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S pecial f ocus:
S e x u a l D y s f u n c t i o n
Since 1948, when sex researcher Alfred C. Kinsey, PhD,
PREVENTION AND SCREENING
All women should be screened for sexual dysfunction during
began publishing his seminal works on human sexual
a routine health maintenance exam. In addition to having the
The robust promotion of erectile dysfunction medications has
behavior, scientists have followed Dr. Kinsey’s lead into
same risk factors as men, women also may be at high risk
perhaps made it easier for patients to broach the subject of
because of genital pain caused by endometriosis, vaginis-
people’s bedrooms, hoping to learn what prevents
sexual dysfunction. But experts say that, for most patients,
mus, vulvodynia or interstitial cystitis, or by infections, such
them from thoroughly enjoying sexual encounters.
it’s up to physicians to “break the ice” and actively screen for
as candidiasis, bacterial vaginosis or chlamydia.
sexual dysfunction. (See also “Sex talks dos and don’ts,”
It might, however, be easier to eliminate the factors
that do not influence sexual satisfaction, rather than
A few questions can help guide your initial discussion. Ask
encompass all the ones that do. Besides the physical
patients, for instance, if they are happy with their sexual per-
For both men and women, use a comprehensive history and
issues, sexual response (or the lack thereof) is closely
formance and response. If patients are in a committed rela-
physical exam to look for common causes of sexual dysfunc-
tied to emotional and relational factors, as well as to
tionship—regardless of whether it’s heterosexual or homo-
tion, which include cardiovascular, endocrine, neurological
sexual—ask if any aspects of their sexual life have changed.
and urogenital disorders, and medication use.
Various diseases, including diabetes, heart disease,
Talk about displays of affection and whether any health prob-
Identifying the cause of sexual dysfunction will directly affect
multiple sclerosis and alcoholism, affect sexual per-
lems, the patients’ or their partners’, have interfered with
sexual expression. Studies have shown, for instance, that the
formance in both men and women. And medical
majority of men who suffer myocardial infarction are afraid
treatments can have a pronounced impact on the
that sex will bring on another heart attack.
quality of a patient’s sex life: As many as 80% of men
You can make an erectile dysfunction diagnosis when
treated for prostate cancer, for instance, experience
Ask patients who are single what their needs are for an inti-
patients have a consistent inability over the course of three
erectile dysfunction—a condition that also has
mate relationship, how they achieve sexual satisfaction, and
months to attain and maintain an erection sufficient for sexu-
been linked to the use of more than 300 prescription
what changes, if any, they have experienced in sexual desire.
al intercourse. The International Index of Erectile Function-5questionnaire may help you determine the severity (mild,
medications, including antidepressants and antihy-
Encourage all patients who have modifiable risk factors for
moderate or severe) of that dysfunction.
sexual dysfunction to try and change that risk. Both men andwomen should be urged to quit smoking, moderate alcohol
You also need to categorize the dysfunction’s cause as psy-
Men, at least, have a clear-cut definition of sexual
use, discontinue recreational drug use, and achieve blood
chogenic (psychological or interpersonal factors); organic,
dysfunction, as well as new drug therapy options. For
pressure control for hypertension and hyperglycemic control
resulting from endocrinological, neurological or vascular dis-
women, “[t]he word ‘dysfunction’ … suggests that
orders; or a combination of both. You can tailor laboratorytesting to a patient’s clinical situation, keeping in mind that
there is an acknowledged norm of female sexual
Make sure patients with chronic conditions—including
extensive testing—including specialized endocrinological
function,” according to a May 2004 article in the
rheumatoid arthritis, irritable bowel syndrome, low back pain
assessment—shouldn’t be performed routinely.
“Harvard Health Publications” series. “That norm has
or migraines—have adequate pain control, because chronic
never been established. Unlike penile erection, which
pain can interfere with sexual function. But remember that
For patients with a history of cardiac disease, assign them to
is a quantifiable physical event, a woman’s sexual
these patients also present a dilemma: While they need pain
a low, intermediate or high risk category, and manage that
response is qualitative.” (www.health.harvard.edu/
control, their medications can often lead to further sexual
risk before recommending sexual dysfunction treatment or
dysfunction. You may need to advise sex therapy for these
Those with low risk have, among other issues, confirmed
What is clear is that sexual dysfunction can impair
And see that patients receive appropriate treatment for psy-
hypertension, mild stable angina and fewer than three cardio-
patients’ mental and physical health, as well as their
chosocial issues such as depression, anxiety and any history
vascular risk factors. Those in the second tier have, among
quality of life. “Sexual dysfunction,” wrote Abraham
other factors, moderate angina, left ventricular dysfunction
Morgentaler, MD, in the June 23/30, 2004, Journal of
and/or class II congestive heart failure, and have experienced
Screen for sexual dysfunction in men with identifiable risk
the American Medical Association
(JAMA), “can lead
a heart attack within the last six weeks. The high-risk catego-
factors. These include chronic illnesses such as diabetes,
to depression and a profoundly altered sense of self-
ry includes patients with unstable or refractory angina, con-
heart disease, hypertension and decreased HDL cholesterol
gestive heart failure (class III or IV), obstructive cardiomy-
esteem that negatively affects many relationships”
levels; medications for those conditions; pelvic trauma or sur-
opathies and moderate to severe valvular disease.
gery; neurological disease or injury; and depression.
291/24/2994). And sexual dysfunction frequently isbrought on or aggravated by advanced age, a keyconcern for internists who treat older patients.
Despite the fact that physicians now routinely takepatients’ sexual history in attempts to diagnose sexu-
Kathleen Walsh, DO, a clinical assistant professor at the
to treat it. But they don’t always have to treat it—just
ally transmitted diseases, doctors often fail to ask
University of Wisconsin Medical School in Madison, spe-
acknowledging the problem can make a huge difference.”
patients about sexual function. A study published in
cializes in treating sexual dysfunction in women.
the Aug. 23, 2003, British Medical Journal,
On choosing between estrogen and testosterone treat-
On primary care physicians’ ability to diagnose and
found that 40% of female patients and 22% of male
ments: “I lean toward prescribing testosterone for treat-
treat FSD: “They are very competent if they read arti-
ing the libido and estrogen for perimenopausal dryness.
patients in 13 British general practices had a sexual
cles, know how to ask the important questions and
But you have to be careful treating perimenopausal
dysfunction diagnosis—but only 4% had that diagno-
determine the baseline evaluation. But very few do.
women with estrogen because of their fluctuating hor-
“At the same time, we assume that patients are sexually
mone levels. I start off prescribing low dosages until I
knowledgeable and competent, but many aren’t.
Some patients diagnosed with sexual dysfunction will
Physicians have to ask questions in such a nonjudgmen-
need to be referred to a subspecialist, but many
“Most physicians working in the area of sexual dysfunc-
tal way and setting—with the patient fully clothed, and
won’t. According to the JAMA article, primary physi-
tion believe a certain level of estrogen is necessary in
face to face—and that helps a patient feel comfortable
cians can treat most men with erectile dysfunction.
the body for testosterone to be effective.”
enough to discuss their sexual concerns. If they don’tapproach the patient the right way the first time, their
On classifying sexual dysfunction among women: “In
And they can treat their female patients as well.
patient will unlikely bring it up again.”
my practice, a conservative estimate among pre-
“Acknowledgement of sexual concerns is very impor-
menopausal women is 20%-30%, which includes low
tant for women,” said Kathleen Walsh, DO, a, clinical
On whether female sexual dysfunction is now more
libido, anorgasmia, diminished arousal and genital pain.
widely treated: “Over the last six years, I’ve seen a very
assistant professor at the University of Wisconsin
Among perimenopausal women, it increases to 50%, pri-
significant rise in physicians’ interest about sexual dys-
Medical School in Madison. “Physicians should
marily because of hormonal fluctuations. It could also
function and how to treat it. It takes only one or two
address the physical and psychological issues that
be that, after they’ve had sexual problems for years,
patients to bring up the topic of sexual dysfunction, and
may affect sexual dysfunction, such as hypertension,
women finally admit to them and seek help. In the post-
the physician usually tries to locate the literature or
peripheral vascular disease, depression and anxiety.
menopausal group, it drops down to 30%. Why? They
another clinician in the community to help. Many physi-
don’t have to worry about getting pregnant, and they
If it is a gynecological issue, such as vaginal dryness,
cians are frightened to talk about sexual dysfunction
have figured out what type of sexual stimulation works
with their female patients, because they don’t know how
As part of your clinical history, assess patients’ sexual history
for issues affecting desire, arousal, orgasm and pain. Using adiagnostic questionnaire—such as the Female Sexual
Arthur L. Burnett, MD, professor of urology and director
“The medications require some lead time. We know
Function Index (www.fsfi-questionnaire.com/) or the Brief
of the Male Consultation Clinic at Baltimore’s Johns
they typically have efficacy within one half hour or one
Index of Sexual Functioning for Women—can help qualify
Hopkins Medical Institutions, spoke with ACP Observer
hour, and the less food, the better. However, food does
patient information about dysfunction. You also should
about treating erectile dysfunction. He primarily treats
not affect the maximal serum concentration of tadalafil
explore the content of patients’ key emotional relationships.
patients who have undergone radical prostatectomies.
after it is taken because of the two-hour duration to
As with male patients, consider lab testing as part of a sys-
On differentiating among erectile dysfunction drugs:
tematic evaluation, and refer patients who need a specialized
“They are mostly interchangeable, they all work by the
On the impact of direct-to-consumer advertising:
same mechanism and action. Tadalafil has a longer half
“All the media events and societal changes have
life of degradation and is being billed as the “weekend
helped. At the same time, only a minority of men are
drug”—take it once and you’re good all weekend.
getting treated. We know that only 10%-25% of men
Sildenafil and vardenafil have four hours before they
with ED get treatment. Treatment barriers include the
are degraded by 50%; tadalafil has 17.”
absence of sexual activity for many years, fears of start-
Use non-drug therapies for all male patients, including:
ing relationships and other interpersonal issues. The
On drug dosing: “Physicians should use a midrange
interpersonal relationship looms over everything, and
■ Changing or discontinuing medications that adversely
dose. Sildenafil, 50 mg; tadalafil and vardenafil, 10 mg.
■ Treating any underlying medical condition.
Treatment efficacy estimates range from 50%-70% with silde-
levels before prescribing hormone supplements but monitor
Recommending lifestyle changes. One study found that
nafil; 98% for vacuum constriction devices; 30% for intrau-
more than 30% of obese men who lost weight and began
rethral therapy; 90% for intracavernous therapy; and 99% for
exercising regained their ability to have an erection, com-
There are also two dozen different investigational medica-
pared to only 5% in the control group.
tions and devices being tested for female sexual dysfunction
that include nasal sprays, creams, patches and devices.
Consider corrective surgery for pelvic or perineal trauma.
Before prescribing non-hormonal or investigational treat-
Other treatment strategies for erectile dysfunction follow a
Advise female patients to correct reversible causes of sexual
ments, thoroughly discuss potential benefits and side effects
dysfunction by making any necessary lifestyle or medication
consists of oral erectogenic agents, vacuum
constriction devices and psychosexual therapy. Drug thera-
Adjunctive non-drug therapies—including stimulation
py—with sildenafil, vardenafil or tadalafil—is an important
devices, biofeedback and psychotherapy—can help treat
■ Reevaluate the patient’s medical and psychosocial situa-
element in a comprehensive approach to erectile dysfunction.
identifiable disorders. For pain disorders, you can recom-
One randomized controlled trial of oral sildenafil in antide-
mend that patients vary sexual positions, use lubricants and
■ Assess any possible adverse drug reactions or interaction
pressant-associated sexual dysfunction found that 54% of
pursue pelvic floor physical therapy.
participants reported sexual function, compared to only 4.4%
While researchers have not found a “little blue pill” that can
■ Consider titrating the dosage or substituting another
address female sexual dysfunction, drug therapy can play a
All three drugs are contraindicated in patients taking nitrates.
significant role in treating women’s low desire, decreased
Experts point out that sildenafil does not have any contraindi-
■ Talk to patients about their treatment or any factors that
cation with alpha blockers, while tadalafil is contraindicated
contributed to the sexual dysfunction.
Consider estrogen therapy, including an estrogen ring, estra-
in patients taking terazosin-like drugs (except tamsulosin
diol tablets, transdermal patches or topical creams, for
hydrochloride), and vardenafil is contraindicated in patients
women who complain of vaginal dryness, burning, and uri-
taking all forms of alpha blockers. All three drugs have essen-
W h e n t o r e f e r
tially the same side effects, which include headaches andflushing.
Testosterone therapy remains controversial, but should be
For tips on when to refer patients with sexual dysfunc-
considered alone or in combination with estrogen in peri- and
tion to urologists, gynecologists, sex therapists or other
Second- and third-line therapies
are reserved for patients
postmenopausal women with decreased desire, dyspareunia
specialists, see the online version of Special Focus:
who don’t respond to one or more first-line treatments, or for
or lack of vaginal lubrication. (When prescribing testosterone,
Sexual Dysfunction at www.acponline.org/journals/
whom first-line therapies are contraindicated. Second-line
periodically obtain liver function tests and lipid panels to
therapy consists of intraurethral suppositories (alprostadil)
monitor for side effects.) Choosing between estrogen and
and intracavernous injections (alprostadil). Third-line therapy
testosterone treatment is primarily based on symptoms, like
low libido. Many physicians don’t obtain specific hormone
You can access PIER’s Erectile Dysfunction (http://pier.
acponline.org/physicians/diseases/d242/d242.html) and Sexual Dysfunction in Women (http://pier.acponline.org/physicians/diseases/d664/d664.html) modules online.
The module author for Erectile Dysfunction is Arthur L.
Module authors for Sexual Dysfunction in Women areKathleen E. Walsh, DO; Jennifer R. Berman, MD; and Laura A.
■ Raise the issue of sexual function, instead of waiting for
■ Assume that a patient of a different race or gen-
der is comfortable discussing sex with you, just
■ Be aware of your own attitudes and beliefs about sexuality.
The information included herein should never be used as a
■ Ask only yes/no questions. Frame questions so
substitute for clinical judgment and does not represent an
■ Stay conscious of your own body language and of what it
patients will be invited to share their experiences.
Keep information about sexuality available in the waiting
Assume that just because patients are older,
Normalize patients’ problems and let them know they are
Make light of or joke about patients’ sexual
Use the same terminology as the patient.
Assume that all patients are heterosexual.
Refer patients to a sex therapist if they need specialized
Share your own personal sexual attitudes or
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La neuropathie périphérique ( Document émis par la Clinique Mayo en novembre 2005) Introduction dysfonctionnements de votre système nerveux périphérique. Celui-ci concerne tous les nerfs de vos bras et jambes, du torse, du visage et quelques nerfs crâniens ; en fait, tous vos nerfs non situés dans votre système nerveux central (cerveau et moelle épinière) sont les nerfs péri