What is the best approach to manage increased sexual and arousal symptoms in a 43-year-old female with a history of brain compression, cytotoxic cerebral ischemia, and stroke, who is not currently on any psychopharmacology?

Management of Increased Sexual and Arousal Symptoms Post-Stroke

Begin with a comprehensive neurological and psychiatric assessment to rule out temporal lobe involvement and seizure activity, as hypersexuality after stroke is most commonly associated with temporal lobe lesions and may require anticonvulsant therapy. 1

Initial Assessment and Workup

Your patient's presentation of increased sexual and arousal symptoms following stroke with brain compression and cytotoxic cerebral ischemia requires immediate evaluation for specific neurological causes:

• Obtain brain imaging (CT or MRI) to identify temporal lobe involvement, as all documented cases of post-stroke hypersexuality have demonstrated temporal lobe lesions on imaging 1
• Screen for seizure activity with EEG, since post-stroke seizures are present in all reported hypersexuality cases and may be the underlying mechanism 1
• Assess for associated behavioral changes including mood alterations, hyperphagia, and other disinhibited behaviors that commonly accompany temporal lobe-related hypersexuality 1

Understanding the Clinical Context

This presentation is uncommon but well-documented. While most stroke survivors experience hyposexuality (decreased sexual function), a small subset develops hypersexuality:

• Temporal lobe lesions are the consistent anatomical finding in patients presenting with increased libido and deviant sexual behavior post-stroke 1
• The mechanism likely involves disruption of temporal lobe structures that normally regulate sexual behavior and impulse control 1
• This differs fundamentally from the more common post-stroke sexual dysfunction, which involves decreased desire, arousal difficulties, and orgasmic problems 2

Treatment Algorithm

If Temporal Lobe Lesion + Seizure Activity Present:

• Initiate anticonvulsant therapy as the primary intervention, since seizure activity appears mechanistically linked to the hypersexuality 1
• Monitor for resolution of hypersexual symptoms with seizure control
• Consider neurology consultation for optimal anticonvulsant selection and dosing

If No Seizure Activity or Temporal Lobe Lesion:

• Evaluate for other neurological contributors: right hemisphere lesions may cause arousal deficits that paradoxically manifest as disinhibited sexual behavior; left hemisphere lesions may contribute through depression and altered emotional regulation 3
• Screen for psychiatric comorbidities including mania, hypomania, or frontal lobe disinhibition syndromes that may present with hypersexuality

Behavioral and Counseling Interventions

Regardless of etiology, implement structured sexual counseling using evidence-based frameworks:

• Use the BETTER model to initiate discussion: Bring up the topic directly, Explain your concerns about quality of life impacts, Tell the patient about available resources, consider Timing of the conversation, Educate about stroke effects on sexual function, and Record your assessment 4
• Provide counseling at regular intervals: 3 months, 6 months, 9 months, and 1 year post-stroke as symptoms may evolve over time 2
• Include the partner in counseling sessions when possible, as stroke-related sexual changes profoundly affect both individuals 2

Pharmacological Considerations

Avoid SSRIs initially despite their known sexual side effects, as introducing psychopharmacology in a patient with complex neurological injury and no psychiatric diagnosis may complicate the clinical picture 5. However, if behavioral interventions fail and hypersexuality causes significant distress or safety concerns:

• SSRIs like sertraline cause decreased libido in 6% of patients and ejaculatory dysfunction in 14% of male patients, which could theoretically reduce hypersexual symptoms 5
• This approach should only be considered after neurological causes are addressed and behavioral interventions have failed
• Close monitoring is essential as SSRIs can worsen other stroke sequelae including fatigue and cognitive changes 5

Critical Pitfalls to Avoid

• Do not assume this is typical post-stroke sexual dysfunction requiring reassurance about safety of sexual activity—increased arousal symptoms suggest a different pathophysiology requiring specific evaluation 1
• Do not delay neuroimaging and EEG if temporal lobe involvement is suspected, as seizure activity may require urgent treatment 1
• Do not introduce psychotropic medications without clear psychiatric indication, as the patient is not currently on psychopharmacology and the symptoms may resolve with treatment of the underlying neurological cause 1
• Never dismiss the partner's concerns or safety, as hypersexuality can strain relationships and create uncomfortable or unsafe situations 2

Monitoring and Follow-Up

• Reassess symptoms at each follow-up visit using structured questions about sexual function, relationship quality, and any distressing behaviors 2
• Monitor for evolution of symptoms, as stroke recovery continues for up to one year and sexual symptoms may change during this period 2
• Screen for depression and anxiety at each visit, as these commonly develop post-stroke and can alter sexual behavior 2, 3