SEXUALITY IS A BASIC HUMAN INSTINCT. THIS FACT does not change for patients with disabilities despite changes in sexual function which may arise as a result of their medical condition. It is the duty of physicians to ensure all patients with sexual dysfunction, including those with disabilities, are given the appropriate evaluation, diagnosis, and treatment options with the hope of ultimately providing them with a better quality of life.
As with all patient interviews, it is important to maintain appropriate bedside manner, especially given the sensitive nature of this topic. A discussion on sexual dysfunction should be approached with tact and cultural competency. For structured guidance to beginning this discussion with patients, one may consider using the “ALLOW,” “PLISSIT,” or “BETTER” models.1,2 The initial evaluation begins with the chief complaint, which is the specific change in sexual function that is causing distress. Then, the line of questioning should progress to the history of present illness of the sexual dysfunction. This includes information regarding a typical sexual encounter, frequency, and time course of the problem—if it is partner-based or during masturbation, if it is situational or generalized, how it has influenced the patient’s quality of life, and strategies or medications that have been tried previously (see Table 85–1).
| Assure confidentiality and be nonjudgmental |
| Remind patients of why the information is clinically relevant |
| Be specific and use nonmedical terminology |
| Ask about sexually transmitted diseases as well as preventive and sexual risk behaviors, including type of sex, condom use, and number and types of partners |
| Make no assumptions based on patient characteristics |
| Explore situations that place individuals at increased risk (e.g., alcohol or substance use) and, together, develop a concrete risk-reduction plan |
| Use direct questions such as, “Do you have sex with men, women, or both?”; “How many partners have you had in the past 2 months, past 1 year”; and “How do you protect yourself from getting STDs?” |
Alternative sources of information include the patient’s sexual partner if the patient is agreeable and the Brief Sexual Symptom Checklist self-report tool that patients can fill out.1 Information regarding the patient’s sexual history also provides appropriate context for the sexual dysfunction. It should include the age of the first sexual experience, types of sexual practices, frequency of masturbation, gender of partners, history of sexually transmitted diseases, safe sex practices, and method of birth control used. When obtaining the past medical history, it is important to directly ask about medical conditions that could be related to sexual dysfunction. This includes, but is not limited to, cardiovascular disease, hyperlipidemia, hypertension, diabetes, cancer, neurological conditions, endocrine deficiencies, psychiatric disorders, benign prostatic hypertrophy in men, and gynecological disease or menstrual problems in women. It is also important to inquire about past surgical history, family history, history of substance use, psychosocial history, and medication history. In particular, questions about major life stressors, relationship dynamics, and history of abuse, sexual trauma, and domestic violence should also be addressed.
When performing the physical examination, special attention should be placed on findings that can help guide the physician to a possible etiology. Therefore, it is important to comprehensively evaluate the genital, nervous, cardiovascular, endocrine, and musculoskeletal systems along with the standard physical examination. The male genital examination involves evaluation of the penis, testes, and rectum. When evaluating the penis, one should assess for penile lesions, urethral position, and fibrous plaques (indicating Peyronie’s disease). When examining the testes, one should evaluate for position, size, lesions, and masses. Pelvic floor muscle tenderness and strength, sphincter tone, and prostate evaluation are performed during the rectal examination. The female genital examination involves a pelvic and rectal examination.
One should be aware that women who experience chronic pain with intercourse have significantly more physical and emotional difficulty with the pelvic examination. The pelvic examination begins with inspection of the external genitalia for findings that could indicate the possible etiology of sexual dysfunction such as episiotomy or child birth scarring or strictures, external dermatological lesions, or inflammation or atrophy of the vulva. The internal vaginal examination involves evaluation of resistance to insertion, tenderness of the levator ani and obturator internus, pelvic floor muscle function evaluation (strength, coordination, and tone), presence of pelvic organ prolapse, and uterine or adnexal tenderness or masses.
The rectal examination can be used to assess anal sphincter tone and pelvic floor muscle function and tenderness. A thorough examination for signs of sexually transmitted disease (STD) or infection (rashes, discharge, and ulcerations) should also be included for both men and women. The neurological examination includes evaluation of mental status, muscle tone, coordination, motor testing, sensory testing (light touch, pinprick, and proprioception), and reflexes (limbs, anal wink, and bulbocavernosus). In particular, the sensation of the T11–L2 and S2–S5 dermatomes is significant given it represents the sympathetic and parasympathetic outflow tracts. Findings on exam that could indicate cardiovascular disease include obesity, diminished peripheral pulses, hypertension, and lower extremity edema. Thyromegaly and gynecomastia can be signs of endocrinopathies. Evaluation of the musculoskeletal system includes assessing the range of motion of joints such as the hip, knee, shoulder, and hand. It is important to be aware that the physical examination can be normal in patients with sexual dysfunction.
As with all diagnostic evaluation, when considering testing for sexual dysfunction, one must assess whether it will alter the treatment plan or outcomes prior to ordering costly and complicated studies. Basic laboratory testing for patients with sexual dysfunction should begin with complete blood cell count, chemistry panel, fasting glucose, and fasting lipid panel. Testing can then be expanded to include thyroid studies, serum free testosterone, prolactin, prostate specific antigen, vaginal wet mount for women, and/or screens for gonorrhea, chlamydia, and HIV based on the history and physical. If there is concern for uterine or adnexal abnormalities in women, pelvic ultrasound can be used for evaluation. Special tests for the evaluation of male sexual dysfunction may include penile color duplex ultrasound and/or nocturnal penile tumescence monitoring. Infrequently used and more invasive procedures include pharmacoarteriography, pharmacocavernosometry, pharmacocavernosography (PHCAS or PHCAG), and electrodiagnostic testing. The use of these tests is based on the suspected etiology and the utility of the procedure to alter treatment plan such as possible surgical options for erectile dysfunction (ED). For example, if vasculogenic ED is suspected based on history and physical, a penile color duplex ultrasound could be considered. These tests can also be used to rule out psychogenic ED. For example, if a patient with ED can attain erections on nocturnal penile tumescence monitoring, then it is more likely that the etiology is psychogenic and not organic.
To diagnose a patient with sexual dysfunction, the problem must be present 75% to 100% of the time, be present for 6 months or more, not be better explained by an alternative diagnosis, and result in significant distress for the patient (based on the Diagnostic and Statistical Manual, fifth edition (DSM-5) criteria).3 For the diagnosis of substance-/medication-induced sexual dysfunction, there is an exception for the time requirement, and instead it requires the onset of the symptoms to correlate with medications use.3 The DSM-5 criteria help further subcategorize each diagnosis of sexual dysfunction into different classifications for men and women and different subtypes such as lifelong versus acquired and generalized versus situational.3 Tables 85–2 and 85–3 list the definition and prevalence for the different categories of sexual dysfunction listed in the DSM-5.3
| Categories | Male Hypoactive Desire Disorder | Premature (Early) Ejaculation | Delayed Ejaculation | Erectile Disorder/Dysfunction (ED) |
| Definition | Persistent or recurrent deficiency or absence of sexual thoughts/fantasies and desire for sexual activity | Persistent or recurrent ejaculation about 1 minute or less after intravaginal penetration and before it was desired | Persistent or recurrent undesired delay, infrequency, or absence of ejaculation despite adequate stimulation and desire | Presence of at least one of the following:
|
| Prevalence | Prevalence ranges from 0% to 15%.4 | Prevalence is 1%–3% based strictly on intravaginal ejaculatory latency time (IELT) and 30% based on self-reports.5,6 | The prevalence ranges from 0.15% to 11%.7 | The estimated prevalence of ED varies from 5% to 52%.4 |
| Categories |
| Female Orgasmic Disorder | Genito-Pelvic Pain/Penetration Disorder |
| Definition |
| Persistent or recurrent delay, infrequency, or absence of orgasm or markedly diminished intensity of orgasmic sensations from any type of stimulation despite the self-report of high sexual arousal/excitement | Persistent or recurrent difficulties with vaginal penetration, genito-pelvic pain during vaginal intercourse or other penetration attempts, fear or anxiety of genito-pelvic pain in anticipation of, during, or resulting from vaginal penetration, and/or increased pelvic floor tension during attempted vaginal penetration. This encompasses the former diagnoses of dyspareunia and vaginismus. |
| Prevalence | The prevalence ranges from 4% to 42%.4 | Prevalence of dyspareunia and vaginismus was reported to be 3%–18% and 1%–6%, respectively.4,9 |
It is important to keep in mind that sexual functioning can be influenced by many factors simultaneously. Therefore, when evaluating patients with sexual dysfunction, one should consider primary physical changes from the disease pathophysiology, secondary physical limitations/indirect effects of the disease process, psychosocial contributions, comorbid conditions, and medication-related factors. Sexual dysfunction in the setting of specific disease states will be discussed in the following sections.
Sexual dysfunction after stroke can be due to complications of the stroke itself (hemiparesis, hemineglect, hemianopsia, neurogenic bowel and bladder, and spasticity) or could be related to medical comorbidities, medications, or psychosocial factors.10 Overall, there is a decrease in frequency of sexual activity and sexual drive in both genders post stroke, and interestingly, spouses of patients with stroke also have been found to have decreased sexual drive.11 Following stroke, 40% to 50% of males experience erectile or ejaculatory dysfunction, 50% of women experience decreased vaginal lubrication, and 20% to 30% of women experience decreased orgasm.11 However, increased libido has been reported in 10% of stroke patients and is commonly associated with temporal lobes lesions and subthalamic or bilateral thalamic infarction.12
Generally, after SCI, both women and men will experience a decrease in frequency and satisfaction of sexual activity. However, this does not mean every SCI results in the same change in sexual functioning. Each SCI patient must be individually evaluated because the level and completeness of the injury determines the type of sexual dysfunction experienced. Intact reflexogenic erections are dependent on preservation of the parasympathetic sacral reflex, and intact psychogenic erections and ejaculation depend notably on the preservation of the thoracolumbar sympathetic outflow tract. Therefore, given sparing of the parasympathetic sacral reflex with upper motor neuron (UMN) SCI, reflexogenic erections are mostly unaffected. Whereas, preservation of thoracolumbar sympathetic outflow tract with lower motor neuron (LMN) SCI will result in psychogenic erections and ejaculation being more likely intact. Table 85–4 lists the results of a study by Bors and Comarr13 that examined the prevalence of erectile and orgasmic dysfunction in men with SCI.
| Reflexogenic Erections | Psychogenic Erections | Ejaculation | Orgasm | |
| Complete UMN | 93% | 0% | 4% | 38%–50% |
| Incomplete UMN | 99% | 19% | 32% | 78%–84% |
| Complete LMN | 0% | 26% | 18% | 0% |
| Incomplete LMN | 90% | 70% | – |
Similarly for women with SCI, intact reflexogenic lubrication is likely dependent on preservation of the parasympathetic sacral reflex. Also, intact psychogenic lubrications depends notably on the thoracolumbar sympathetic outflow tract, which can be predicted by the preservation of sensation in the T11–L2 dermatomes.14 Therefore, in women with complete UMN injuries, reflexogenic lubrication remains intact but psychogenic lubrication does not. In regards to orgasms, even though overall 44% to 54% of women with SCI are able to achieve orgasm, women with LMN injuries affecting S3–S5 segments are less likely achieve orgasm.14
Men with SCI can have decreased ability to ejaculate and decreased semen quality (decreased sperm motility, decreased mitochondrial activity, and increased sperm DNA fragmentation), therefore, fertility is often impaired.15 For women, fertility is dependent on menstruation. Therefore, even though fertility is initially impaired post injury, it returns to baseline after approximately 5 months when menstruation typically restarts.16
Sexual dysfunction following TBI can be directly due to the damage of brain tissue or indirectly related to depression, perceived health status and quality of life, low self-esteem, anxiety, or perceived decline in personal sex appeal.10 Given the wide range of types and severity of TBI, the reported prevalence rate of sexual dysfunction with TBI varies greatly—from 4% to 71%.17 However, there is no consistent correlation between injury severity and sexual dysfunction.17 Patients with TBI may experience decrease in sexual desire, decrease in frequency of sexual activities, ED and ejaculatory dysfunction in men, and dyspareunia, anorgasmia, and reduced lubrication in women.10 On the other hand, patients with injuries to the limbic system, prefrontal regions, or bilateral temporal poles may experience hypersexual behavior.
Sexual dysfunction in MS patients was initially ascribed to the location and duration of the brain or spinal cord lesion, but it is now believed to be multifactorial. Therefore, sexual dysfunction in MS is appropriately broken up into three categories based on the factors resulting in the change in sexual functioning (Table 85–5).19
| Category | Sexual dysfunction related to: |
| Primary | Neurologic impairments in libido, lubrication, and orgasm |
| Secondary | Fatigue and physical limitations such as bowel and bladder dysfunction, weakness, numbness, paresthesias, pain, cognitive impairment, and incoordination, positioning, and body control during sexual encounter.18 |
| Tertiary | Psychological, emotional, and social impact of MS.18 |
The prevalence of MS-induced sexual dysfunction in men and women is 50% to 90% and 40% to 80%, respectively.19 More specifically, women with MS may experience decreased sexual desire, decreased vaginal lubrication, increased spasticity with sexual encounters, and anorgasmia.10 While men with MS may experience decreased sexual drive, ejaculatory dysfunction, orgasmic dysfunction, and decreased genital sensation.10
Post amputation patients experience both sexual dissatisfaction (13%–75% of amputees) and increased sexual dysfunction, which can be due to comorbid conditions (diabetes, cardiac disease), medications treating comorbidities, or the amputation itself.20 The amputation can affect sexual functioning due to phantom sensations and pain, problems with balance/movement, issues with positioning, and psychological changes (depression, poor self-esteem/body image). If possible, preserving the knee joint helps improve balance issues during sexual activity. If not, pillows can be utilized by transfemoral amputees. Positions such as supine or lateral decubitus might be more beneficial for upper limb amputations because it allows free movement for the residual limb and the intact arm.21
Diabetes is likely a risk factor for sexual dysfunction given its association with vasculopathy, autonomic neuropathy, and decreased nitric oxide production leading to neurogenic vasodilation.18 Men with DM have been reported to have ED (prevalence of 35%–75%), premature ejaculation (prevalence of 40%), and hypoactive sexual desire disorder (prevalence of 25%).22 Men with DM are three times more likely to have ED than the general population and are affected by ED 10 to 15 years earlier than non-diabetics.23 Poor glycemic control, longer duration of DM, and diabetic complications are possible indicators for sexual dysfunction in men with diabetes.24 Women with diabetes have been reported to have sexual arousal disorder and decreased lubrication.25
Hypertension (HTN), coronary artery disease, and congestive heart failure are common comorbidities in patients with sexual dysfunction. ED is considered an early indicator of cardiovascular disease.18 In regards to prevalence, 42% to 75% men with HTN have been reported to have ED, and 25% to 63% of women with cardiac disease experience sexual dysfunction (decreased sexual desire, vaginal dryness, dyspareunia, decreased genital sensation, and decreased orgasmic ability).18,26 Sexual dysfunction may also be related to psychological issues such as depression and anxiety after myocardial infarction or fear of recurrence of cardiac problems with sexual activity.
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