6 General adult psychiatry6.5 Psychosexual health
6.5.1 Non organic sexual dysfunction
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Written by Resident Doctor Committee · Published
Classification
ICD-11 groups sexual dysfunctions under conditions related to sexual health, without dividing them into organic and non-organic disorders. Qualifiers describe lifelong or acquired, and generalised or situational, patterns and associated causes.
Presentation | ICD-11 category |
|---|---|
Reduced desire | Hypoactive sexual desire dysfunction |
Erectile difficulty | Erectile dysfunction |
Reduced female arousal | Female sexual arousal dysfunction |
Absent or markedly reduced orgasm | Anorgasmia |
Markedly delayed male ejaculation | Male delayed ejaculation |
Ejaculation earlier than desired | Male early ejaculation |
Persistent penetration difficulty, pain or fear | Sexual pain-penetration disorder |
A diagnosis usually needs persistent difficulty over several months, occurring frequently and causing significant distress; medical, psychological, medication and relationship factors are assessed together.
Vaginismus
Vaginismus is a lifelong inability to allow penetration, with reflex tightening of the pelvic floor and a normal examination.
The classic cause is fear of penetration rooted in traumatic early sexual experience.
Treatment combines pelvic floor relaxation with graded exploration or vaginal trainers; examination is offered with consent and never forced.
Premature ejaculation
Premature ejaculation is ejaculation within about one minute of penetration, with normal erections.
Performance anxiety speeds the ejaculatory reflex and sets up a cycle of dread and avoidance.
Excessive masturbation is an old folk explanation with no evidence behind it.
Stop-start and squeeze techniques are the behavioural treatments.
SSRIs (selective serotonin reuptake inhibitors) are the drug treatment of choice: they block presynaptic and somatodendritic serotonin transporters, so serotonin rises at postsynaptic receptors and ejaculation is delayed.
Dapoxetine 30 to 60 mg, taken on demand before sex, is the licensed SSRI for lifelong premature ejaculation; daily SSRIs are off label.
Psychotropic drugs as a cause
Patients rarely volunteer sexual side effects, so ask directly and record baseline function. Depression itself lowers desire, so establish the timeline.
Drug | Sexual effect |
|---|---|
SSRIs and SNRIs (serotonin and noradrenaline reuptake inhibitors) | Delay or abolish orgasm through serotonergic inhibition of the sexual response |
Paroxetine | Highest rate of anorgasmia among SSRIs |
Clomipramine | High burden, being strongly serotonergic |
Agomelatine, bupropion, mirtazapine, moclobemide, vortioxetine | Lowest burden, though none is risk-free |
Trazodone | Priapism, through alpha-1 adrenoceptor blockade that impairs detumescence |
Risperidone, paliperidone, amisulpride, sulpiride | Raise prolactin; aripiprazole carries less risk |
Priapism is a painful erection lasting over four hours without sexual stimulation, and is a urological emergency.
Sexual dysfunction from SSRIs and SNRIs can persist after people stop the drug.
Sildenafil or tadalafil help drug-induced erectile dysfunction but do not restore desire.
Assessment
Ask about onset, the phase affected, lifelong versus acquired and generalised versus situational patterns, medicines, substances and relationships.
Situational difficulty with preserved spontaneous erections points to psychological causes, but new erectile dysfunction still warrants cardiovascular risk assessment.
Treatment
Annon's PLISSIT level | What it involves |
|---|---|
Permission | Making concerns discussable and normalising variation |
Limited information | Correcting misconceptions |
Specific suggestions | Practical, individual advice |
Intensive therapy | Specialist psychosexual work |
Sensate focus uses agreed non-demand touch, at first without penetration or the goal of orgasm, to remove performance pressure.
Directed masturbation can help orgasmic difficulty.
Phosphodiesterase type 5 (PDE5) inhibitors are first-line for erectile dysfunction; nitrates, amyl nitrite and riociguat contraindicate them.