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”,
SeriesSexual sequelae of general medical disorders
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 However, the traditional dualistic notion that sexual dysfunction has either psychological or organic origins has been replaced by an understanding that the two are inseparably combined.2, 3 Psychological factors such as personality, coping style, and external stressors can modulate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
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