Comprehensive Workup for Sexual Dysfunction
The workup for sexual dysfunction should begin with a thorough medical, sexual, and psychosocial history, a physical examination, and selective laboratory testing to identify underlying causes and guide appropriate treatment. 1
Initial Assessment
Medical History
- Evaluate for medical conditions associated with sexual dysfunction:
- Cardiovascular disease
- Diabetes mellitus
- Obesity
- Hypertension
- Neurological disorders
- Endocrine disorders
- Cancer and cancer treatments
- History of pelvic surgery or radiation
Medication Review
- Identify prescription and over-the-counter medications that may contribute to sexual dysfunction:
- Antidepressants (especially SSRIs)
- Hormone therapy
- Narcotics/opioids
- Antihypertensives
- Antiandrogens
Psychosocial Assessment
- Screen for:
- Anxiety and depression
- Relationship issues
- Drug or alcohol use
- Stress factors
- History of sexual trauma
- Body image concerns
Sexual History
- Assess:
- Sexual function before current problems
- Onset and progression of symptoms
- Current level of sexual activity
- Impact on quality of life and relationships
- Sexual orientation and gender identity
Physical Examination
For Men
- Focused examination including:
- Chest (for gynecomastia)
- Abdomen
- Phallus
- Scrotum/testicles
- Cord structures 1
For Women
- Physical and gynecologic examination to assess:
- Points of tenderness
- Vaginal atrophy
- Anatomic changes associated with cancer and cancer treatment
- Pelvic floor muscle tone 1
Validated Assessment Tools
For Men
- Sexual Health Inventory for Men (SHIM) 1
- International Index of Erectile Function (IIEF) 2
- Premature Ejaculation Diagnostic Tool 2
For Women
- Female Sexual Function Index (FSFI) 1
- Brief Sexual Symptom Checklist for Women 1
- Changes in Sexual Functioning Questionnaire (CSFQ) 3
Laboratory Testing
Basic Testing
- Complete blood count
- Comprehensive metabolic panel
- Lipid profile
- Urinalysis
Hormonal Assessment
For men:
- Total and free testosterone
- Prolactin
- Thyroid function tests
- Luteinizing hormone (LH)
- Follicle-stimulating hormone (FSH)
For women:
- Estradiol
- Testosterone
- Thyroid function tests
- Prolactin
Specialized Testing (When Indicated)
- For men with erectile dysfunction:
- Nocturnal penile tumescence testing
- Penile Doppler ultrasound (for vascular assessment)
- Cardiovascular risk assessment 1
Cardiovascular Risk Assessment
For men with erectile dysfunction, cardiovascular risk should be estimated, as ED and cardiovascular disease often coexist. Sexual activity is considered equivalent to walking 1 mile in 20 minutes or climbing 2 flights of stairs in 20 seconds. Men who cannot perform these exercises without symptoms should be referred to a cardiologist before treatment for ED 1.
Common Pitfalls and Caveats
Overlooking psychological factors: Sexual dysfunction often has both physical and psychological components. Even when a physical cause is identified, psychological factors may still contribute.
Focusing only on erectile function in men: Sexual dysfunction in men includes issues with desire, ejaculation, and orgasm, not just erectile dysfunction.
Neglecting partner factors: Partner's sexual function, expectations, and relationship dynamics can significantly impact treatment outcomes.
Failure to follow up: Sexual dysfunction often requires ongoing assessment and adjustment of treatment strategies.
Medication-induced dysfunction: Always consider if current medications are contributing to sexual problems before adding new treatments 4.
Treatment Considerations
Treatment should be guided by the specific type of sexual dysfunction identified and its underlying causes. The American Urological Association emphasizes that shared decision-making is the cornerstone of treatment for erectile dysfunction, with patients being informed of all treatment options that are not contraindicated 1.
For female sexual dysfunction, treatment should be targeted to the specific problem identified, with options including lubricants and moisturizers for vaginal dryness, pelvic floor muscle training for pain and arousal issues, and psychotherapy for psychological components 1.
By following this comprehensive approach to the workup of sexual dysfunction, clinicians can identify underlying causes, develop appropriate treatment plans, and improve patients' quality of life and relationships.