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Managing Sexual Disorders: Treatment Options and Considerations
- 1. Dr Hosam Hassan Egyptian Fellowship of Psychiatry Senior Registrar Psychiatrist Mental Health Hospital In Taif
- 3. Why are we discussing Sexual Disorders ? When to consider diagnosing a Sexual Disorder ? How can we manage Sexual Disorders ?
- 4. Sexual Disorder Non Adherence Low Self Esteem DepressionAnxiety Dissatisfaction Low Quality of Life Relapse Interpersonal Troubles Substance Abuse Mental Illness Medications
- 5. 31 % 43 % Sexual Dysfunction in 18-59 years old males Sexual Dysfunction in 18-59 years old females Up to 60% Sexual Dysfunction in Patients taking Antipsychotics Up to 80% Sexual Dysfunction in Patients taking Antidepressants
- 9. Clinically Significant Disturbance Response Experience Pleasure Almost All Partnered Sexual Activity For at Least 6 Month Life long Acquired Generalized Situational Mild Moderate Severe Partner Relationship Personal Vulnerability Cultural Religious Other Medical FactorSignificant Stress
- 10. • Delayed EjaculationF52.32 • Erectile DysfunctionF52.21 • Female Orgasmic DisorderF52.31 • Female Sexual Interest/Arousal DisorderF52.22 • Genito-Pelvic Pain/Penetration DisorderF52.6 • Male Hypoactive Sexual DisorderF52.0 • Premature EjaculationF52.4 • Substance Medication induced sexual Dysfunction • Other Specified Sexual DysfunctionF52.8 • Unspecified Sexual DysfunctionF52.9
- 11. Stress Related to Incongruence Assigned Expressed For at Least 6 Month Significant Stress With Disorder of Sex Development Posttransition
- 12. • Gender Dysphoria in ChildrenF64.2 • Gender Dysphoria in Adolescents & AdultsF64. 1 • Other Specified Gender DysphoriaF64.8 • Unspecified Gender DysphoriaF64.9
- 13. Intense sexual Interest Impairment or harm to self non consenting other For at Least 6 Month Significant Stress In Controlled Environment In Full Remission
- 14. • Voyeuristic DisorderF65.3 • Exhibitionistic DisorderF65.2 • Frotteuristic DisorderF65.81 • Sexual Masochism DisorderF65.51 • Sexual Sadism DisorderF65.52 • Pedophilic DisorderF65.4 • Fetishistic DisorderF65.0 • Transvestic DisorderF65.1 • Other Specified Sexual DysfunctionF65.8 • Unspecified Sexual DysfunctionF65.9
- 16. Management of Male Sexual Dysfunction Improve Libido Acquire & Maintain Erection Delay Ejaculation Evaluation
- 17. Antidepressants ↑Serotonin ↓ Libido /Orgasm Citalopram Paroxetine Wait ≠ Lower Dose √ Switch √√ Add √√ Bupropione Mirtazapine Fluxetine ? +PDE-5 Inhibitor Antipsychotics ↓ Dopamine ↑Prolactine ↓ Desire Risperidone Paliperidone olanzapine Lower dose Switch Add Arpiprazole + Metformin 1g/day
- 18. Yohimbine Penile Self Injectable Drugs Papaverine Pharmacotherapy Testosterone Hormonal Replacement Therapy Psychotherapy Life Style Changes Weight Loss Physical Activity PDE-5 Vacuum assisted Erection Devices Alprostadil Surgery Penile Prosthesis Penile Revascularization
- 20. Cautious Contraindicated BP Precautions Before Prescribing PDE-5 Heart Diseases Nitrates α- Adrenergic Blockers Isosorbide dinitrate Isosorbide mononitrate Nitroglycerin Trazodone Mirtazapine Yohimbine Prazosin MI Sudden Death Post Coital
- 21. Duration of ActionOnset of Action Dosage & Administration Drug About 4 Hours (8-12hrs if Mild ED) 1 hr50 mg (up to 100 mg / dose) (25mg if side effects are present) On empty stomach Sildenafil (Viagra) About 4 Hours (8-12hrs if Mild ED) 1 hr ODT form 30 min 10 – 20 mg On empty Stomach Vardanafil (Levitra) Up to 36 hrs1 hr10 – 20 mg 2.5 – 5 mg / day (on daily basis ) if complete ED Tadalafil (Cialis) About 4 Hours (8-12hrs if Mild ED) 30 min onset 15 min onset 50 – 100 mg 100 – 200 mg Avanafil (Spedra) Side Effects BlueVision 3% Flushing 12% Headache 11% Dyspepsia 5% Hearing Loss Optic Neuropathy
- 22. Management of Female Sexual Dysfunction •Gynecologist •Psychiatrist •Cardiologist •Sex / CoupleTherapist •Pelvic PhysicalTherapist • Non-Pharmacological • Hormonal • Other Pharmacological •Desire / Arousal •Pelvic Pain •Orgasm • Social / Partner • Psychological • Physical Multi Factorial Multi Faceted Team Approach Treatment plan
- 23. Couple Therapy Counseling Non-Pharmacological Psychotherapy Life Style Changes Improve Body Image Lubricants & Moisturizers Sex Therapy Pelvic Physiotherapy Privacy Spare time Novelty Yoga Weight loss Exercise
- 24. PharmacologicalTherapies Flibanserin (Addyi) Centrally Acting Serotonin Modulator 1st & currently the only FDA approved medication for females sexual dysfunction (Approved on August 2015) Modest increase in Sexually Satisfying Events & Sexual Desire Dose & Administration 100 mg / daily Bed time 1 month onset of efficacy Side Effects Somnolence Dizziness Fatigue Headache precautions Safety in Pregnancy ?? Drug Interaction ?? Syncope ??
- 25. PDE-5 inhibitors Effective in SSRIs Related Sexual Dysfunction In Premenopausal women Herbal supplements Bupropion 150 – 300 mg SR / day Effective in premenopausal females With arousal/interest dysfunction without underlying depression Buspirone Effective in SSRIs Related Sexual Dysfunction In Premenopausal women precautions Safety & Efficacy Unproven Minimal Regulatory Oversight Usually Costly Considerations Predicted 30% Placebo Response Few reported side effects Alvimil Supplement Zestra Massage Oil Examples
- 26. HormonalTherapy Androgen Estrogen Ospemifen Tibolone OtherTherapies Clitoral SuctionVacuum Device Not available now High Cost yet as effective as over-the-counter devices Hirsutism ,Acne (mild, transient ) Not Effective in SDs 1st FDA approved for Dyspareunia (Vulvovaginal Atrophy) Not FDA approved Risk Outweigh Benefit
- 27. Sexual dysfunction in the United States: prevalence and predictors (1999) Laumann EO, Paik A, Rosen RC Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis (2009) Serretti A, Chiesa A Overview of male sexual dysfunction, UpToDate (2015) Glenn R Cunningham, Rosen RC . Evaluation of Flibanserin: Science and Advocacy at the FDA (2015) GelladWF, Flynn KE, Alexander GC