20 - Sexual Dysfunction in Men and Women

Abstract

Sexual health is an important determinant of quality of life and a good marker of physical and mental health. Common sexual disorders in men include hypoactive sexual desire disorder, erectile dysfunction, premature ejaculation, and delayed ejaculation; those common in women include sexual interest/arousal disorder, female orgasmic disorder, and genitopelvic pain/penetration disorder. Erectile disorder is the most common form of sexual dysfunction in men, and low sexual desire is the most prevalent sexual concern in women. Penile erection results from hemodynamic events that are associated with cavernosal smooth muscle relaxation, increased blood flow into cavernosal sinuses, and venous occlusion. Corporal smooth muscle tone is regulated by transmembrane and intracellular calcium flux, which in turn is regulated by potassium channels; connexin43-derived gap junctions; and cholinergic, adrenergic, and nonadrenergic noncholinergic mediators, including nitric oxide. Sexual dysfunction in men is often associated with diabetes, coronary artery disease, lower urinary tract symptoms, depression, or hormonal problems. Selective phosphodiesterase 5 inhibitors are safe and effective first-line therapy for men with erectile dysfunction. Testosterone therapy in androgen-deficient men improves overall sexual activity, sexual desire, erectile function, nighttime erections, and ejaculate volume. In women, sexual dysfunction is strongly linked to mental health. Women’s sexual disorders are not associated with androgen levels. Psychological therapies are the mainstay of treatment of women’s sexual disorders, with emerging evidence of benefit from mindfulness-based cognitive therapy. About 10% to 15% of women have dyspareunia from provoked vestibulodynia—a chronic pain disorder associated with sensitization of the nervous system and occasionally precipitated by low-dose combined contraceptives.