What are the treatment options for sexual dysfunction?

Treatment Options for Sexual Dysfunction

Treatment for sexual dysfunction should follow a stepwise approach, beginning with risk factor modification and progressing to medication and specialized interventions based on the specific type of dysfunction and its underlying causes. 1

Assessment and Evaluation

For Male Sexual Dysfunction:

• Screen using validated tools like Sexual Health Inventory for Men
• Evaluate for psychosocial factors: anxiety, depression, relationship issues, substance use
• Review medications that may contribute (hormone therapy, opioids, beta blockers, SSRIs)
• Assess cardiovascular risk - patients should be able to walk 1 mile in 20 minutes or climb 2 flights of stairs in 20 seconds without symptoms 1
• Check morning testosterone levels if hypogonadism is suspected
• Perform focused physical examination including chest, abdomen, genitalia 1

For Female Sexual Dysfunction:

• Screen using validated tools like Female Sexual Function Index (FSFI)
• Evaluate for psychosocial factors and relationship issues
• Review medications that may contribute to dysfunction
• Assess traditional risk factors and impact of cancer/treatment if applicable 1

Treatment Algorithm for Male Sexual Dysfunction

First-Line Interventions:

1. Risk factor modification:

   • Smoking cessation
   • Weight loss
   • Increased physical activity
   • Reduced alcohol consumption 1

2. Address psychosocial issues:

   • Referral to sex therapy or couples counseling as appropriate
   • Treatment of anxiety or depression if present 1

3. Medication review:

   • Consider alternative medications with lower risk of sexual dysfunction 1

Second-Line Interventions:

1. Phosphodiesterase type 5 inhibitors (PDE5i):

   • Start with conservative dosing and titrate as needed
   • Consider daily low-dose treatment as an alternative to on-demand dosing
   • Ensure adequate trial (at least 5 occasions at maximum dose)
   • Try a different PDE5i if first agent fails
   • Important: Contraindicated with nitrates due to risk of dangerous hypotension 1, 2
   • Cardiovascular evaluation is essential before prescribing 2

2. Testosterone therapy if total morning testosterone <300 ng/dL:

   • Not for use in prostate cancer patients on active surveillance or ADT 1

Third-Line Interventions (if PDE5i fails):

1. Intraurethral alprostadil suppositories
2. Intracavernous vasoactive drug injection therapy
3. Vacuum constriction devices 1

Fourth-Line Intervention:

• Penile prosthesis implantation 1

Treatment Algorithm for Female Sexual Dysfunction

First-Line Interventions:

1. Risk factor modification and lifestyle changes

2. Psychosocial interventions:

   • Cognitive behavioral therapy
   • Sex therapy or couples counseling 1

3. Integrative approaches:

   • Yoga and meditation
   • Relaxation techniques 1

Second-Line Interventions (based on specific symptoms):

1. For vaginal dryness/discomfort:

   • Non-hormonal vaginal moisturizers and lubricants
   • Topical vitamin D or E 1

2. For sexual pain:

   • Topical anesthetics (e.g., lidocaine)
   • Pelvic floor physical therapy
   • Vaginal dilators 1

3. For hormonal issues:

   • Vaginal estrogen (pills, rings, or creams) for postmenopausal women
   • Vaginal DHEA (prasterone) for vaginal dryness or pain 1

Special Considerations

Cardiovascular Risk

• Assess cardiovascular status before initiating treatment for erectile dysfunction
• PDE5i should not be used in men for whom sexual activity is inadvisable due to cardiovascular status
• At least 48 hours should elapse between PDE5i use and nitrate administration 2

Medication-Induced Sexual Dysfunction

• For antipsychotic-related sexual dysfunction, consider switching to medications with lower impact on sexual function (aripiprazole, olanzapine, quetiapine, ziprasidone) 3
• For antidepressant-induced dysfunction, consider medication adjustment or addition of counteracting agents

Cancer Survivors

• Sexual dysfunction is common in cancer survivors and requires specialized approaches
• Treatment should address both physical and psychological aspects of dysfunction 1

Common Pitfalls to Avoid

• Failure to screen: Sexual dysfunction is often underreported unless specifically addressed
• Overlooking psychological factors: Even with organic causes, psychological overlay frequently exists
• Inadequate PDE5i trials: Ensure adequate dosing and sufficient number of attempts before declaring failure
• Neglecting partner involvement: When appropriate, include partners in discussions and treatment planning
• Missing cardiovascular risk: Always assess cardiovascular status before treating erectile dysfunction

Remember that sexual dysfunction often has multifactorial causes requiring a combination of physical and psychological interventions for optimal outcomes.