm.org/ itary disorders. Libido loss can be profound in a normal sex drive perceive their parents' attitudes . In women, early pregnancy toward sex and their parents' affectionate interac­ should also be considered. tion with each other as more positive than do In severe forms, such as sexual aversion, the those with hypoactive sexual desire.!l Parental cause is commonly rooted in developmental fac­ attitudes and modeling can be latent predisposing

tors (often sexual trauma), family-of-origin con­ factors that influence sexual interest in later life. on 1 October 2021 by guest. Protected copyright. flicts, or serious individual . In Incestuously eroticized relationships with the less severe cases, lack of sexual desire can accom­ parent of the opposite sex, exposure to parental pany a major depression, relationship issues, or conflict, and failure to introject the sex role of the negative beliefs about sex. Some cases involve loss same-sex parent are also adverse influences. of desire in a specific situation only and are rela­ tively uncomplicated. Sexual Arousal Disorders Because loss of sexual interest is a symptom Organic origins of male sexual impotence include diagnostic of depression, the diagnosis of sexual more than 100 distinct entities. The major disor­ desire disorder is complicated. 'When events are ders are listed in Table 2. Organic origins of fe­ present that clearly make a reactive or anticipa­ male sexual arousal disorders have not been stud­ tory depression diagnosis appropriate, the depres­ ied as extensively. Many of the same factors, sion should be treated presuming that sexual de­ however, might be important, e.g., chronic car­ sire will return. Other individual factors include diovascular and neurologic disorders; pituitary,

56 JABFP Jan.-Feb. 1992 Vol. 5 No.1 Tllble 2. Medical Problea AIIocIated with Erecdle DIIorden. J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from Category Condition or Disease Cardiovascular , arteritis, arterial thrombosis, arterial embolism, aortic aneurysm, the Leriche syndrome, cardiac failure Endocrine Pituitary problems (e.g., , chromophobe adenoma, craniopharyngioma, pituitary destruction, hyperprolactinemia), adrenal problems (Addison disease, the Cushing syndrome), thryroid problems (hyperthyroidism, hypothyroidism), gonadal dysfunction (castration, postinflammatory fibrosis, exogenous , feminizing interstitial-cell tumor), mellitus, the Frohlich syndrome Genetic The , the male Turner syndrome, congenital vascular or structural abnormalities (extrophy, epispadias, hypospadias, , varicocele) Hematologic , leukemia, immunologic disorders, Hepatic Cirrhosis (usually alcoholic) Infectious Urethritis, , seminal vesiculitis, cystitis, gonorrhea, tuberculosis, elephantiasis, mumps Neurologic , myasthenia gravis, Parkinson disease, amyotrophic lateral sclerosis, , central (CNS) tumors, CNS infections (espec:ia1ly of the temporal lobe), trauma (head, ), ~inal cord compression (disc, tumor, abscess, ), tabes dorsalis, , spina bifida, syringomjrelia, subacute combined degeneration of the spinal cord, , cerebral palsy, electroconvulsive therapy, transverse myelitis Nutritional Malnutrition, vitamin deficiencies, morbio Poisoning Lead, herbicide Pulmonary Respiratory failure Renal and urologic Peyronie disease, , urethral stricture, chronic renal failure Surgical Perineal , perineal prostatic biopsy, suprapubic and transurethral prostatectomy, abdominal aortic aneurysmectomy, aortofemoral bypass, retroperitoneallvrnphadenectomy, sympathectomy (lumbar, dorsal, pelvic), cystecomy, abdominoperineal resection, external sphincterotomy naumatic Pelvic fraCture, urethral rupture, penectomy Other problems , any severe or debilitating systemic problem adrenal, and thyroid disorders; hematologic, he­ psychologically "nwnbing" the body and sensual­ patic, pulmonary, and renal disorders; and pelvic ity.75 By inhibiting arousal, depression causes dif­ surgery, trawna, or infection. ficulty with for men and problems with Diabetes mellitus deserves special mention as lubrication and emotional involvement for the most common medical disorder causing male women. Anxiety can also interfere with sexual sexual impotence. Between 30 and 60 percent of arousal. It is most common as performance anxi­ all diabetic men will develop erectile dysfunc­ ety, the pressure to perform, to please one's part­ tion.48,72 Impotence can occur as the presenting ner, or to succeed sexually as a medium for prov­ symptom of diabetes, as a of the ing sexual and personal adequacy. Personal disease, or as a transient phenomenon during pe­ deficits in knowledge and perception can contrib­ riods of poor control.73 There is no apparent ute to arousal disorders by creating a set of im­ correlation between impotence and the severity possible expectations, which create a failure men­ http://www.jabfm.org/ of diabetes, the duration of the illness, or the type tality that predictably results in an inhibited or amount of hypoglycemic .73 Preva­ performance. Self-prophesied sexual failures then lence rates of25 to 30 percent are reported among invariably lead to cognitive interference (a series diabetics in their 20s and 30s up to 50 to 70 of identifiable negative thoughts and judgments) percent in diabetic men aged> 50 years,73 Most that creates anxiety and detaches people from the

investigators believe that the erectile dysfunction sensual experience of sexual arousal. on 1 October 2021 by guest. Protected copyright. in diabetes mellitus is caused principally by the Pressures from the partner can exacerbate the and the macrovascular individual pressures just described. Some persons and microvascular changes that result from the express ambivalence toward their partner, an am­ disease. 74 bivalence that might reflect marital dysfunction. While most research exploring the psychologi­ Others choose partners in whom they are less cal causes of sexual dysfunction has examined in­ interested as a defensive protection from personal hibited excitement in men, many clinicians as­ rejection. Conjoint adherence to the expectations swne that the findings apply to women as well. that sex should always "work, " be "spontaneous," Further research on female arousal disorders is and conform to other societal standards is invari­ needed to establish whether this asswnption is ably involved in arousal dysfunctions. In some warranted. cases, conflict with one's social sex role, non­ Depression again is a common factor inhibiting acceptance of the other sex, and relationship fac­ the arousal phase of the sexual response cycle by tors such as anger, resentment, frustration, disap-

Sexual Dysfunction 57 J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from pointment, and fear of intunacy, sexual sucCe~, or more detailed aspects of his own sexual response. rejection are causa rive. In a few cases, fears of This inattention results in failure to perceive the hurting the partner, of pregnancy, and of sexually erotic'sensations that precede orgasm and, there­ transmitted disease are important. fore, failure to control the arousal and ejaculatory Cultural guilt about st:x, prior failwe!>, and st:x· response. ual trauma inhibit arousal in some patients, as can In addition to the individual frustration of fear­ neganve am tudes toward sexuality that are ing that he cannot control ejaculation, the man learned in the family of origm, Oedipal problems, with worries about disap­ and unresolved interpersonal conflicts with family pointing his partIlt:r, pat"Oler misunderslanding members. and rejection, and appearing unmanly. In some A common cause of male erectile dysfuncrion is men, premature ejaculation is the manifestation the man's effo:ccs to resolve a more profound of a narcissistic personality where only the man's problem of premature ejaculation by literally in·· pleasure is pursued. In thi!> case, the premature hibiting arousal to the point that the inhibition ejaculation is perceived as a problem by the part­ causes difficulty with erection. ner but not by the man involved.

Orgasm Disorders Sexual Pain Disor-det-s Both men76 and women7i can experience delayed Dyspareunia is associated with many organic fac­ or absent orgasm. To date, no common organic tors.9,'1&;79 Gynecologic factors include a rigid causes of primary inhibited orgasm are identified hymen, painful hymeneal tags, hymeneal fibrosis, other than pharmacologic agents; therefore; psy­ scats, w"ethral carbuncle, Bartholin chological causes are implicated. Partial inhibi-­ cyst, clitoral inflatnmation atld adhesions, vulvar tion for both men and women is manifest by lesions, atOusal··induced adhesive vaginal bands, distres!> with the amount of time and effort vaginal atrophy, , vaginal infec­ needed to achieve orgasm, unreliability at reach tions, radiation , the Sjogren syndrome, ing orgasm, or deficient subjective pleasure .. 1m pelvic relaxation syndrome, , pelvic mediate psychological causes involve obsessive inflanlmatory disease, pelvic tunlors, pathologic self· observation during sex, unresolved marital conditions caused by , ectopic preg­ conflict, inability to abandon oneself to pleasure, nam.)" and allergic reactions to contraceptive ma­ or msufficient stunulation for orgasm. More re­ terials, douches, or deodorant sprays. Dyspareu­ mote causes include chronic hostility toward the nia has also been associated with cystitis and acute opposite sex, post-traumatic stress reaction, sex'" urethral syndrome. Gastrointestinal associations http://www.jabfm.org/ ual guilt or conflicting beliefs about the adult include constipation, hemorrhoids, proctitis, and male or female role, family·of-origin issues such moderately severe to severe irritable bowel as loyalty to the family's sexual value!> (sex as bad), syndrome. 80 01' placmg limIted value on sex (procreation only)., In men, dyspareunia is associated with struc­ Organic conditions are rarely implicated as a tw·al abnornlalities of the penis, Peyronie disease,

cause of premature ejaculation. Surgical trauma priapIsm, urethral stricture, previous genital sur­ on 1 October 2021 by guest. Protected copyright. to the sympathetic nervous system during surgery gt:ry, or genital infections. for aortic aneurysm, pelvic fracture, local gerutal MallY psychologic-al factors are associated with disease, such as prosratiti!> and urethritis, and drug the sexual pain disorders. Cognitive-behavioral withdrawal from narcotics 01' trifluoperazine have and social le.uning theory resealch81 supports all been associated WIth premature ejaculation. such variables as anxiety about intercourse based Premature ejaculation often start!> with Igno on misinformation; fear of pain based in child­ rance or inappropriate social learning. Men'S first hood learning or memories of distressing early sexual experiences are often accompanied byanxi·· sexual experiences; guilt about intercour!>e and ety. Ejaculation comes quickly; Thi!> pattern of pleasw"e; feal' of penetration; dislike of the part­ quick ejaculation can become habitual in men nel, anger at the partner; feelings of shame, guilt. with premature ejaculation. The man's !>exual or tension associated with. new sexual situations; focus is often directed toward the parmer's body and inept precoital male stimulation atld tech­ rather than his own. Thus, he rarely learns the nique. Primary dyspilleunia more commonly in-

-----~-,-".,,'.----. --~--~-""-.~ .. -,,.---- .--. 58 JABFP Jan. Feb. 1992 VoL 5 No.1 J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from volves ignorance, faulty infonnation, a post-trau­ 2. Masters WH, Johnson VE. sexual inade­ matic stress history, and intrapsychic issues, quacy. Boston: Little, Brown, 1970. whereas relationship problems more often result 3. Greene BL. A clinical approach to marital problems: evaluation and management. Springfield, IL: in secondary dyspareunia. Classical psychoana­ Charles C Thomas, 1970. lytic theory considers this dysfunction a conver­ 4. Sager CJ. Sexual dysfunctions and marital discord. sion symptom or histrionic manifestation, con­ In: Kaplan HS, editor. The new sex therapy: active ceptualized as the symbolic expression of a treatment of sexual dysfunctions. New York: Tune specific unconscious, intrapsychic conflict. Books, 1974:501-16. 5. Moore JT, Goldstein Y. Sexual problems among fam­ ily patients. J F am Pract 1980; 10: 243-7. Summary 6. Frank E, Anderson C, Rubinstein D. Frequency of Sexual dysfunction is an unusually common but sexual dysfunction in "normal" couples. N Engl J infrequently recognized problem in primary care. Med 1978; 299:111-5. The usual method of classification categorizes the 7. American Psychiatric Association. Diagnostic and dysfunctions based on the part of the normal statistical manual of mental disorders. 3rd ed. Re­ vised. Washington, DC: American Psychiatric Ass0- sexual response cycle that they affect. Conse­ ciation, 1987. quently, there are sexual desire disorders (hypoac­ 8. Vliet LW, Meyer JK. Erectile dysfunction: progress tive sexual desire and sexual aversion), sexual in evaluation and treatment. Johns Hopkins Med J arousal disorders (female arousal disorder and 1982; 151:246-58. male erectile disorder), orgasm disorders (in­ 9. Kaplan ill, Sadock BJ. Synopsis of . Balti­ more: Williams & Wtlkins, 1988:363-76. hibited female orgasm, inhibited male orgasm, 10. Fordney DS. Dyspareunia and vaginismus. Clin Ob­ and premature ejaculation), and sexual pain disor­ stet Gyneco11978; 21:205-21. ders (dyspareunia and vaginismus). The cause of 11. LaFerlaD. Inhibited sexual desire and orgasmic dys­ sexual dysfunction is , involving an inter­ function in women. Clin Obstet Gynecol 1984; play of organic, psychogenic, and relationship 27:738-49. variables. General organic problems include 12. Masters WH,Johnson VE. Human sexual response. Boston: Little, Brown, 1966. chronic illness, pregnancy, pharmacologic agents, 13. Perkins RP. Sexuality during pregnancy. Clin Obstet endocrine alterations, and a host of other dys­ Gynecoll984; 27:706-16. function-specific medical, surgical, and traumatic 14. Buffum]. Pharmacosexology: the effects of drugs on factors. Psychogenic issues include a variety of sexual function, a review. J Psychoactive Drugs 1982; general individual, relationship, and psychosexual 14:5-44. 15. Aldridge SA. Drug-induced sexual dysfunction. Clin concerns, as well as developmental factors and Pharm 1982; 1:141-7. http://www.jabfm.org/ family-of-origin concerns. In some cases, the dys­ 16. Goodman LS, Gilman A. Pharmacologic basis of function is caused by inadequate skill and igno­ therapeutics. 8th ed. New York: MacMillan, 1990. rance about sexual anatomy and or 17. Lemere F, SmithJw. Alcohol-induced sexual impo­ unrealistic performance expectations. tence. AmJ Psychiatry 1973; 130:212-3. Because of the complex mosaic ofbiopsychoso­ 18. Ellinwood EH Jr, Rockwell W]. Effect of drug use on sexual behavior. Med Aspects Hum Sex 1975; cial factors and the impact of sexual disorders on 9(3):10-32. the family system, the sexual dysfunctions are 19. Hollister LE. Drugs and sexual behavior in man. Life on 1 October 2021 by guest. Protected copyright. very much part of the family physician's prac­ Sci 1975; 17:661-7. tice domain. As family physicians understand 20. Arato M, Erdos A, Polgar M. Endocrinological more about these problems, they will become changes in patients with sexual dysfunction under long-term neuroleptic treatment. Pharmakopsychi­ better equipped to identify them and to manage att Neuropsychopharmakol1979; 12:426-31. them independently, with consultation, or by 21. Webster J. Male sexual dysfunction and cimetidine referral. [letter]. Br MedJ 1979; 1:889. 22. Franks S, Jacob HS, Martin N, Nabarro JD. Hyperprolactinemia and impotence. Clin En­ docrino11978; 8:277-87. References 23. VasquezJM, EllegoodJO, Nazian SJ, Mahesh VB. 1. Marsland DW, Wood M, Mayo F. Content offamily Effect of hyperprolactinemia on pituitary sensitivity practice. Part I. Rank order of diagnosis by fre­ to luteinizing -releasing hormone follow­ quency. Part ll. Diagnosis by disease category and ing manipulation of sex steroids. Fertil Steril 1980; age/sex distribution.J Fam Pract 1976; 3:37-68. 33:543-9.

Sexual Dysfunction 59 24. Loriaux DL, Menard R, Taylor A, PitaJC, Santen R. 44. Hanbury R, Cohen M, Stimmel B. Adequacy of sex­ J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from Spironolactone and endocrine dysfunction. Ann In­ ual performance in men maintained on methadone. tern Med 1976; 85:630-6. AmJ Drug 1977; 4:13-20. 25. Herzberg BN, Draper KC, Johnson AL, Nicol GC. 45. Gossop MR, Stem R, Connell PH. Drug depend­ Oral contraceptives, depression, and libido. Br Med ence and sexual dysfunction: a comparison of in­ J 1971; 3:495-500. travenous users of narcotics and oral users of 26. Adams DB, Gold AR, Burt AD. Rise in female-initi­ amphetamines. Br J Psychiatry 1974; 124:431-4. ated sexual activity at and its suppression 46. Schon M, Sutherland AM. The role of in by oral contraceptives. N Engl J Med 1978; human behavior. m. Changes in female sexuality 299:1145-50. after hypophysectomy. J Clin Endocrinol Metab 27. Kotin J, Wilbert DE, Verburg D, Soldinger SM. 1960; 20:833-41. Thioridazine and sexual dysfunction. AmJ Psychia­ 47. Buvat J, Lemaire A, Buvat-Herbaut M, Fourlinnie try 1976; 133:82-5. JC, Racadot A, Fossati P. Hyperprolactinemia and 28. Drugs that cause sexual dysfunction. Med Lett Drugs sexual function in men. HormRes 1985; 22:196-203. Ther 1980; 22:108-10. 48. Cooper AJ. Diagnosis and management of "endo­ 29. Nininger JE. Inhibition of ejaculation byamitripty­ crine impotence." Br MedJ 1972; 2:34-6. line. AmJ Psychiatry 1978; 135:750-1. 49. Kaplan HS, editor. The evaluation of sexual disor­ 30. Vmarova E, Uhlir 0, Stika L, Vmar O. Side effects of ders: psychological and medical aspects. New York: lithium administration. Act Nerv Super (Praha) Brunner/Mazel, 1983. 1972; 14:105-7. 50. Leiblum SR, Rosen RC, editors. Sexual desire disor­ 31. Burnett WC, Chahine RA. Sexual dysfunction as a ders. New York: Guilford Press, 1988. complication of propranolol therapy in men. Car­ 51. Derogatis LR, Meyer JK. A psychological profile of diovasc Med 1979; 4:811-5. the sexual dysfunctions. Arch Sex Behav 1979; 32. Warren SC, Warren SG. Propranolol and sexual im­ 8:201-23. potence Oetter]. Ann Intern Med 1977; 86: 112. 52. Kaplan HS. Disorders of sexual desire and other new 33. Stessman J, Ben-Ishay D. Chlorthalidone-induced concepts and techniques in sex therapy. New York: impotence. Br MedJ 1980; 281:714. Brunner/MazeI1979. 34. Ahmad S. Hydralazine and male impotence Oetter]. 53. Leif H. Handbook of . Chicago: Chest 1980; 78:358. American Medical Association, 1982. 35. BrouwersJR, AssiesJ, Wiersenga WM, Huizing G, 54. Kaplan HS. The new sex therapy. New York: Brun­ Tytgat GN. Plasma prolactin levels after acute and ner/Mazel, 1978. subchronic oral administration of doperidone and of 55. LoPiccolo J, Stock WE. Treatment of sexual dys­ metoclopramide: a cross-over study in healthy vol­ function. J Consult Clin Psychol 1986; 54: 158-67. unteers. Clin Endocrinol1980; 12:435-40. 56. Cooper AJ. Hostility and male potency disorders. 36. Evans BE, Aledort LM. Inhibition of ejaculation due Compr Psychiatry 1968; 9:621-6. to epsilon aminocaproic acid [letter]. N EnglJ Med 57. Ellis A. Reason and in . 1978; 298:166-7. Seacaucus, NJ: Lyle Stuart, 1962. http://www.jabfm.org/ 37. Schneider J, Kaffarnik H. Impotence in patients 58. Derogatis LR. Psychological testing. In: Meyer JK, treated with clofibrate. Atherosclerosis 1975; SchmidtCWJr, WlSeTN, editors. Clinical manage­ 21:455-7. ment of sexual disorders. Baltimore: Williams & 38. Barton JL. Orgasmic inhibition by phenelzine [let­ Wtlkins, 1983:76-85. ter]. AmJ Psychiatry 1979; 136:1616-7. 59. Sager C. Sex as a reflection of the total relationship. 39. Strauss B, Appelt H. Psychological concomitants of J Sex Marital Ther 1976; 2:3-5. the menstrual cycle: a prospective longitudinal ap­ 60. Snyder DK, Berg P. Determinants of sexual dissatis­

proach. J Psychosom Obstet Gynecol 1983; 2: faction in sexually distressed couples. Arch Sex on 1 October 2021 by guest. Protected copyright. 215-20. Behav 1983; 12:237-46. 40. Cocores JA, Miller NS, Pottash AC, Gold MS. Sex­ 61. Epstein N, Eidelson RJ. Unrealistic beliefs of clinical ual dysfunction in abusers of cocaine and alcohol. couples: their relationship to expectations, goals and AmJ Drug Alcohol Abuse 1988; 14:169-73. satisfaction. AmJ Fam Ther 1981; 9(4):13-22. 41. Smith DE, Smith N, Buxton ME, Moser C. PCP and 62. Hartman LM. The interface between sexual dys­ sexual dysfunction. J Psychedelic Drugs 1980; function and marital conflict. AmJ Psychiatry 1980; 12:269-73. 137:576-9. 42. Siegel RK. Cocaine and sexual dysfunction: the curse 63. Frank E, Anderson C, Kupfer DJ. Profiles of couples of mama coca. J Psychoactive Drugs 1982; 14:71-4. seeking sex therapy and marital therapy. Am J Psy­ 43. Smith DE, Moser C, Wesson DR, Apter M, Buxton chiatry 1976; 133:559-62. ME, DavisonJY, et al. A clinical guide to the diagno­ 64. Polyson JA. and sexual problems: societal sis and treatment of heroin-related sexual dysfunc­ censure of the sexually troubled male. Psychol Rep tion.J Psychoactive Drugs 1982; 14:91-9. 1978; 42:843-50.

60 JABFP Jan.-Feb.1992 Vol. 5 No.1 65. Mosher DL. Measurement of guilt in females by self- 74. Lehman TP, Jacobs JA. Etilogy of diabetic impo- J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from report inventories. J Consult Clin Psychol 1968; tence.J Uro11983; 129:291-4. 32:690-5. 75. Munjack DJ, Oriel LJ, Kanno PH, Whipple R, 66. Kaufman G. Shame: the power of caring. Cam- Leonard MD. Psychological characteristics of males bridge, MA: Schenkman, 1980. with secondary erectile failure. Arch Sex Behav 67. Whalen SR. Cognitive factors in sexual behavior. J 1981; 10:123-31. Sex Marital Ther 1980; 6:87-101. 76. Munjack DJ, Kanno PH. Retarded ejaculation: a re- 68. Eklund PL, Gooren LJ, Bezemer PD. Prevalence of view. Arch Sex Behav 1979; 8:139-50. transsexualism in the Netherlands. Br J Psychiatry 77. HeimanJ, LoPiccolo J. Becoming orgasmic: a sexual 1988; 152:638-40. growth program for women. Englewood Cliffs, NJ: 69. Schein M, Zyzanski SJ, Levine S, MedalieJH, Dick- Prentice Hall, 1988. man RL, Alemagno SA. The frequency of sexual 78. Sandberg G, Quevillon RP. Dyspareunia: an inte- problems among fumily practice patients. Fam Pract grated approach to assessment and diagnosis. J Fam ResJ 1988; 7:122-34. Pract 1987; 24:66-70. 70. Kaplan HS, editor. Comprehensive evaluation of dis- 79. Steege JR Dyspareunia and vaginismus. Clin Obstet orders of sexual desire. Washington, DC: American GynecoI1984; 27:750-9. Psychiatric Press, 1985. 80. Guthrie E, Creed FR, Whorwell PJ. Severe sexual 71. Idem. Sexual , sexual aversion, and panic dis- dysfunction in women with the irritable bowel orders. New York: BrunnerlMazel, 1987. syndrome: comparison with inflammatory bowel 72. Karacan I, Salis PJ, Ware JC, Dervent B, Williams disease and duodenal ulceration. Br Med J 1987; RL, Scott FB, et al. Nocturnal penile tumescence 295:577-8. and diagnosis in diabetic impotence. AmJ Psychiatry 81. Stuart FM, Hammond DC. Sex therapy. In: Stuart 1978; 135:191-7. RB, editor. Helping couples change: a socialleaming 73. Martin LM. Impotence in diabetes: an overview. approach to marital therapy. New York: Guilford Psychosomatics 1981; 22:318-20,325,328-9. Press, 1980:301-66. http://www.jabfm.org/ on 1 October 2021 by guest. Protected copyright.

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