What are the treatment options for psychosexual dysfunction?

Treatment of Psychosexual Dysfunction

The management of psychosexual dysfunction requires a multidimensional treatment plan that addresses the underlying issues specific to the type of problem, with referrals to specialists (psychotherapy, sexual/couples counseling, urology, sexual health specialist) as appropriate. 1

Diagnostic Evaluation

Initial Assessment

• Obtain detailed sexual, medical, and psychosocial history
• Screen for psychological factors (anxiety, depression, relationship issues, substance use)
• Identify medications that could contribute to sexual dysfunction (hormone therapy, opioids, SSRIs)
• Assess traditional risk factors (cardiovascular disease, diabetes, obesity, smoking, alcohol use)
• Perform focused physical examination

Laboratory Testing

• Morning serum total testosterone levels in males
• Fasting glucose/HbA1c and lipid profile for cardiovascular risk assessment

Treatment Approaches by Type of Dysfunction

Erectile Dysfunction (ED)

1. First-line treatment: Oral PDE5 inhibitors (if not contraindicated)

   • Start conservatively and titrate to maximum dose as needed
   • Monitor periodically for efficacy and side effects
   • Consider an adequate trial as at least 5 separate occasions at maximum dose 1
   • Contraindicated in patients taking oral nitrates 1

2. Second-line options (if PDE5 inhibitors fail):

   • Intraurethral alprostadil suppositories
   • Intracavernous vasoactive drug injection therapy
   • Vacuum constriction devices 1

3. Third-line option:

   • Penile prosthesis implantation 1

4. Adjunctive treatments:

   • Testosterone therapy for hypogonadism (if not contraindicated by primary diagnosis) 1
   • Lifestyle modifications (smoking cessation, weight loss, increased physical activity, reduced alcohol) 1
   • Pelvic physical therapy 1

Female Sexual Dysfunction

1. For vaginal dryness and pain:

   • Water-, oil-, or silicone-based lubricants and moisturizers 1
   • Vaginal estrogen (pills, rings, or creams) for postmenopausal women (if not contraindicated) 1

2. For vaginismus/sexual pain:

   • Vaginal dilators for vaginismus, sexual aversion disorder, vaginal scarring, or stenosis 1
   • Pelvic floor muscle training 1

3. For arousal and orgasmic disorders:

   • PDE5 inhibitors are not recommended for women due to lack of evidence 1

Problems with Ejaculation

1. For premature ejaculation:

   • SSRIs (paroxetine, sertraline, citalopram, fluoxetine) dosed daily 1
   • Clomipramine dosed on demand 1
   • Vibratory therapy 1

2. For delayed or absent ejaculation:

   • Testosterone therapy if indicated 1
   • Pelvic physical therapy 1

3. For climacturia:

   • Empty bladder prior to sex
   • Pelvic physical therapy
   • Use of condoms to catch urine 1

Problems with Orgasm

1. For decreased intensity or difficulty achieving:
   • Vibratory therapy
   • PDE5 inhibitors (for men) 1
   • Cabergoline (dopamine agonist) for subjective improvement 1

Psychosexual Therapy

• Psychotherapy and psychosexual counseling to improve communication about sexual concerns
• Cognitive behavioral therapy for anxiety reduction
• Sensate focus exercises to reduce performance anxiety
• Referral to sex and couples therapy as appropriate 1

Special Considerations

Medication-Induced Sexual Dysfunction

• For antipsychotic-related sexual dysfunction:

  • Consider switching to medications with lower impact on sexual function (aripiprazole, olanzapine, quetiapine, ziprasidone) 2
  • Adjunctive treatment with aripiprazole may help reduce sexual dysfunction 2

• For SSRI-induced sexual dysfunction:

  • Be aware that SSRIs commonly cause delayed ejaculation, decreased libido, and other sexual side effects 3
  • Consider dose reduction or medication switch if appropriate

Cardiovascular Risk Assessment

• ED is a risk marker for underlying cardiovascular disease
• Assess exercise capacity before recommending treatment
• Sexual activity is equivalent to walking 1 mile in 20 minutes or climbing 2 flights of stairs in 20 seconds 1
• Refer to cardiology if unable to perform these activities without symptoms

Common Pitfalls to Avoid

• Failing to address psychological factors contributing to sexual dysfunction
• Not considering medication side effects as potential causes
• Overlooking the impact of relationship dynamics on sexual function
• Neglecting to assess cardiovascular risk before treating ED
• Inadequate follow-up to monitor treatment efficacy and side effects

Treatment Algorithm

1. Identify the specific type of sexual dysfunction
2. Address modifiable risk factors and medications
3. Provide first-line treatments specific to the dysfunction type
4. Refer to specialists (psychotherapy, sexual counseling, urology) as needed
5. Re-evaluate at regular intervals and adjust treatment as necessary