J Am Board Fam Pract: first published as 10.3122/jabfm.5.1.51 on 1 January 1992. Downloaded from Sexual Dysfunction, 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 desire disorders (hypoactive sexual desire, sexual aversion disorder), (2) sexual arousal disorders (female sexual arousal disorder, male erectile dysfunc:tion), (3) orgasmic disorders (inhibited male or female orgasm, premature ejacu1ation), and (4) sexual pain disorders (dyspareunia, 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, pregnancy, 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., depression, anxiety, fear, frustradon, guUt, hypochondria, intrapsychic contlict), interpersonal and relationship factors (e.g., poor communic:ation, relationship conflict, diminished trust, 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 therapy.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 Health, 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 erection, 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 vagina ,8\,':'I:-.io- by increased pubococcygeal muscle tension and vasocongesnon, vasocongesrion of the labia Fipu 1 'Ibe sexualleSponse cycle, with several DOnna! minora, breast tumescence, 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 prostate, sefllinal and female O1gasm, characterized by delayed or vesicles, and urethra 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 ejaculation, 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 sexual intercourse 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 vaginismus; 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 libido and altering potency, perhaps by response cycle. According to current estimates, increasing brain serotonin 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 cannabis, barbiturates, and benzodiazepines, as mates ranging as high as 75 to 85 percent.9Thirty well as antihypertensive and anticonvulsant medi­ percent of surgical procedures on the female cations that have sedating properties. genital tract result in temporary dyspareunia, and Increased prolactin levels reduce the respon­ 30 to 40 percent of the women seen in sex therapy siveness of the male gonads to leutinizing hor­ clinics for dyspareunia have pathologic pelvic mone, thereby inhibiting testosterone