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A system should be in place for obtaining followup information from patients on the use of medications, use of healthcare services, return to gainful employment, functional activities, ability to manage pain, and subjective pain intensity. Provisions should also be made for periodic contact after discharge. Program evaluation should encompass goals and objectives that are achievable and end results that are measurable. A program evaluation report should include primary objectives, measures, time of measurement, source of information, and expectancies as well as outcome.
BIBLIOGRAPHY

I . Accident Rehabilitation and Compensation Insurance Corporation and the National Health Committee: New Zealand Acute Low Back Pain Guide. Wellington, New Zealand, AAC and NHC, 1997. 2. American Academy of Pain Medicine and American Pain Society Consensus Statement: The use of opioids for the treatment of chronic pain. Pain Forum 6:77-79, 1997. 3. Cicala RS, Wright H: Outpatient treatment of patients with chronic pain: An analysis of cost savings. Clin J Pain 5:223-226, 1989. 4. Commission on the Accreditation of Rehabilitation Facilities: Standards Manual for Organizations Servicing People with Disabilities, Tucson, Arizona, CARF, 1999. 5. Fishbain DA, Cutler R, Rosomoff HL, Rosomoff RS: Chronic pain-associated depression: Antecedent or consequence of chronic pain? A review. Clin J Pain 13: 116-137, 1997. 6. Follick MJ, Ahern DK, Aberger EW: Behavioral treatment of chronic pain. In Blumenthal JA, McKee DC (eds): Applications in Behavioral Medicine and Health Psychology: A Clinicians Source Book. Sarasota, Florida, Professional Resource Exchange, Inc., 1987, pp 237-270. 7. Fordyce WE (ed): Back Pain in the Workplace: Management of Disability in Nonspecific Conditions. Seattle, International Association for the Study of Pain Press, 1995. 8. Gatchel RJ, Turk DC (eds): Psychological Approaches to Pain Management: A Practitioners Handbook. New York, The Guilford Press, 1996. 9. Jamison R N Learning to Master Your Chronic Pain. Sarasota, FL, Professional Resource Press, 1996. 10. Jamison RN: Mastering Chronic Pain: A Professionals Guide to Behavioral Treatment. Sarasota, FL, Professional Resource Press, 1996. 1 I . Karoly P, Jensen MP: Multimethod Assessment of Chronic Pain. New York, Pergamon Press, 1987. 12. Nigl AJ: Biofeedback and Behavioral Strategies in Pain Treatment. New York, Spectrum Publications, Inc., 1984. 13. Turk DC, Melzack R (eds): Handbook of Pain Assessment. New York, The Guilford Press, 1992.

70. THE ASSESSMENT AND TREATMENT OF SEXUAL DYSFUNCTION

Thomas D.Stewart, M.D
1. Can sexual dysfunction be a symptom of medical illness? Yes. Sexual dysfunction is a neglected vital sign in medical history taking. It can be the first presenting symptom for conditions as diverse as diabetes mellitus, temporal lobe epilepsy, multiple sclerosis, and thyroid dysfunction. 2. Describe a framework for the clinical evaluation of sexual dysfunction. Masters and Johnsons well-known sexual response cycle provides a paradigm for understanding and treating sexual dysfunction: Appetitive phase-involves noticing attractive people and having an intact libido. There are no specific physiologic responses. Excitement-is marked by vascular engorgement and lubrication in women and erection in men. These responses, associated with flushed skin, intensify and reach a plateau phase before orgasm.

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Orgasm-is associated with pelvic muscle contraction and pleasure and is accompanied by ejaculation in men. Resolution-genital vascular engorgement gradually abates. The exercise involved in sex can cause perspiration in all phases, but only in the resolution phase is sweating a specific, associated finding, regardless of exercise levels. All sexual dysfunctions are connected with one or more phases of this response cycle.
3. Name medical conditions that disrupt the appetitive phase. Which medications are corrective? Hypoactive sexual desire disorder can be caused by temporal lobe epilepsy, hyperprolactinemia, and hypogonadotropic hypogonadism. Carbamazepinecan stabilize temporal lobe input to the anterior pituitary gland, which has been disrupted by the complex partial seizures of temporal lobe epilepsy. This stabilized input allows the anterior pituitary to increase luteinizing hormone (LH) release, leading to increased production of testosterone from Leydig cells found in the testicles. Testosterone regulates libido in both sexes. Bromocriptine, a D agonist, can reduce prolactin levels coming from pituitary microadenomas. Intramuscular testosterone offsets the low testosterone levels resulting from low LH production in hypogonadotropic hypogonadism. These medications can restore sexual desire by correcting the underlying medical problem. Medications (e.g., alpha methyl dopa) also can impair libido. Libido is reduced in psychiatric conditions such as depression, anxiety, and post-traumatic stress disorder. Psychotropic medications can restore libido lost through mental illness. Proper use of psychotropics helps improve mood and reduce apprehension that underlies loss of desire.

4. What are the analogies between the excitement phase in men and women?
Erections, vaginal engorgement, and lubrication are analogous. They are similar from both embryologic and physiologic perspectives. The work-up for disorders of the excitement phase in men and women (see Questions 7-9) is virtually identical.

5. Which factors in the medical history might contribute to an impaired excitement phase? Here is a rule of thumb: if something is bad for the heart, it is bad for erections, lubrication, and engorgement. For example, smoking, diabetes, alcohol abuse, hypertension, and hyperlipidemia are associated with excitement phase dysfunction.
6. Name physical findings connected with erectile dysfunction. Gynecomastia, hypogonadism, hyperreflexia, reduced peripheral pulses, and loss of sensation.

7. What constitutes an endocrine work-up for impairment of the sexual excitement phase? Thyroid function, liver function, and glucose tolerance tests. Also serum testosterone and prolactin levels.
8. What are some vascular studies that shed light on the etiology of sexual arousal impairment? There are several, including Doppler determination of penile blood flow, and penile blood pressure compared to brachial blood pressure. Penile angiography can spot arterial occlusion. Venous cavernoscopy can pinpoint venous valvular incompetence that leads to impotence. Internal iliac angiography can identify arterial occlusions that impair erections or lubrication.

9. List some medication categories that can disrupt the excitement phase. Beta blockers, such as inderal; anticholinergics like tricyclic antidepressants, low-potency phenothiazines, and selective serotonin reuptake inhibitors (SSRIs); and diuretics such as hydrochlorothiazide.
10. What is a nocturnal penile tumescence (NPT) study? The NPT is a sleep study usually done over at least two nights. A donut-shaped plethysmographic device is placed over the penis. It transduces erectile pressure changes into graphic data. The

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sleep EEG records rapid eye movement sleep that is associated with firm erections in healthy subjects. This study can demonstrate physiologically intact erectile function, which may be undermined by psychogenic factors such as anxiety in the waking state.

11. Is the NPT really the gold standard for separating organic from psychogenic sexual dysfunction? The NPT is subject to false-positives. Consider the format for this study: a man sleeps in a strange bed with electrodes glued to his hair. He has a gel-filled donut around his penis. Should he have the good fortune to achieve an erection while sleeping in the EEG lab, a technician emerges and checks the buckling pressure. Is it any surprise that there are false positives? In addition, clinical anxiety and depressive disorders cause abnormal results in men known to be physiologically intact. Furthermore, results of the NPT may not correlate with known functional capabilities. While the NPT is sometimes a helpful diagnostic tool, it is not a gold standard.

12. Name some antihypertensive medication categories that do not appear to cause excitement-phase dysfunction. ACE inhibitors (enalapril, captopril), calcium channel blockers (verapamil, diltiazem), and alpha antagonists (terazosin, prazosin). The latter category may help potency and lubrication.
13. What are some practical techniques for improving sexual functioning in the excitement phase? Water-soluble lubricants can help women with problems in arousal. These lubricants do not linger and dissolve diaphragms and condoms as oils do. Men can enhance their erections by pushing down their index and third finger at the base of the penis, thus partially occluding venous return. This method requires females to be in a superior position for intercourse, with their bodies at a 45" angle to their partners and their weight on their arms. 14. Which medications restore erectile function? Intraurethral application of alprostadil, a prostaglandin E derivative vasodilator, can enhance erections for previously impotent men with relatively intact vasculature. These erections occur in the absence of sexual stimulation, but are enhanced by it. The dosage range is 500-1000 mcg. Sildenafil is an oral medication that enhances erection by inhibiting the metabolism of cyclic guanosine monophosphate, which relaxes genital arteriolar smooth muscle, producing vasodilatation and erection. Sildenafil has no effect in the absence of sexual stimulation. Studies are underway to assess its possible beneficial effects for enhancing female arousal states. Side effects include flushing, dyspepsia, and headache. Priapism has not been reported. Sildenafil is contraindicated in patients receiving nitrates used to treat chest pain. The dosing range is 50-100 mg. 15. Does sildenafil have benefits beyond enhanced erections? Yes. There is evidence that overall sexual satisfaction and quality of climaxes are improved. There is an open-label trial that demonstrates improvement in orgasmic function in those with SRIinduced orgasmic dysfunction.

16. What is a vacuum constriction device? It is a plastic tube, closed at one end, that is placed over the penis. Vaseline forms a seal between the device and the mons pubis. Air is pumped out of the tube, creating a partial vacuum. Within 5-10 minutes an erection develops. A constriction band is then placed at the base of the penis, and the vacuum is released, allowing removal of the tube. This erection allows vaginal penetration for 20-30 minutes. The erections produced by these devices are wider and shorter than those that occur naturally. They are light blue and cool to touch. Complications include pain and bruises. Several studies have demonstrated their safety and effectiveness.

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17. What does a psychodynamic approach to excitement disorders involve? Psychodynamic psychotherapy can help resolve unconscious conflicts over sexual expression, leading to restored responsiveness. This method explores the meaning of potency and arousal, along with fears avoided by not having intercourse. 18. Give an example of a behavioral approach to arousal dysfunction. Masters and Johnson have described a behavioral approach that emphasizes deconditioning stress-related responses that impair sexual functioning. Couples are encouraged to stop attempting relations and to start sensate focus explorations of how to please each other without genital contact. As they become more comfortable, they progress to more overtly sexual contact according to a protocol designed to enhance feelings of safety and control. Helen Singer Kaplan modified this technique to include more exploration of individual and couple dynamics and patterns of communication. Kaplan uses deconditioning techniques to treat sexual dysfunction similar to those emphasized by Masters and Johnson. Her method includes more evaluation and treatment of maladaptive patterns of communication that interfere with a couples relationship in and out of bed. It also considers the individual, psychodynamic, conflictual issues germane to sexual dysfunction. Couples benefit from understanding each others irrational fears of sexual activity as uncovered with Kaplans approach.
19. What are some vascular interventions to restore excitement phase function? Balloon angioplasty can open the internal iliac arteries leading to restored potency or lubrication. Repair of incompetent venous valves, the most common vascular cause of impotence, can restore erectile function.

20. Describe penile intracavernosal injections used to restore erectile function. A vasodilator, such as phentolamine and yohimbine, or prostaglandin E is injected through 29gauge needles into the corpora cavernosum at 3 oclock and 9 oclock. The urethra is at 6 oclock, and the dorsal artery of the penis at 12. Injection at 12 or 6 would cause injury, whereas injection at 3 or 9 allows safe entry into the corpora cavemosa. Prostaglandin E is locally metabolized in the corpora cavernosa and thus less apt to cause priapism than the other agents, which must enter systemic blood flow to be metabolized in the liver. Prostaglandin E also can be dose adjusted to control the duration of erection, but it may cause a burning sensation at the injection site. 21. What are complications of these injections? There is a low risk of priapism. There can be painful bruising and the development of fibrosis, leading to adhesions with Peyronies disease, a condition characterized by painful curvature of the penis during erections.
22. Describe penile prostheses. Penile prostheses are now in widespread use; well over 100,000have been installed. Implants vary in design. Some have wire inside silastic to allow the penis to be moved into position. Others are inflatable to allow a more normal appearance. Surgical complications following the insertion of prostheses are remarkably rare, even in diabetics. Postoperative infection and erosion through the skin are the main complications. Several studies indicate that patient and partner satisfaction with these devices exceeds 80%. 23. What are some expectations men may have about these devices that lead to disappointment? It will make her respond. 1 will regain my self-esteem. I will now have something to offer her. Should a urologist recommend placement of a phallic prosthesis, the consulting psychiatrist should carefully explore the patients expectations regarding this operation. These expectations are

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likely to lead to disappointment if not combined with a concern for the quality of relationship which these men want to achieve with their partners. Patients should be strongly encouraged to discuss the prosthesis with their partners so as to gather their feelings about this device. One woman surprised her partner by saying, Your message is more important than your method. She was clear that she wanted him and not a prosthetic device.

24. Are there sexual dysfunctions specific to the plateau phase? No, disruptions of this phase are secondary to malfunctions in other phases. Disorders of excitement undermine the evolution of the plateau phase. Orgasmic dysfunction prolongs the plateau phase in both genders, leading to discomfort and irritability secondary to lack of release of sexual tension and genital engorgement.

25. What are some causes of orgasmic phase dysfunction?

Peripheral neuropathy, psychodynamic conflict, and medications.

26. What are some medications that cause orgasmic dysfunction? SSRIs (fluoxetine, paroxetine, and sertraline), monoamine oxidase inhibitors (phenelzine, tranylcypromine), and anticholinergic agents (low-potency neuroleptics, tricyclic antidepressants), can inhibit orgasm. Alpha 2 blockers such as trazadone, prazosin, and thioridazine can impair sperm emission by paralyzing the vas deferens.
27. What helps restore orgasm in patients on SSRIs? Four milligrams of cyproheptadine, a serotonin antagonist, taken 30 minutes before sexual activity has been reported to help. 28. Are there other antidepressantswith few autonomic side effects that are less apt to impact sexual function than SSRIs? Yes. Examples are nefazadone and bupropion.

29. What are some treatments for premature ejaculation? SSRIs have been reported to help. Masters and Johnson describe a behavioral method designed
to help a couple achieve mastery over ejaculation timing. This technique features deconditioning the anxiety that leads to premature ejaculation. The male communicates to his partner that he is close to ejaculation, and the partner then stops the stimulation, squeezes the glans with the index and third fingers, and presses the urethra with the thumb. The couple can gradually prolong sexual activity before orgasm with this method.

30. Is there a disorder of the resolution phase? Yes, priapism is an erection that does not go away. It can be caused by alpha blockers, such as trazodone, and penile injections (described in Questions 19 and 20).

CONTROVERSY
31. Is sildenafil safe for treatment of erectile dysfunction? No: There have been several reports of sudden death following the use of sildenafil. The fatal scenario often involves a man with coronary artery disease (CAD) and poor physical fitness. He becomes sexually active with the aid of sildenafil and suffers a myocardial infarction (MI) as a result of this activity. Emergency medical professionals give intravenous nitrates to this man as part of routine management. The man does not tell them he just took sildenafil. He then becomes hypotensive with an acutely damaged heart. He dies in cardiovascular shock. Yes: Properly used, sildenafil is a safe medication, even for those with hypertension and CAD. It was developed initially to treat angina, and it was shown to be safe as long as it was not used in conjunction with nitrates. In phase I1 placebo-controlled studies of 2722 patients taking nonnitrate

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antihypertensive medications, the discontinuation rate for adverse cardiovascular events for sildenafil was equal to that for placebo. In these same studies, the incidence of MI for those using sildenafil was 1.7 per 100 man years of treatment, versus 1.4 for those on placebo-yielding no statistically significant difference between the two groups. Open-label sildenafil studies provided an even lower rate of MI: 1 infarction per 100 man years. Sildenafil clearly is safe as long as it is properly prescribed. Patients receiving sildenafil must be able to tolerate moderate exercise and must not receive nitrate agonists. BIBLIOGRAPHY
I . Condra M, Morales A, Surridge D, et al: The unreliability of nocturnal penile tumescence recording as an outcome measurement in the treatment of organic impotence. J Urol 135:280-282, 1986. 2. Drugs that cause sexual dysfunction. Med Lett 34:73-78, 1992. 3. Fava M, Rankin M, Alpert J, et al: An open trial of oral sildenafil in antidepressant-induced sexual dysfunction. Psychother Psychosom 67:328-331, 1998. 4. Goldstein I, Lue TF, Nathan-Padma H, et al: Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 338:1397-1404, 1998. 5. Kaplan HS: The New Sex Therapy. Active Treatment of Sexual Dysfunction. New York, Bruner/Mazel, 1974. 6. Masters W, Johnson V: Human Sexual Inadequacy. Boston, Little Brown, 1970. 7. Morales A, Gingell C, Collins M. et al: Clinical safety of oral sildenafil citrate in the treatment of erectile dysfunction. Int J lmpot Res 1059-74,1998. 8. Nadig PW: Vacuum constriction devices in patients with neurogenic impotence. Sexuality Disability 12:99-105, 1994. 9. Nathan-Padma H, Hellstrom WJ, Kaiser FE, et al: Treatment of men with erectile dysfunction with transurethral alprostadil. N Engl J Med 336:l-7, 1997. 10. Rendell M, Rajfer J, Wicker P Sildenafil for treatment of erectile dysfunction in men with diabetes. JAMA 281:421-425, 1999.

7 1 . PSYCHIATRIC ASPECTS OF AIDS

Carl Clark, MD.

1. What are HIV and AIDS? Human immunodeficiency virus (HIV) is a retrovirus that infects humans and causes various clinical problems ranging from an asymptomatic carrier state to fatal immune deficiency. Acquired immunodeficiency syndrome (AIDS), the most serious form of HIV infection, results from progressive destruction of the immune system.

2. How does HIV act in the body?

HIV propagates best in lymphocytes and leads to the destruction of its host cell, primarily the CD4 helper-inducer cells. Destruction of CD4 helper-inducer cells impairs the bodys ability to mount an effective immune response. HIV also infects the central nervous system cells and leads to dysfunctions such as peripheral neuropathies and encephalopathies. Current treatments attempt to stop viral replication and maintain viral suppression in order to assist immune system functioning.

3. How is HIV detected?

HIV antibodies, which develop in most people in response to HIV infection, can be detected by two standard laboratory tests, the enzyme immunoassay (EIA, formerly ELISA, or enzyme-linked immunosorbent assay) and the Western Blot. The EIA uses a reactive serum and is regarded as positive if