Anatomy and physiology of female sexual function and dysfunction: classification, evaluation and treatment options

Female sexual dysfunction is a significant age-related, progressive and highly prevalent problem that affects a substantial number of women in the United States. The female sexual response cycle is initiated by neurotransmitter-mediated vascular and nonvascular smooth muscle relaxation resulting in increased pelvic blood flow, vaginal lubrication, and clitoral and labial engorgement. These mechanisms are mediated by a combination of neuromuscular and vasocongestive events. Physiological impairments that interfere with the normal female sexual response bring about complaints associated with diminished sexual arousal, libido, vaginal lubrication, genital sensation, and ability to achieve orgasm. Therapy aimed at restoring hormone levels as well as genital blood flow will be discussed.     

Female sexual dysfunction

Female sexual dysfunction (FSD) is a very common disorder in Germany with a prevalence of approximately 38%. FSD includes persistent or recurrent disorders of sexual desire, disorders of subjective or genital arousal and pain during intercourse. An overview of the epidemiology, the current definitions of the single domains of FSD, the pathophysiology and recommendations on the treatment of FSD is given.     

Female sexual dysfunction

Female sexual dysfunction is a common problem with detrimental effects on woman’s quality of life. It also has an economical and societal impact. It is defined as disorders of sexual desire, arousal, orgasm, and sexual pain, which lead to personal distress. The etiology of sexual dysfunction is frequently multifactorial as it relates to general physical and mental well-being, quality of relationship, past sexual functioning, social class, education, employment, life stressors, personality factors, the presence of a sexual partner, and partner’s age and health. It is very important to adopt the most efficient approach to gather information, and this may be achieved via standardized questionnaires or open-ended questions. Therapy should be tailored according to the patient’s needs and may involve a multidisciplinary team approach including psychosexual counselor/sexologist/therapist and the physician. There is still more work needed to optimize the care of women with this problem. Priority should be given to international standardization and training of health care professionals.     

Female sexual dysfunction

The ideal approach to female sexual dysfunction would be a collaborative effort between therapists and physicians and would include a complete medical and psychosocial evaluation, and inclusion of the partner spouse in the evaluation and treatment process. Despite significant anatomic and embryologic parallels between men and women, the multifaceted nature of female sexual dysfunction clearly is distinct from that of the man. The clinician cannot approach female patients or their sexual function problems in the same fashion as in male patients. The context in which a woman experiences her sexuality is equally if not more important than the physiologic outcome she experiences, and these issues should be determined before beginning medical therapy or determining treatment efficacies.     

Diagnostic evaluation, classification, and treatment of men with sexual dysfunction

During a two-year period, 165 men were evaluated for sexual dysfunction. Most evaluations were conducted on an outpatient basis and required two separate visits. Fifty-one per cent, 47 per cent, and 2 per cent of the patients were found to have functional disorders, organic disorders, and incomplete evaluations, respectively. Treatment recommendations were tailored to each patient using information gathered during the diagnostic evaluation.     

Female sexual disorders: assessment, diagnosis, and treatment

Despite the increased popular attention that sexual dysfunction has received in the recent past, more often than not physicians and their patients remain avoidant of the topic in clinical visits. The patient hesitancy in this dynamic suggests that clinicians can best serve their patients by routinely initiating discussions about sexual function during clinical visits. In this article, we provide an overview of the female sexual dysfunctions and address screening and treatment options.     

Female sexual dysfunction: state of the art

Female sexual dysfunction, a common, multifactorial, and often undertreated medical condition, attracted the attention of the medical community with the successful introduction of medical therapy for male erectile dysfunction. This review discusses the updated classification systems and definitions, epidemiologic aspects, and new pathophysiologic and therapeutic implications of this sexual disorder.     

The epidemiology, anatomy, physiology, and treatment of erectile dysfunction in chronic renal failure patients.

Erectile dysfunction (ED) is an associated morbidity for men with chronic renal failure. An understanding of the epidemiology, anatomy, physiology, and treatment options for ED can greatly improve the quality of life for men with chronic renal failure. There are psychological and physiological causes for erectile dysfunction. Once the key features leading to the patient's loss of potency have been identified, appropriate treatment plans can be instituted, often with successful outcomes. The purpose of this article is to assist the nephrology interdisciplinary team in the management of ED by reviewing possible causes, available studies, and treatment options for their patients.     

Female sexual dysfunction: what Arab gynecologists think and know

Introduction and hypothesis

We aimed to assess the knowledge and practice of gynecologists (Gyns) from different Arab countries with regard to female sexual dysfunction (FSD) in comparison with members of the American Urogynecologic Society (AUGS) and the British Society of Urogynecology (BSUG).

Methods

An anonymous questionnaire was used to survey attendees of the annual meeting of the Saudi Obstetrics and Gynecology Society.

Results

Six hundred and forty questionnaires were distributed, and the response rate was 66%. The majority of Arab Gyns (73%) were unsatisfied with their training, and 87% never or rarely screened for FSD compared with 47% and 23% of BSUG and AUGS members, respectively (p?Conclusion Our results reveal an apparent global lack of adequate education in female sexuality and expose the breadth of the problem among Arab Gyns. Therefore, there is a need to improve training at the undergraduate and postgraduate levels to enable Gyns in Arab countries to provide better sexual healthcare.     

Female sexual dysfunction following vaginal surgery: a review

PURPOSE: Depending on age it has been estimated that up to 40% of women have complaints of sexual problems, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. In this review we address the etiologies and incidence, evaluation and treatment of female sexual dysfunction following vaginal surgery for indications such as stress urinary incontinence and pelvic organ prolapse; anterior/posterior colporrhaphy, perineoplasty and vaginal vault prolapse. MATERIALS AND METHODS: Literature on the mechanisms by which vaginal surgery affects female sexual function are discussed along with related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as related to vaginal surgery. Techniques to avoid neurovascular damage during pelvic floor surgery were corroborated by supporting literature. Literature regarding female sexual dysfunction following other procedures, such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair were also discussed. RESULTS: Current literature does not support an association between vaginal length following vaginal surgery and sexual function. The proportion of women who are sexually active does not appear to be affected by vaginal surgery. Sling surgery for urinary incontinence does not appear to adversely affect overall sexual function, although individual parameters of sexual function scores may vary, eg a significant percent of women report pain during intercourse. Some patients experience improved overall sexual function due to complete relief from coital incontinence CONCLUSIONS: Symptomatic vaginal narrowing is rare even in women undergoing simultaneous posterior repair. Overall sexual satisfaction appears to be independent of therapy for urinary incontinence or prolapse. Data indicate that defect specific posterior colporrhaphy with the avoidance of levator ani plication may improve sexual function. The possible etiological factors for sexual dysfunction following vaginal surgery deserve further investigations.     

Female sexual dysfunction: a new urogynaecological research field

Associate Editor Michael G. Wyllie Editorial Board Ian Eardley, UK Jean Fourcroy, USA Sidney Glina, Brazil Julia Heiman, USA Chris McMahon, Australia Bob Millar, UK Alvaro Morales, Canada Michael Perelman, USA Marcel Waldinger, Netherlands

OBJECTIVE

To critically review published data on the urogynaecological aspects of female sexual dysfunction (FSD), as FSD is a developing multidisciplinary issue associated with several biological, medical and psychological factors.

METHODS

The reported prevalence of FSD is 19–50% and women with lower urinary tract symptoms or urinary incontinence (UI) not only complain of a deteriorating of quality of life but also of sexual life with an incidence as high as 26–47%. Furthermore, urogynaecological surgery represents an important but underestimated cause of FSD. Different databases (Pub Medical, Medline, serial titles, the Cochrane library and the NLM gateway database) were searched for the keywords ‘sexuality; sexual function; urinary incontinence; pelvic organ prolapse; questionnaire; symptom severity; epidemiology; quality of life; instruments; sexual health; vagina; vaginal surgery; pelvic surgery’.

RESULTS

There is a lack of a standardized instrument for assessing FSD. Recent studies investigate the impact of UI on sexual function, but the pathophysiology has not been elucidated. Vaginal or pelvic surgery does not affect overall sexual satisfaction.

CONCLUSIONS

Our investigation highlights the need for studies to assess the anatomical, physiological and sensory mechanisms related to FSD. Specific questionnaire are needed to quantify the problem. In the definition, symptoms assessment and preoperative counselling is important, to make a distinction between overall sexual function and individual parameters, such as psychosocial context. Only in this way, will it be possible to identify new therapeutic targets. A definition of success in urogyneacological terms should include aspects of quality of life and quality of sexual life. Immediate research in this field is needed.     

Female neurogenic vesicourethral dysfunction: evaluation and management

This paper outlines the evaluation and management of neurogenic vesicourethral dysfunction (NVUD). The anatomy and neurophysiology involved with lower urinary tract functions are reviewed. Multiple sclerosis, diabetes, lumbar disc prolapse, and Parkinson’s disease are specifically addressed. Proper evaluation of patients suspected of having NVUD, which is fundamental to making an accurate diagnosis, is discussed. This is followed by options for initiating individualized management plans that focus on protecting and preserving renal function, in addition to relieving the symptoms of NVUD.     

Female sexual dysfunction: are urogynecologists ready for it?

The aim of this study was to assess the practice of members of the British Society of Urogynaecology (BSUG) with respect to female sexual dysfunction (FSD) and compare it to members of the American Urogynecologic Society (AUGS). A web-based anonymous electronic questionnaire was sent to all (n = 150) BSUG members. Frequencies of responses and chi-square test for association with demographics were calculated. One hundred questionnaires were returned of which 95 were sufficiently filled. Fifty percent regularly screened for FSD at clinic visits and 49.5% after surgery, compared to 77% and 76% of AUGS members, respectively. The most important barrier was lack of time. Only 2% said FSD was not an important problem. Seventy-six percent found training for FSD unsatisfactory. FSD is not part of normal practice for half of BSUG members. There is, therefore, a need for better implementation of education and training at both undergraduate and postgraduate levels.     

Tear trough deformity: review of anatomy and treatment options

The lower eyelid can be a challenging area in facial rejuvenation. While lower eyelid bags are commonly the reason that patients present for lower eyelid rejuvenation, a separate entity known as a tear trough deformity may occur in conjunction with lower eyelid bags or alone. In this article, the authors outline the current understanding of the tear trough anatomy; describe multiple classification systems, which provide an objective means of evaluating the deformity and aid the surgeon in choosing appropriate treatment options; and review surgical and nonsurgical techniques for correcting the tear trough deformity. Treatment options include hyaluronic acid filler, fat grafting, skeletal implants, and fat transposition. Each procedure is associated with advantages and disadvantages, and each should be considered more complex than traditional lower blepharoplasty alone. While lower blepharoplasty removes excess fat and may tighten the anterior lamella, tear trough procedures require the addition of volume to the underlying depression. These procedures requiring release of the ligamentous structures and orbicularis (of which the tear trough is composed), as well as fat transposition or fat grafting, are associated with additional complications, which are also reviewed.     

Female sexual dysfunction, voiding symptoms and depression: common findings in partners of men with erectile dysfunction

The aim of this study was to investigate the prevalence of female sexual dysfunction (FSD), urinary symptoms, and depressive symptoms in female partners of men presenting with erectile dysfunction (ED). A multi-component questionnaire was administered to female partners of men with erectile dysfunction presenting to a urology center. It contained a standardized sexual function component (the Brief Index of Sexual Function for Women), a depression scale (Centers for Epidemiologic Studies-Depression, CES-D), a demographics questionnaire and a general medical questionnaire. A total of 73 consecutive female partners of male patients presenting with ED, were surveyed using the questionnaire at their counterpart’s visit. Fifty-two women responded, of whom 50 filled out the questionnaire adequately for proper evaluation. This indicated a response rate of 68% (50/73). The mean age was 44.8 years (range 20.0–83.0). Thirty-eight of the 50 women (76%) reported being sexually active. A variety of sexual behaviors were reported including 40% (20/50) of women engaging in vaginal intercourse. Sexual dysfunction symptoms included: anxiety/inhibition (26%), hypoactive desire (20%), arousal/lubrication difficulty (30%), orgasmic difficulty (24%), dyspareunia (18%), incontinence during intercourse (8%), and sexual dissatisfaction (34%). Eight women (16%) reported difficulty communicating sexual issues with their partners. Forty-one women (82%) rated sexual activity as an important part of their lives. Urinary symptoms of frequency and urgency were reported by 18/50 (36%). Depressive symptoms were present in 22/50 (44%). FSD disorders, urinary symptoms and depressive symptoms are common in partners of men with erectile dysfunction.     

Neuromodulators: available agents, physiology, and anatomy

Neuromodulators have risen to the forefront of aesthetic medicine. By reversibly relaxing target muscles, neuromodulators exhibit their effect by softening hyperfunctional lines. An understanding of their physiology, relevant facial anatomy, and current agents is imperative for a successful aesthetic practice.     

Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options

Despite recent advances in pharmacological management of rheumatoid arthritis, forefoot deformity, with its symptoms, remains a common problem, often requiring operative treatment. Typical deformities in these patients comprise hallux valgus and deformity of the lesser metatarsophalangeal (MTP) joints and toes. With regard to the lesser rays the standard operative procedure, advocated for the disabling forefoot pain in these patients, remains metatarsal head resection. It should be considered that with increasing success of pharmacological treatment the degree of forefoot deformity in these patients is becoming less and that resection of the lesser MTP joints is becoming more and more superfluous. This supports a trend towards metatarsal head-preserving surgery. The optimal treatment of the hallux deformity remains unclear. Fusion of the first MTP joint is, generally, recommended. This article will discuss the current surgical options in rheumatoid forefoot pathology.