Elsevier

The Lancet

Volume 369, Issue 9559, 3–9 February 2007, Pages 409-424
The Lancet

Series
Sexual sequelae of general medical disorders

https://doi.org/10.1016/S0140-6736(07)60197-4Get rights and content

Summary

That sexual symptoms can signal serious underlying disease confirms the importance of sexual enquiry as an integral component of medical assessment. Data on sexual function are sparse in some medical specialties. However, increased scientific understanding of the central and peripheral physiology of sexual response could help to identify the pathophysiology of sexual dysfunction from disease and medical interventions, and also to ameliorate or prevent some dysfunctions. Many common general medical disorders have negative effects on desire, arousal, orgasm, ejaculation, and freedom from pain during sex. Chronic disease also interferes indirectly with sexual function, by altering relationships and self-image and causing fatigue, pain, disfigurement, and dependency. Current approaches to assessment of sexual dysfunction are based on models that combine psychological and biological aspects.

Introduction

Medical understanding of sexual responses has increased substantially in the past 15 years. Neurotransmitters and endothelial factors that mediate genital congestion have been identified—albeit with far more data in men than in women. More recently, brain imaging techniques have afforded a window on the neurological circuits that appraise and process sexual stimuli: the intricacies of the “gyrus fornicatus” (cingulate gyrus) discovered by anatomists a century ago1 are now being unravelled.

This sexual medicine series reviews the accumulating data on the comorbidity of sexual and other medical disorders. Diseases and medical interventions can directly interfere with central and peripheral sexual physiology. However, the traditional dualistic notion that sexual dysfunction has either psychological or organic origins has been replaced by an understanding that the two are inseparably combined.2, 3 Psychological factors such as personality, coping style, and external stressors can modulate immune, inflammatory, endocrine, and neurological mechanisms.4 Furthermore, medical disease has psychological repercussions that could potentially disrupt physiology. Although in its early stages, functional brain imaging is beginning to clarify the modulation of sexual response by psychological and medical factors.5, 6, 7 Such factors can predispose to, precipitate, or maintain sexual dysfunction, and therefore they need to be considered.8

We outline the general medical disorders and treatments that interfere with sexual motivation, desire, subjective arousal and excitement, orgasm, pleasure, and freedom from pain. We also discuss the physical response of genital congestion that is organised by the autonomic-nervous system. Two very common dysfunctions—vascular erectile dysfunction and dyspareunia from vulvar vestibulitis syndrome—are addressed in detail. The other two articles in this series review the sexual sequelae of specific neurological and endocrine disorders.

Data about the concurrence of sexual dysfunction with many medical disorders are scarce. Well-validated questionnaires about sexual dysfunction, tested in a range of languages, have only recently become available. Some questionnaires focus on genital issues rather than subjective responses even though, in both men and women, the two do not always correlate.9, 10 Despite evidence to the contrary, the assumption that women regularly sense desire in between sexual experiences, as men do, is common.11, 12 Some investigators advocate that validated diagnostic methods should be revised to more accurately correspond to contemporary ideas about the sexual responses of men and women,13, 14, 15 and to up-to-date definitions of women's dysfunction (although these have yet been incorporated into official definitions of mental disorders).13 Many studies include only patients in stable relationships or those who are sexually active, and thus exclude those for whom sexual dysfunction has precluded sexual activities or relationships.

The available studies of the prevalence of dysfunctions are derived from clinical samples of widely varying size, with and without controls; the levels of evidence for treatment diverge widely. Throughout the series, we cite case-control prevalence studies and randomised controlled treatment trials, but where unavailable we refer to treatment based on open-label studies or clinical experience (personal and from published work) and note the limitations of the evidence.

Section snippets

Sexual function and dysfunction

Sexual dysfunction can herald serious underlying disease. Onset of erectile dysfunction, the most common sexual disorder in older men, is seen as a pointer to generalised endothelial dysfunction, which invites assessment of cardiovascular health and, in particular, the health of coronary arteries. One study showed that, of 132 men who received coronary angiographies, 45% had a history of erectile dysfunction, which preceded the diagnosis of coronary artery disease in 58% of these men.16 In a

Hypoactive sexual desire

Men and women have multiple incentives and reasons for initiation of, or agreement to have, partnered sexual activity.11, 12, 25 One reason is to fulfil desire, or so-called sexual drive, which is typically sensed daily or more often by young and middle-aged men and by women who are in the early stages of sexual relationships, but infrequently in most middle-aged women, despite the fact that they report satisfactory sexual lives.12, 26 Thus, the definition of hypoactive sexual desire disorder

Disorders of sexual response

Accepted models of human sexual response are circular, and consist of overlapping phases, in a variable order,3, 25 with some responses more characteristic of one sex than the other. Men (commonly) and women (sometimes) have a sense of desire at the beginning of a sexual experience. Although this desire might be absent initially, a person can become motivated to sexually engage.12, 25 Figure 168 shows that desire can be triggered later during the experience once the person is subjectively

Future directions

Both an increased understanding of sexual physiology and a wider acceptance that sexuality is often an important part of life might encourage physicians to routinely consider risk factors for sexual dysfunctions, to assess and manage those dysfunctions, and to avoid iatrogenesis. Improved assessment, which includes validated questionnaires revised to take account of contemporary views of sexual response, could increase our understanding of the prevalence of sexual dysfunction in different

Search strategy

We searched the MEDLINE, EMBASE, LILACS, and PubMed databases (2000–present) using the key words “sexual function”, “sexual dysfunction”, “sexual dysfunction—psychological”, “dyspareunia”, “sexuality”, “sexual disorders”, “sexual behaviour”, “ejaculation disorders”, “orgasmic disorders”, “sexual desire disorders”, “sexual arousal disorders”, and “Peyronie's disease” in combination with the diseases “hypertension”, “coronary artery disease”, “congestive cardiac failure”, “depression”,

References (177)

  • H Croft et al.

    A placebo-controlled comparison of the efficacy and effects on sexual functioning of sustained- release bupropion and sertraline

    Clin Ther

    (1999)
  • Y Drory et al.

    First acute myocardial infarction: comparison of sexual activity of women and men after first acute myocardial infarction

    Am J Cardiol

    (2000)
  • SJ Servoss et al.

    Triggers of acute coronary syndromes

    Cardiovasc Dis

    (2002)
  • JB Kostis et al.

    Sexual dysfunction and cardiac risk (the second Princeton Consensus Conference)

    Am J Cardiol

    (2005)
  • GMC Rosano et al.

    Comparison of trimetazidine plus sildenafil to chronic nitrates in the control of myocardial ischemia during sexual activity in patients with coronary artery disease

    Am J Cardiol

    (2005)
  • S Friedman

    Cardiac disease, anxiety, and sexual functioning

    Am J Cardiol

    (2000)
  • M Zamd et al.

    Sexual dysfunction amongst 68 Moroccan male hemodialysis patients: clinical and endocrine study

    Ann Endocrinol

    (2004)
  • BF Palmer

    Sexual dysfunction in men and women with chronic kidney disease in end-stage kidney disease

    Adv Renal Replace Ther

    (2003)
  • YS Peng et al.

    Sexual dysfunction in female hemodialysis patients: a multi-centre study

    Kidney Int

    (2005)
  • A Salonia et al.

    Sexual dysfunction is common in women with lower urinary tract symptoms and urinary incontinence: results from cross-sectional study

    Eur Urol

    (2004)
  • D Grady et al.

    Postmenopause hormones and incontinence: the heart and estrogen/progestin replacement study

    Obstet Gynecol

    (2001)
  • BC Eriksen

    A randomized, open, parallel group study of preventive effect of an estradiol-releasing ring (Estring) on recurrent urinary tract infections in postmenopausal women

    Am J Obstet Gynecol

    (1999)
  • P Kadioglu et al.

    Sexual dysfunction in women with hyperprolactinemia: a pilot study report

    J Urol

    (2005)
  • R Fogari et al.

    Sexual function in hypertensive males treated with lisinopril or atenolol: a cross-over study

    Am J Hypertens

    (1998)
  • MJ Taylor et al.

    Strategies for managing antidepressant-induced sexual dysfunction: systematic review of randomized controlled trials

    J Affect Disord

    (2005)
  • ML Chivers et al.

    A sex difference in features that elicit genital response

    Biol Psychol

    (2005)
  • F Montorsi et al.

    Erectile dysfunction prevalence, time of onset and association with risk factors in 300 consecutive patients with acute chest pain and angiographically documented coronary artery disease

    Eur Urol

    (2003)
  • SE Rosas et al.

    Prevalence and determinants of erectile dysfunction in hemodialysis patients

    Kidney Int

    (2001)
  • G Bellinghieri et al.

    Ultra-structural changes of corpora cavernosa in men with erectile dysfunction in chronic renal failure

    Semin Nephrol

    (2004)
  • R. Rosen et al.

    Lower urinary tract symptoms and male sexual dysfunction. The multinational survey of the aging male (MSAM–7)

    Eur Urol

    (2003)
  • HA Taylor

    Sexual activity and the cardiovascular patient: guidelines

    Am J Cardiol

    (1999)
  • E Akkus et al.

    Prevalence and correlates of erectile dysfunction in Turkey: a population-based study

    Eur Urol

    (2002)
  • RA Kloner et al.

    Effect of sildenafil in patients with erectile dysfunction taking antihypertensive therapy. Sildenafil study group

    Am J Hypertens

    (2001)
  • JS Kalsi et al.

    A nitric-oxide releasing PDE5 inhibitor relaxes human corpus cavernosum in the absence of endogenous nitric oxide

    J Sex Med

    (2005)
  • AM Traish et al.

    Are androgens critical for penile erections in humans? Examining the clinical and preclinical evidence

    J Sex Med

    (2006)
  • D Margel et al.

    Severe but not mild obstructive sleep apnoea is associated with erectile dysfunction

    Urology

    (2004)
  • H Gray

    Gray's Anatomy: the classic collector's edition

  • F Wschiansky et al.

    Troubles érectiles: place de l'ensemble organique et psychologique. [Erectile dysfunction: the place of the organic and the psychologic.]

    Med Hyg

    (2004)
  • R Basson

    Human sex response cycles

    J Sex Marital Ther

    (2001)
  • MA Cranston-Cuebas et al.

    Cognitive and affective contributions to sexual functioning

    Ann Rev Sex Res

    (1990)
  • RHW van Lunsen et al.

    Genital vascular responsiveness in sexual feelings in midlife women: psychophysiologic, brain, and genital imaging studies

    Menopause

    (2004)
  • C Meston

    Why humans have sex

    Arch Sex Behav

    (2006)
  • VS Cain et al.

    Sexual functioning and practices in multi-ethnic study of midlife women: baseline results from SWAN

    J Sex Res

    (2003)
  • R Basson et al.

    Definitions of women's sexual dysfunction reconsidered: advocating expansion and revision

    J Psychom Obstet Gynaecol

    (2003)
  • RC Rosen

    Assessment of sexual dysfunction in patients in benign prostatic hypoplasia

    BJU Int

    (2006)
  • WA Blumentals et al.

    Should erectile dysfunction be considered as a marker for acute myocardial infarction? Results from a retrospective cohort study

    Int J Impot Res

    (2004)
  • JJDM Van Lankveld et al.

    Psychiatric comorbidity in heterosexual couples with sexual dysfunction assessed with the composite international diagnostic interview

    Arch Sex Behav

    (2000)
  • A Soykan et al.

    Do sexual dysfunctions get better during dialysis? Results of a six-month prospective follow-up study from Turkey

    Int J Impot Res

    (2005)
  • P Enzlin et al.

    Sexual dysfunction in women with type I diabetes

    Diabetes Care

    (2002)
  • DO Perkins

    Predictors of noncompliance in patients with schizophrenia

    J Clin Psychiatry

    (2002)
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