Chapter 16 Sexuality and Contraception
Physiology of coitus
It is important to understand the physiology of sexual function as sexual dysfunction cannot only be the primary reason for a referral to gynaecology, but often may be a secondary issue that is related to other complaints, for example pain and fertility. Sexual history should be taken sensitively and the patients should be able to express their concerns in a non-judgmental environment.
The response to sexual stimulation is primarily an autonomic nervous reflex which can be reinforced or inhibited by psychological, hormonal and social factors. These factors are infinitely variable and understanding the social and psychological influences that are affecting an individual cannot be easily covered during a single consultation. Referral to a specialist psychosexual counselling service should also be considered.
The normal sexual response has been categorised into a series of phases by researchers Masters and Johnson in the 1960s. These are excitement, plateau, orgasm and refractory. The initial interest in sex, also known as libido, is probably harder to define, but as a generalisation, it may be said that the female responds to the consciousness of being desired as a whole person, while satisfaction in the male depends to a greater extent on visceral sensation.
Excitement phase
| Female | Male |
|---|---|
| Vasodilatation and vasocongestion of all erectile tissue. Breasts enlarge, the vaginal ostium opens and secretion from the vestibular glands and vaginal exudations cause ‘moistening’ | Penile erection occurs and may be transient and recur if this stage is prolonged. Scrotal skin and dartos muscle contract and draw testes towards the perineum |
Plateau phase
In both, the male and the female, the pulse rate, blood pressure and respiratory rate increase. Both partners make involuntary thrusting movements of the pelvis towards each other.
| Female | Male |
|---|---|
| Vasocongestion increases, and contraction of the uterine ligaments (which contain muscle) lift the uterus and move it more into alignment with the axis of the pelvis. The cervix dilates. There is engorgement of the lower third of the vagina and ballooning of the upper two thirds | The intensity of penile erection increases and the testes are enlarged by congestion. Seminal fluid arrives at the urethra as a result of sympathetic nervous stimulation of the vas deferens, seminal vesicles and the prostate. There is some pre-ejaculatory penile discharge which may contain sperm |
Orgasm
Pulse and respiration rate are at double their resting rate, and blood pressure may reach 180/110. Pelvic and genital sensations are completely dominating, and there is a noticeable reduction in the sensory awareness in other parts of the body. The pelvic floor contracts involuntarily, with rhythmic contraction of the vagina, urethra and the anal sphincter.
| Female | Male |
|---|---|
| Climactic sensations appear to be caused by spasmodic contractions of vaginal muscles and uterus. The female is potentially capable of repeated orgasm | Strong contractions pass along the penis causing ejaculation of seminal fluid. The greater the volume of ejaculate (after several days’ abstinence) the more intense the sensations of orgasm |
Postcoital phase or resolution phase
Pulse, respiratory rate and blood pressure rapidly return to normal and there is marked sweating. Vasocongestion recedes over about 5 min and there is complete relaxation of all muscles and a detumescence of erectile tissue. In the male, but less so in the female, there occurs a refractory period, which varies with individuals, from a few minutes to several hours during which there is no response to further stimuli.
Sexual problems
Normal sexual activity and behaviour change with a number of factors including age, social circumstances, background and values, but it can also be affected by illness or medication and adverse psychological experiences.
Loss of libido
As previously discussed, interest in sex is a more complex process for women and it can be adversely affected by a number of common social factors, for example having a baby, stress at work, bereavement, etc. There is some evidence that it is influenced by hormonal factors; in particular, it has been shown that women who have had their ovaries removed have lower levels of androgens and these women may benefit from testosterone supplementation. For some postmenopausal women standard hormone replacement therapy may be of benefit.
Failure to achieve orgasm
The failure to achieve an orgasm is a common problem in women, although relatively few women seek medical advice. As with the loss of libido, there may be a number of causative factors. However, many women do not experience orgasm during penetrative intercourse and require stimulation of the clitoris or other erogenous zones. Psychosexual counselling should be offered.
Dyspareunia
Dyspareunia (painful coitus)
Superficial Dyspareunia
It is vaginal pain during sexual intercourse.
This may be due to an inflamed or fibrous scar following childbirth, or to an imperfectly repaired episiotomy or tear.
Deep Dyspareunia
Pain is due to pressure on an area of tenderness near the vaginal vault. The cause is often difficult to identify and there may be no obvious disease but a number of pelvic pathologies should be considered.
Vaginismus
It is a partly voluntary contraction of the pelvic muscles that takes place when the introduction of the penis is attempted, making coitus impossible. It can also occur with insertion of tampons or during a vaginal examination.
Causes are as those for the other forms of sexual dysfunction.
Treatment
Referral to psychosexual counselling can often be helpful in treating vaginismus and should be a key element of any treatments offered.
Vaginal dilators of graduated sizes are useful. The purpose is not to dilate a narrow vagina but to give the patient control over her vaginal muscle and the confidence that sexual intercourse will not be painful.
Mild vaginismus usually responds well to these simple measures, but in severe cases the results are poor.
Botox therapy is a new technique which may be beneficial in severe cases. The pelvic floor muscles are temporarily paralysed and for many women normal sexual function continues after muscle function has resumed.
Sexual problems affecting the male
The gynaecologist is not normally called upon to deal directly with the male, but it can be useful to be aware of their sexual problems and know something of their management.
Premature ejaculation
The male ejaculates with minimal sexual stimulation or before he wishes it to occur.
There are a number of behavioural techniques that can prolong the sexual episode, such as stopping repeatedly or the squeeze technique where intermittent pressure is applied to the penis by the partner.
There are also some medications that may be beneficial, including some antidepressants, but referral should be made to a specialist with an interest in male sexual disorders.
Erectile dysfunction
This is also known as impotence, is the inability to achieve or sustain an erection. Erectile dysfunction becomes more common with age and may have either a physical or psychological basis. Social, domestic and relationship pressures can have significant effects, but it has been increasingly recognised that organic causes are common.
Treatment options for erectile dysfunction
Organic causes
These may be reversible, as in endocrine lesions and drugs, and, where possible, treatment of the underlying condition may be of benefit.
Psychosexual counselling
This is most useful when social and psychological factors predominate and is often used in conjunction with drug treatment.
Sildenafil (Viagra)
An oral therapy for erectile difficulties, this does not produce an erection without sexual stimulation. Side effects have been reported in men with cardiovascular problems who are on cardiovascular medication.
Sex hormones
Simple prescription of a male sex hormone is seldom successful and its part in the physiology of erection and ejaculation is not yet known. It has been shown that testosterone levels do decline with age, but there does not appear to be a male equivalent of the female menopause, and the role of testosterone replacement therapy remains unclear.
Papaverine
This is a smooth muscle relaxant. Intracavernosal injection is an effective treatment for impotence.
Ejaculatory failure
It is the inability to ejaculate although there is no loss of erotic drive, erection and intromission are normal.
The ejaculatory reflex requires intact pathways in both the autonomic and somatic systems. Somatic nerves receive the sensory stimuli of coitus and pass these impulses to the sympathetic nerves which then stimulate the delivery of seminal fluid to the urethra by the vasa deferentia, seminal vesicles and prostate, and prevent retrograde ejaculation into the bladder by causing contractions of the internal urinary sphincters.
Sympathectomy from T12 to L3 will abolish ejaculation without affecting erectile ability or the sensations of an orgasm, producing a phenomenon known as ‘dry sex’.
Medico-legal problems
Rape
The doctor may on occasion be asked to examine a victim of alleged rape. This crime has heavy penalties and the examination must be thorough and careful. Ideally, the examination should be performed by a clinician with requisite specialist training and experience. The victim is likely to have experienced significant trauma and an appropriate supportive environment and staff trained in counselling techniques, should be available. Major police forces have specially trained rape investigation teams whose expertise is invaluable.
The following preliminary notes should be made:
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