Sexual Dysfunctions, Assessment and Treatment
© Blue Cross and Blue Shield of Montana
Current Effective Date:
December 27, 2013
Original Effective Date:
July 07, 1997
September 27, 2013
November 12, 2003; January 11, 2007; May 1, 2007; January 2, 2008; March 1, 2008; March 1, 2010; September 13, 2013
Most sexual dysfunctions are related to disturbances in one or more phases of the sexual response cycle. The disturbance may be physiologic/organic or psychological. This dysfunction is usually chronic and perceived by the patient as a change in the sense of sexual pleasure as well as in performance.
For women, female sexual dysfunction (FSD) is the persistent or recurrent failure to attain or maintain the lubrication-swelling response of sexual excitement until completion of the sexual activity.
Laser Vaginal Rejuvenation (LVR) is an outpatient surgical procedure designed to enhance sexual gratification. These procedures are reported to be a modification of a gynecological surgical procedure used for the treatment of stress urinary incontinence. Laser Vaginal Rejuvenation® (LVR®) is claimed to effectively enhance vaginal muscle tone, strength, and control, and effectively decrease the internal and external vaginal diameters as well as build up and strengthen the perineal body.
Male sexual dysfunction or erectile dysfunction is the inability to attain or sustain an erection satisfactory for normal intercourse. Causes contributing to male sexual or erectile dysfunction include, but are not limited to:
- Organic as a result of or secondary to a disease process or treatment (e.g., diabetes mellitus, hypertension, blood lipid abnormalities, or peripheral vascular disease);
- Penile trauma;
- Spinal cord injuries;
- Abnormalities of the penis (e.g. penile fibrosis and Peyronie’s disease);
- Veno-occlusive dysfunction;
- As a result of radical pelvic surgery (e.g. radical prostatectomy or cystectomy);
- Alcohol and/or drugs;
- Psychological/psychogenic factors such as anxiety, fatigue, interpersonal stresses, and chronic illness.
The evaluation of sexual dysfunction begins with a comprehensive history and physical examination. A careful sexual history and knowledge of concurrent illnesses and medications are essential.
A complete evaluation of sexual dysfunction includes, but is not limited to, the following tests:
- Hormonal assessment;
- Diabetes screening;
- Morning sleep nap/nocturnal penile tumescence testing;
- Pharmacologic screening which includes administering vascular dilating agents testing the penile erection process;
- Dynamic cavernosometry, penile and vaginal plethysmography, or duplex scan of penis;
- Nocturnal penile tumescence and/or rigidity test;
- Evaluation of penile arterial flow including Doppler studies, angiography or arteriography;
- Veno-occlusive dysfunction tests to include cavernosography and cavernosometry.
Dynamic infusion cavernosometry is a technique in which fluid is pumped into the penis at a known rate and pressure. It gives a measurement of the vascular pressure in the corpus cavernosum during an erection. To do this test a vasodilator like prostaglandin E-1 is injected to measure the rate of infusion required to get a rigid erection and to help find how severe the venous leak is. The cavernosography is an adjunct to this procedure, where a contrast material is injected and then x-rayed to visualize leakage.
A plethysmograph is an instrument that measures variations in the size of an organ or body part on the basis of the amount of blood passing through or present in the part. Penile or vaginal plethysmography is used to measure physiological sexual arousal.
The nocturnal penile tumescence (NPT) test determines whether a man is having normal erections during sleep. The presence of normal erections during rapid eye movement (REM) sleep indicates that no organic etiology is present.
Treatment for sexual dysfunctions includes:
- Inflatable or non-inflatable penile implants (prostheses);
- Vacuum erection devices;
- Intracavernosal injection therapy;
- (Trans)urethral suppository method;
- Oral Medication;
- Vacuum therapy as a treatment of female sexual dysfunction;
- Arterial reconstructive procedures;
- Penile revascularization for vasculogenic erectile dysfunction;
- Dorsal vein arterialization procedures;
- Penile venous occlusive surgery (e.g., venous ligation, dorsal vein ligation).
Inflatable or non-inflatable penile implants (prostheses) are devices that provide an erection on demand. The inflatable penile implants are made of silicone rubber or polyurethane rubber. The multi-component inflatable prostheses consist of two inflatable cylinders implanted in the penis. These are connected to a reservoir filled with fluid implanted in the abdomen and a manual pump implanted in the scrotum. In order to get an erection, the pump must be squeezed. The non-inflatable prostheses are rigid, semi-rigid and malleable rods that produce varying degrees of penile rigidity to allow for vaginal penetration.
The vacuum erection device is a plastic cylinder that is placed around the penis. When negative pressure is applied, the penis becomes rigid. A rubber ring traps the blood in the penis and keeps the penis rigid until ejaculation. These devices are made by a number of manufacturers and have very variable levels of sophistication, from manual pumps to battery operated devices. The devices are reusable.
Intracavernosal injection therapy is the direct introduction of vasodilator substances into the corpora cavernosa of the penis via syringe and needle, creating an erection. The most effective and well-studied agents are Papaverine, Phentolamine, Verapamil and Prostaglandin E [sub 1] (PGE1). These have been used either singly (such as Caverject that contains Alprostadil as the naturally occurring form of PGE1) or in combination.
The (trans) urethral suppository method introduces the medication into the urethra after urination, via an applicator stem, and is absorbed by the surrounding erectile tissues, creating an erection. On November 19, 1996, the Food and Drug Administration approved a medicated urethral system for erection (MUSE), the first and only non-injectable, transurethral delivery system of Alprostadil.
To ensure safe and effective use of these substances, the patient should be thoroughly instructed and trained in the self-injection technique and solution preparation or the self-insertion before urethral suppository.
The desirable dose should be initially established in the physician's office, known as titration. This may require two or more physician office visits. Dosage adjustments can be done via the telephone with the physician once self-injection training has been completed. The patient will have periodic routine follow-up visits and long-term therapy management, as often as three month intervals.
Oral medication acts by enhancing the smooth muscle relaxant effects of nitric oxide, a substance that is normally released locally in response to sexual stimulation. The medication does not directly cause penile erections, but the smooth muscle relaxation allows blood to enter and pool leading to an erection.
Penile revascularization is vascular reconstructive surgery to improve blood flow to the penis. Revascularization involves bypassing blocked veins or arteries by transferring a vein from the leg and attaching it so that it creates a path to the penis that bypasses the area of blockage. Young men with only local arterial blockage are the best candidates for this procedure.
The arterial revascularization procedure usually involves taking an artery from a leg and then surgically connecting it to the arteries at the back of the penis, bypassing the blockages and restoring blood flow. In a related procedure called deep dorsal vein arterialization, a penile vein is used for the bypass. Young men with local sites of arterial blockage or those with pelvic injuries generally achieve the best results. In studies of selected patients, there was improvement in erectile dysfunction in 50% to 75% of men after five years.
Venous ligation is performed when the penis is unable to store a sufficient amount of blood to maintain an erection. This operation ties off or removes veins that are causing an excessive amount of blood to drain from the erection chambers. The success rate is estimated at between 40% and 50% initially, but drops to 15% over the long term. It is important to find a surgeon experienced in this surgery. In a variation of this technique called venous ablation, ethanol is injected into the deep dorsal vein, the main vein that drains blood from the penis. The ethanol causes scarring that closes off smaller veins and prevents blood leakage, thereby bolstering erectile function.
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||Policy formatting and language revised. Expanded policy statement to include sexual dysfunctions rather than solely erectile dysfunction. Title changed from "Erectile Dysfunction (Impotence)" to "Sexual Dysfunctions, Assessment and Treatment".|