Oxford Handbook of Genitourinary Medicine, HIV, and Sexual
Health (2 edn)
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Psychological aspects
Personality types
In those attending clinics for STIs:
extroversion—associated with ↑ sexual partners, varied sexual behaviour, and ↑ STIs.
psychoticism—related to ↑ sexual curiosity, promiscuity, and hostility.
neuroticism—associated with ↓ sexual satisfaction but ↑ sexual guilt, inhibition, and exaggerated concerns about STIs.
Clinic patients
20–40% of new patients attending clinics for STIs have been classified as ‘psychiatric cases’ based on general health questionnaire scores showing high levels of anxiety. It is important to recognize and manage this during the consultation to help address the presenting problem as well as improve subsequent attendance. The origins of anxiety at presentation are multi-factorial, although stigma and shame are prominent. New diagnoses of HIV infection, anogenital herpes, and syphilis generate the greatest anxiety and are also the most common STIs associated with phobias.
The greatest psychological reaction usually arises from a diagnosis of HIV infection. It does not necessarily relate to the stage of the disease and may exhibit a ‘bereavement’-type reaction—disbelief, denial, anxiety, and depression. There may also be suicidal tendencies. In addition, such feelings may be complicated by guilt, resentment, and stigmatization. Regular support is important, ensuring that information is given at and over a time best suited to the individual. Referral for specialist advice/treatment may also be required.
Certain procedures (e.g. colposcopy for abnormal cervical cytology) are associated with very high levels of anxiety. Stress and depression are common features of chronic conditions, e.g. HIV infection, vulval vestibulitis, chronic pelvic pain, prostatitis, and persistent anogenital warts. They are also reported with conditions that may recur (e.g. anogenital herpes, warts, and vaginal candidiasis). Patients need sufficient time to express their anxiety and a careful explanation of the condition (with written information) is important. Therapeutic intervention (e.g. antiretroviral treatment for HIV and suppressive treatment for frequent recurrences of herpes) may ↓ psychological morbidity. Stigma and shame, associated especially with chronic STIs, fuel anxiety and may hinder disclosure to sexual partners.
Neuroses associated with STIs
Over-reaction and hypochondriasis
Examples include:
inappropriate reaction to the condition diagnosed
undue vigorous penile squeezing to produce a urethral discharge
obsessional attention to genital marks and irregularities.
May be a symptom of some other underlying problem (e.g. rumours about a sexual partner). Managed by exploring the patient’s anxieties and correcting misinformation.
Phobias
Excessive and inappropriate anxiety reactions triggered by specific situations or objects, despite having an insight into the lack of reason or appropriateness. Often triggered by stress and media publicity. Likely to be prompted by underlying guilt or a sexual concern which should be addressed when formulating management strategies.
Factitious illness and Munchausen’s syndrome
In GUM often related to HIV infection with imagined positive test result. Reasons and motivation are often unclear, but may be used to gain sympathy, hospital care, or social benefits. Psychiatric referral is often required.
Sexual dysfunction
Classification by the American Psychiatric Association
Sexual desire disorders:
hypoactive
sexual aversion
Sexual arousal disorder
Orgasmic disorder
Sexual pain disorders:
dyspareunia
vaginismus
After organic problems have been identified and treated the management of sexual dysfunctions requires the cooperation and support of both partners. Emotional issues which may also underlie or complicate the presenting problem should be explored and addressed through counselling. Simple counselling, provided to an individual or couple, is often brief:
it provides basic information and corrects false ideas
it makes suggestions, e.g. positions during intercourse
it provides permission and reassures—often linked with a new suggestion (e.g. the use of vibrators and other sex aids)
it facilitates communication between partners in particular to develop self-assertiveness and self-protection.
This may lead to behavioural psychotherapy for individuals, couples, or sometimes groups. The framework consists of the following:
setting behavioural tasks (i.e. ‘homework’).
analysis of the patient’s or couple’s success, identifying obstacles or difficulties
provision of help, support, and advice to address the obstacles and problems
review of the new situation with new tasks set or revised.
More common problems seen in women presenting to GUM
Low sexual desire/arousal (sexual anhedonia) and orgasmic dysfunction
Heterogeneous condition
Causal factors include:
partner conflict and disharmony
ignorance
psychological causes (e.g. anxiety, depression, body dysmorphism)
physical causes—local (e.g. endometriosis, cystitis), systemic (e.g. diabetes mellitus, multiple sclerosis), drugs (e.g. oral contraceptives, hypotensives, tranquillizers), surgery affecting body image (e.g. hysterectomy, mastectomy)
post-menopause—~15% significant decline in arousal.
Management
Definition and management of any underlying problem. In post-menopausal ♀ hormone replacement treatment with androgenic activity (e.g. tibolone).
Testosterone transdermal patch (Intrinsa®)—licensed for female hypoactive sexual desire disorder in bilaterally oopherectomized and hysterectomized (i.e. surgically induced menopause) ♀ receiving concomitant oestrogen therapy, although only recommended up to the age of 60 years. Statistically significant improvement in sexual desire demonstrated in 6 month duration clinical trials although ↑ adverse effects, mainly hirsutism and acne, also demonstrated.
Sensate focus (of benefit despite level of inhibition)—a three-stage programme in which the couple progresses stepwise from non-genital pleasuring through genital pleasuring to non-demanding coitus under the control of the ♀.
Insufficient data on drugs but apomorphine may benefit some with arousal and hypoactive sexual disorders. Phosphodiesterase-5 inhibitors appear to be disappointing.
Dyspareunia
Genital pain just before, during, or after sexual intercourse. More common in ♀ and liable to be exacerbated by vaginismus (involuntary bulbo-cavernosus muscle spasm) and psychological factors especially anxiety and marital/partner adjustment.
Vulvovaginal problems
Congenital—e.g. rigid hymen)
Physiological—inadequate lubrication (e.g. oestrogen deficiency)
Traumatic—e.g. episiotomy, radiation therapy
Inflammatory:
infective—e.g. candidosis, trichomoniasis
ulcerative—e.g. genital herpes, syphilis, aphthosis, Behçet’s disease
dermatological—e.g. irritant dermatitis, lichen sclerosis or planus
degenerative—atrophic vulvovaginitis
vulvar vestibulitis
Neoplastic—e.g. squamous cell carcinoma
Bartholin gland—abscess, cyst
Uterine/pelvic problems
Retroverted uterus, pelvic congestion, cervicitis, endometritis, pelvic inflammatory disease, pelvic adhesions, endometriosis, fibroids, adnexal pathology (e.g. ovarian cysts, tumours).
Anal/intestinal problems
Anal fissure/fistula, irritable bowel, inflammatory bowel disease.
Urinary problems
Urethritis, urethral caruncle, cystitis.
Vaginismus
A learned response, often secondary to dyspareunia (e.g. from vestibulitis, atrophic vaginitis, trauma), leading to recurrent or persistent involuntary contraction of the musculature of the outer third of the vagina, interfering with coitus and causing distress. Other causes/factors include fear of pregnancy, loss of control, association of intercourse with violence, previous sexual abuse, relationship difficulties, and religious/cultural taboos. Tampons are usually avoided, and external towels are used for menstruation. Involuntary perineal spasms may occur while preparing for/conducting a pelvic examination which is often evaded.
Management
Management is in stages—problem-oriented therapy with behavioural and desensitization exercises.
Exclude or manage physical causes and psychological factors. Inform and correct misunderstanding of sexual functioning, ideally with the partner’s involvement if agreeable.
Encourage ♀ to become comfortable touching her genitalia and inserting a finger into the vagina.
Proceed to more fingers and/or the use of lubricated graded dilators.
Advise Kegel’s exercise—perineal contraction (against inserted finger(s) or dilators) followed by relaxation, to help muscle control.
Suggest partner involvement—gentle introduction of a finger into the vagina, slowly escalating to more fingers or dilators.
When comfortable, proceed to penetrative sexual intercourse with the ♀ adopting a position (e.g. superior) to maintain control.
More common problems seen in men presenting to GUM
Erectile dysfunction (ED) (Table 34.1)
Common, affecting over 50% aged 40–70 years (although only 10% fail to achieve nocturnal erections): 60% organic, 15% psychogenic, 25% mixed.
Main causes
Lifestyle factors: obesity, smoking (×1.5), alcohol, recreational drugs.
Trauma and iatrogenic, e.g. prolonged bicycle riding, prostatic/pelvic surgery, pelvic fracture, and local radiation treatment.
Drugs, e.g. antidepressants (most), antipsychotics (many), hypotensives (most), androgen inhibitors (e.g. finasteride for benign prostatic hypertrophy).
Vascular: responsible for nearly 50% of cases in those aged >50 years, e.g. ischaemic heart disease (IHD), hypertension, peripheral vascular disease. Coexisting IHD (up to 40%) manifests a mean of ~38 months after ED (penile arteries 1–2mm, coronary 3–4mm).
Endocrine: diabetes mellitus (~50% have ED), neurogenic and vascular factors; hyper/hypothyroidism; hypogonadism, both physiological and pathological; hyperprolactinaemia.
Neurological: multiple sclerosis; Parkinson’s disease.
Psychogenic (depression, anxiety): ↑ sympathetic tone. Performance anxiety may become self-perpetuating.
| Over the past 6 months | Score | ||||
|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | |
Confidence in getting and keeping an erection | Very low | Low | Moderate | High | Very high |
Erections on sexual stimulation hard enough for penetration | Never/almost never | <50% of the time | ~50% of the time | >50% of the time | Always/almost always |
Maintaining erection afterpenetration | Never/almost never | <50% of the time | ~50% of the time | >50% of the time | Always/almost always |
Maintaining erection to completion of intercourse | Extremely difficult | Very difficult | Difficult | Slightly difficult | Not difficult |
Satisfactory intercourse | Never/almost never | <50% of the time | ~50% of the time | >50% of the time | Always/almost always |
| Over the past 6 months | Score | ||||
|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | |
Confidence in getting and keeping an erection | Very low | Low | Moderate | High | Very high |
Erections on sexual stimulation hard enough for penetration | Never/almost never | <50% of the time | ~50% of the time | >50% of the time | Always/almost always |
Maintaining erection afterpenetration | Never/almost never | <50% of the time | ~50% of the time | >50% of the time | Always/almost always |
Maintaining erection to completion of intercourse | Extremely difficult | Very difficult | Difficult | Slightly difficult | Not difficult |
Satisfactory intercourse | Never/almost never | <50% of the time | ~50% of the time | >50% of the time | Always/almost always |
IIEF-5 score 21 correlates with ED (98% sensitive and 88% specific)
Basic assessment
History: for risk factors; libido, shaving (need and frequency).
Examination: genital abnormalities including hypogonadism, facial/body hair, neurological (S2–S4 dermatomes), blood pressure/peripheral pulses.
Investigations: exclude diabetes (urinalysis/blood glucose); consider serum testosterone, prolactin + other endocrine tests (thyroid, pituitary function). Ultrasonography and angiography rarely required.
First-line management
Psychosexual therapy (alone or in combination).
Phosphodiesterase-5 inhibitors:
Sildenafil: recommended dose 50mg (range 25–100mg) 1 hour before intercourse. Advise 1 dose in 24 hours (100mg maximum). 29% ↓ in plasma concentration with food. Half-life, 4–5 hours.
Vardenafil: recommended dose 10mg (range 2.5–20mg) 25–60 minutes before intercourse. Advise 1 dose in 24 hours (20mg maximum). 20% ↓ in plasma concentration with food. Half-life, 4.8–6 hours.
Tadalafil: recommended dose 10mg (range 10–20mg) 30 minutes–12 hours before intercourse. Maximum dose over 24 hours, 20mg. No ↓ in plasma concentration with food. Half-life, 17.5–21 hours.
Success rates (erection suitable for intercourse) of phosphodiesterase-5 inhibitors up to 75%, but high placebo rates (22–38%). Contraindicated in patients taking nitrates (both therapeutic and recreational) and those with hypotension, unstable angina, recent cerebrovascular accident, or myocardial infarction.
Alternative management methods
Central dopamine agonist: apomorphine. Recommended dose 2mg (up to 3mg) sublingually 20 minutes before intercourse. Minimum of 8 hours between doses. Success rate ~50% (32% with placebo). Contraindications include hypotension, severe unstable angina, severe heart failure, or recent myocardial infarction. With the exception of Parkinson’s disease, ♂ with neurological disease do not respond.
Synthetic prostaglandin E1 agent (e.g. alprostadil): available as intra-urethral pellets (usual starting dose 250mcg up to 1mg) or as an intra-cavernosal injection (usual dose range 5–20mcg). Up to 90% response rate with injection and 40–60% with pellets.
Testosterone (IM or transdermal): should only be considered when ED is related to hypogonadism, otherwise no evidence of benefit. Hepatotoxic.
Pelvic floor exercises with biofeedback (including perineal muscle electrical stimulation). Only if ED related to venous leakage or occlusion (success rate ~50%).
Mechanical aids:
Vacuum devices: suck venous blood into the penis, causing an erection maintained by a firm constricting band. Lacks spontaneity, may cause bruising and produces a venous (cold/blue) erection.
Implants: e.g. inflatable devices, malleable rods.
Premature ejaculation
Most common sexual dysfunction in ♂ under 40 years, reported in ~40%. Difficult to define as dependent on sexual partner and may indicate delayed ♀ orgasm, but generally indicative of ejaculation with minimal sexual satisfaction occurring before the person wishes. Generally considered to be a psychological problem; rarely reported with chronic prostatitis.
Primary Patient has always ejaculated prematurely. Often considered to be a conditioned response from teenage masturbatory practices but may reflect deep sexual anxiety from childhood traumatic experiences including sexual assault and/or familial conflict. Current research suggests genetic susceptibility and ↓ central serotonin (5-hydroxy tryptamine (5-HT)) mediated neurotransmission are also important factors.
Secondary Previous ejaculatory control. Probably largely related to performance anxiety.
Management
If associated with erectile dysfunction treat this first.
Stop/start: manual stimulation (initially) by partner or patient until ejaculation is imminent. Then cease for 30 seconds before resuming. The sequence is repeated until ejaculation is required.
Squeeze technique: similar approach but firm pressure is applied across the penis at the frenum, aborting imminent ejaculation.
Over time these methods progress to vulval contact and then vaginal penetration (♀ superior), stopping for 30 seconds or withdrawing and squeezing as ejaculation approaches. Success rate 65–90% with active participation of partner.
Ejaculation 1–2 hours before coitus: young ♂—longer latent period for coital ejaculation. (Older ♂ may have problems attaining erection even after 2 hours.)
Reduce sensation:
local anaesthetic gel/ointment, e.g. lidocaine (provided that there is no allergy)
use of less sensitive condoms.
Drug treatment (not licensed): selective serotonin re-uptake inhibitors (SSRIs) and clomipramine delay ejaculation by their effect on central 5-HT receptors. SSRIs take at least 3 weeks to produce the effect but clomipramine is effective after a single dose. Regimens shown to be effective:
daily—clomipramine 10–40mg or SSRI (paroxetine 20–40mg, sertraline 50–100mg, or fluoxetine 20mg).
‘On-demand’—clomipramine 10–50mg 5–6 hours before coitus.
Pelvic floor (Kegel) exercises.
Retarded ejaculation
Difficulty, delay, or absence of orgasm following sufficient sexual stimulation which causes personal distress.
Aetiology
Physiological: ↓ sensitivity, inadequate stimulation
Congenital: Wolffian and Mullerian duct malformations
Benign prostatic hypertrophy, prostatic carcinoma
↑ age: neuronal degeneration, ↓ sensitivity associated with ↓ testosterone
Pelvic surgery: e.g. prostatectomy (transurethral/radical), bladder neck surgery, proctocolectomy
Neurological: e.g. multiple sclerosis, spinal cord damage
Endocrine: diabetes mellitus (neuropathy), hypogonadism
Drugs: e.g. alcohol, most anti-depressants and drugs for treating obsessive–compulsive disorders, α- and β-blockers, anticholinergic agents
Psychological: e.g. fear of being seen, pregnancy, infection.
Management
Treat underlying cause, when relevant. If associated erectile
dysfunction, this should be managed first. If drug related,
consider altering medication or adding pharmacological
adjuvants, e.g. amantadine (100–400mg for 2 days prior to
coitus), bupropion (75–150mg), buspirone (15–60mg),
cyproheptadine (4–12mg), or yohimbine (5–10mg), all as needed,
if SSRI induced (
outwith product
licences).
Psychological approach.
Explore and resolve any underlying anxieties.
Establish extra-genital ejaculation, with suitable stimulation (mechanical, visual, etc. as required), gradually introducing vaginal contact and insertion into the programme.
Male superior position—facilitates ejaculation.
Dyspareunia
Genital
Congenital/post-traumatic: e.g. phimosis, tight frenum
Inflammatory: urethritis, genital herpes, syphilis, candidosis, dermatological (e.g. lichen sclerosis), aphthosis, Behçet’s disease
Peyronie’s disease
Iatrogenic (e.g. intracorporeal and transurethral alprostadil; rarely priapism following phosphodiesterase type-5 inhibitor use)
Testicular lesions: e.g. epididymitis, torsion
Neoplastic: e.g. squamous cell carcinoma
Ejaculatory pain
Seminal vesicle disorders: calculi, cystic malformations, metastatic cancer
Other pelvic causes: chronic prostatitis, benign prostatic hypertrophy and prostatic carcinoma, urethral stricture, pelvic arteriovenous malformation, hernia repair
Drugs: antidepressants, neuroleptics
Mercury poisoning
Psychogenic: e.g. fear of being seen
Anal
Anal dyspareunia during receptive anal intercourse may be due to psychogenic factors or intestinal tract diseases including anal fissures, inflammatory disease, and irritable bowel disease.
HIV infection
Bereavement reaction with new HIV-positive result
Extreme anxiety and phobia generated by HIV
May be associated with reduced testosterone levels due to hypogonadism (or possibly related to the aromatization of testosterone to oestrogen) leading to a ↓ in libido and ED
Effect of lipodystrophy for those on antiretroviral treatment on self-image and self-esteem
Retarded ejaculation associated with peripheral neuropathy related directly to either HIV infection or drug toxicity
Recreational and illicit drugs used by some HIV-infected men who have sex with men may ↑ unsafe sex and contribute to poor therapeutic adherence
