Diagnosis of Sexual aversion disorder
Diagnostic Tests for Sexual aversion disorder: Online Medical Books
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DYSPAREUNIA:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Does the history indicate that the difficulty is on penetration? Difficulties on penetration usually point to a vulval or vaginal origin for the problem. In that case, bartholinitis, vulvitis, vulval dystrophy, cystitis, urethritis, and urethral caruncle should be suspected.
- Is the urinalysis abnormal? An abnormal urinalysis may indicate cystitis or a bladder calculus.
- Are there abnormalities on rectal examination? Hemorrhoids, anal fissures, and impacted feces may cause dyspareunia.
- Is the pelvic examination totally normal? If this is true, one would consider functional dyspareunia, or it may be that the patient does not have dyspareunia at all and simply has no sexual desire or dislikes the sexual act.
DIAGNOSTIC WORKUP
It is extremely important to look for evidence of sexual abuse both on history and physical examination before undertaking an expensive workup. Routine studies include a CBC, sedimentation rate, urinalysis, urine culture and sensitivity, and vaginal smear and culture. A Pap smear should also be done. If pregnancy is suspected, a pregnancy test should be done. If there is a pelvic mass, pelvic ultrasound may be helpful. A referral to a gynecologist is usually made before ordering this study, however. If vulval dystrophy is suspected, a vaginal biopsy may be useful. If the vaginal examination is normal, perhaps a psychiatrist should be consulted.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
IMPOTENCE:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a history of alcohol or drug ingestion? A host of antihypertensive drugs, including the beta-blockers, may cause impotence. In addition, tricyclic drugs, nicotine, and alcohol intoxication may cause impotence.
- Is there loss of secondary sex characteristics? These findings suggest Fröhlich's syndrome,
Klinefelter's syndrome, and other congenital disorders.
- Are there abnormalities on urologic examination? Various conditions such as Peyronie's disease, atrophied testes, prostatitis, and Leriche's syndrome may be found on urologic examination.
- Are there abnormalities on the neurologic examination? Neurologic examination may reveal diabetic neuropathy, spinal cord tumor, multiple sclerosis, and other neurologic disorders.
DIAGNOSTIC WORKUP
A thorough psychiatric and sexual history is necessary before undertaking expensive laboratory tests. It is wise to interview the spouse or sexual partner also because the symptom may be exaggerated by the patient. Do not hesitate to order a drug screen. Routine tests include a CBC and differential count, a urinalysis, a urine culture and colony count, a chemistry panel, VDRL test, thyroid profile, serum testosterone, and gonadotrophin assay. A referral to a urologist is probably wise at this point. He will work up the patient further with a nocturnal tumescent study, Doppler ultrasonography, and penile blood pressure studies. In addition, he may want to do a cystoscopy. It may be wise to perform a postage stamp test before referral for a formal tumescence study.
Nerve conduction velocity studies and EMGs may be needed to rule out diabetic neuropathy. MRI of the spine, cystometric studies, and SSEP studies will help to rule out multiple sclerosis and other spinal cord lesions. A sacral reflex latency time may be very helpful in diagnosing sacral nerve injury. A spinal tap may help rule out central nervous system lues. Angiography may be needed to exclude a Leriche's syndrome.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Dyspareunia:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Definitions
–Sexual pain disorder: Persistent or recurrent genital pain of nonorganic cause associated with sexual stimulation, thus causing personal stress; subcategories include dyspareunia and vaginismus
–Superficial dyspareunia: Pain or dysfunction felt upon initial penetration
–Deep dyspareunia: Pain or dysfunction felt deep within the pelvis during intercourse
–Vaginismus: Painful involuntary spasm of the vagina, preventing intercourse
–Vulvar vestibulitis: A chronic and persistent clinical syndrome characterized by severe pain with vestibular touch or attempted vaginal entry, tenderness in response to pressure within the vulvar vestibule, and physical findings confined to various degrees of vestibular erythema
–Vulvodynia: Chronic vulvar discomfort
(e.g. burning, stinging, irritation, rawness)
-
Neurologic etiologies: Nerve damage or infection, dysesthetic (essential) vulvodynia
-
Gynecologic etiologies: Gynecologic tumors (e.g., vulvar, cervical, uterine, ovarian, or rectal cancer; fibroids), Bartholin's gland inflammation
-
GI: Constipation, irritable bowel syndrome, colitis, diverticulitis, GI tumors (in pelvis)
-
Urinary: Interstitial cystitis, urethritis, urethral diverticulum
-
Infectious: Endometritis, vaginitis, PID, salpingitis, vulvovaginitis, herpes genitalis, post-herpetic neuralgia, Bartholin's abscess
-
Dermatologic etiologies: Vaginal atrophy, lichen sclerosis, Behçet syndrome, contact dermatitis
-
Musculoskeletal: Pelvic floor myopathy, fibromyalgia, levator ani myalgia, dysfunctional vaginismus
-
Endocrine: Estrogen deficiency, endometriosis
-
Psychiatric: Female sexual dysfunction(s)
-
Iatrogenic: Surgical (e.g., pelvic adhesions, episiotomy, strictures), pharmacologic (drying soaps or agents, topical medications, OCPs)
-
Trauma: Vaginal lacerations or ecchymoses
-
Primary pain disorder
-
Severely retroverted uterus
-
Imperforate hymen
Workup and Diagnosis
- History and physical examination with pelvic and rectal exams
–Timing: Onset (e.g., upon entry, after intercourse), duration, persistence after intercourse, prior occurrence(s)
–Associations: Symptoms may occur with all vaginal or vulvar contact, with intercourse only, with exams only, with masturbation, or with memories or recollections of prior occurrences or traumatic experiences
–Alleviating and aggregating factors during intercourse
–Qualifiers: Burning, sharp, dull, aching, throbbing,
stabbing
–Old medical records may be of crucial importance
–Include complete psychiatric history and exam
-
Cervical and/or vulvar cultures and microscopic evaluation of normal saline and potassium hydroxide wet mounts should be done
-
Imaging studies may be indicated, including pelvic and/or abdominal ultrasound and/or CT scan
-
Management of psychiatric causes is particularly challenging and requires specific and specialized therapy
-
Consider gynecology and/or psychiatry consult
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Impotence:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient complains of impotence or of a condition that may be causing it, let him describe his problem without interruption. Then begin your examination in a systematic way, moving from less sensitive to more sensitive matters. Begin with a psychosocial history. Is the patient married, single, or widowed? How long has he been married or had a sexual relationship? What’s the age and health status of his sexual partner? Is he feeling stress or pressure from his partner to conceive a child? Find out about past marriages, if any, and ask him why he thinks they ended. If you can do so discreetly, ask about sexual activity outside marriage or his primary sexual relationship. Also ask about his job history, his typical daily activities, and his living situation. How well does he get along with others in his household?
Focus your medical history on the causes of erectile dysfunction. Does the patient have type 2 diabetes mellitus, hypertension, or heart disease? If so, ask about its onset and treatment. Also ask about neurologic diseases such as multiple sclerosis. Obtain a surgical history, emphasizing neurologic, vascular, and urologic surgery. If trauma may be causing the patient’s impotence, find out the date of the injury as well as its severity, associated effects, and treatment. Ask about alcohol intake, drug use or abuse, smoking, diet, and exercise. Obtain a urologic history, including voiding problems and past injury.
Next, ask the patient when his impotence began. How did it progress? What’s its current status? Make your questions specific, but remember that he may have difficulty discussing sexual problems or may not understand the physiology involved.
The following sample questions may yield helpful data: When was the first time you remember not being able to initiate or maintain an erection? How often do you wake in the morning or at night with an erection? Do you have wet dreams? Has your sexual drive changed? How often do you try to have intercourse with your partner? How often would you like to? Can you ejaculate with or without an erection? Do you experience orgasm with ejaculation?
Ask the patient to rate the quality of a typical erection on a scale of 0 to 10, with 0 being completely flaccid and 10 being completely erect. Using the same scale, also ask him to rate his ability to ejaculate during sexual activity, with 0 being never and 10 being always.
Next, perform a brief physical examination. Inspect and palpate the genitalia and prostate for structural abnormalities. Assess the patient’s sensory function, concentrating on the perineal area. Next, test motor strength and deep tendon reflexes in all extremities, and note other neurologic deficits. Take the patient’s vital signs and palpate his pulses for quality. Note any signs of peripheral vascular disease, such as cyanosis and cool extremities. Auscultate for abdominal aortic, femoral, carotid, or iliac bruits, and palpate for thyroid gland enlargement.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Dyspareunia:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Physical examination and laboratory tests help determine the underlying disorder. Diagnosis also depends on a detailed sexual history and the answers to such questions as: When does the pain occur? Does it occur with certain positions or techniques or at certain times during the sexual response cycle? Where does the pain occur? What’s its quality, frequency, and duration? What factors relieve or aggravate it?
When the disorder causes marked distress or interpersonal difficulty, it may fulfill the diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Dyspareunia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin by asking the patient to describe the pain. Does it occur with attempted penetration or deep thrusting? How long does it last? Is the pain intermittent or does it always accompany intercourse? Ask whether changing coital position or using a vaginal lubricant relieves the pain.
Next, ask about a history of pelvic, vaginal, or urinary tract infection. Does the patient have signs and symptoms of a current infection? Have her describe any discharge. Also, ask about malaise, headache, fatigue, abdominal or back pain, nausea and vomiting, and diarrhea or constipation.
Obtain a sexual and menstrual history. Determine whether dyspareunia is related to the patient’s menstrual cycle. Are her cycles regular? Ask about dysmenorrhea and metrorrhagia. Has the patient had a baby? If so, did she have an episiotomy? Note whether she’s breast-feeding. Ask about previous abortion, sexual abuse, or pelvic surgery. Also, find out what contraceptive method the patient uses. Does her partner use condoms? Does he or could he have a latex allergy? Then try to determine her attitude toward sexual intimacy. Does she feel tense during coitus? Is she satisfied with the length of foreplay? Does she usually achieve orgasm? Ask about a history of rape, incest, or sexual abuse as a child.
Next, perform a physical examination, starting with vital signs. Palpate the abdomen for tenderness, pain, or masses and for inguinal lymphadenopathy. Finally, inspect the genitalia for lesions and vaginal discharge.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Impotence:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of impotence or of a condition that may be causing it, let him describe his problem without interruption. Then begin your examination in a systematic way, moving from less sensitive to more sensitive matters. Begin with a psychosocial history. Is the patient married, single, or widowed? How long has he been married or had a sexual relationship? What’s the age and health status of his sexual partner? Find out about past marriages, if any, and ask him why he thinks they ended. If you can do so discreetly, ask about sexual activity outside marriage or his primary sexual relationship. Also ask about his job history, his typical daily activities, and his living situation. How well does he get along with others in his household?
Focus your medical history on the causes of erectile dysfunction. Does the patient have type 2 diabetes mellitus, hypertension, or heart disease? If so, ask about its onset and treatment. Also ask about neurologic diseases such as multiple sclerosis. Obtain a surgical history, emphasizing neurologic, vascular, and urologic surgery. If trauma may be causing the patient’s impotence, find out the date of the injury as well as its severity, associated effects, and treatment. Ask about intake of alcohol, drug use or abuse, smoking, diet, and exercise. Obtain a urologic history, including voiding problems and past injury.
Next, ask the patient when his impotence began. How did it progress? What’s its current status? Make your questions specific, but remember that many patients have difficulty discussing sexual problems, and many don’t understand the physiology involved.
The following sample questions may yield helpful data: When was the first time you remember not being able to initiate or maintain an erection? How often do you wake in the morning or at night with an erection? Do you have wet dreams? Has your sexual drive changed? How often do you try to have intercourse with your partner? How often would you like to? Can you ejaculate with or without an erection? Do you experience orgasm with ejaculation?
Ask the patient to rate the quality of a typical erection on a scale of 0 to 10, with 0 being completely flaccid and 10 being completely erect. Using the same scale, also ask him to rate his ability to ejaculate during sexual activity, with 0 being never and 10 being always.
Next, perform a brief physical examination. Inspect and palpate the genitalia and prostate for structural abnormalities. Assess the patient’s sensory function, concentrating on the perineal area. Next, test motor strength and deep tendon reflexes in all extremities, and note other neurologic deficits. Take the patient’s vital signs and palpate his pulses for quality. Note any signs of peripheral vascular disease, such as cyanosis and cool extremities. Auscultate for abdominal aortic, femoral, carotid, or iliac bruits, and palpate for thyroid gland enlargement.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Impotence:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Basic history. Although written questionnaires may elicit sexual dysfunction, most patients prefer to communicate such issues in the privacy of verbal communication with their primary care provider. For the initial inquiry, simply ask: “Are you sexually active?” For sexual dysfunction evaluation, gender orientation is not relevant to diagnosis or therapy, so that whether the patient is homosexual, heterosexual, or bisexual has no distinct bearing on the diagnostic or therapeutic direction. For persons who are not sexually active, next determine whether this is a matter of choice or an obstacle that prevents sexual activity (e.g., lack of partner, ED, physical disorder).
For persons who are sexually active, a series of follow-up questions will uncover most relevant psychosexual pathology. Begin with: “How would you rate your sex life on a scale of 1 to 10?” If the response is 10, sexual dysfunction is decidedly unlikely. However, most individuals respond, “Oh, about a 7.” Follow with, “What would have to be different to change your sex life from a 7 to a 10?” This forced-choice inquiry often produces responses which directly indicate problematic underlying issues: “Well, if I could just get a good erection.” “If my erection could last more than 30 seconds.” “If my partner didn’t always pick a fight with me and then expect to have sex.”
For impotent men, their response is usually direct and simple, indicating an inability to get or maintain an erection. Follow-up questions should determine the duration and nature of onset. Absence of morning erections should be sought, as this typifies organic impotence. Men who are much more likely to have psychogenic ED are those who report sudden, complete loss of sexual function, or “circumstantial” impotence, for example, (a) good function with one partner, but not another; (b) good erections with masturbation but not with interactive sex; (c) good morning erections, but not at times of interactive sex; or (d) overt anxiety or relationship conflict. Because organic ED generally leads to psychological consequences, many patients suffer a combination of psychogenic and organic impotence.
B. Inquiry about libido is a crucial diagnostic point for testosterone deficiency. Testosterone is necessary for libido, but not erections. Men who present with good libido have only a remote possibility of having testosterone deficiency.
C. A medication history should be taken for all men complaining of impotence, recalling that most medication-induced impotence is evident by the temporal relationship between onset of impotence and medication initiation. On the other hand, agents such as thiazides can produce impotence after months of use. Similarly, some antidepressants can produce sexual dysfunction either early or after weeks of therapy. The relationship of medications to impotence can often be clarified by a drug holiday.
Physical examination
Although physical examination is usually not enlightening, general agreement is seen that the genitals should be examined for evidence of overt testicular atrophy, and the penis for Peyronie’s disease. In the latter, inflammatory plaques in the corpora cavernosa produce an area of limited expansile capacity, with subsequent penile deviation on erection which can prevent intromission. A rectal examination to document rectal sensation as well as tone can be complemented by the bulbocavernosus reflex. This reflex is elicited by briskly squeezing the glans penis in one hand while a single digit from the other is in the rectum. A normal examination, indicating an intact reflex arc, is manifest as a rectal contraction in response to the glans squeeze. Prostate examination is pertinent at this point, in the event testosterone therapy is required.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Impotence:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of impotence or of a condition that may be causing it, let him describe his problem without interruption. Then begin your examination with a psychosocial history. Is the patient married, single, or widowed? How long has he been married or had a sexual relationship? What's the age and health status of his sexual partner? Is he feeling stress or pressure from his partner to conceive a child? Find out about past marriages, if any, and ask him about his sexual experiences with former spouses. Ask about sexual activity outside marriage or his primary sexual relationship. Also ask about his job history, his typical daily activities, and his living situation. How well does he get along with others in his household?
Focus your medical history on the causes of erectile dysfunction. Does the patient have diabetes mellitus, hypertension, or heart disease? If so, ask about its onset and treatment. Also ask about neurologic diseases such as multiple sclerosis. Obtain a surgical history, emphasizing neurologic, vascular, and urologic surgery. If trauma may be causing the patient's impotence, find out the date of the injury as well as its severity, associated effects, and treatment. Ask about alcohol intake, drug use or abuse, smoking, diet, and exercise. Obtain a urologic history, including voiding problems and past injury.
Next, ask the patient when his impotence began. How did it progress? What's its current status? Make your questions specific, but remember that he may have difficulty discussing sexual problems or may not understand the physiology involved.
Other questions that can help yield helpful data include: When was the first time you remember not being able to initiate or maintain an erection? How often do you wake in the morning or at night with an erection? Do you have wet dreams? Has your sexual drive changed? How often do you try to have intercourse with your partner? How often would you like to? Can you ejaculate with or without an erection? Do you experience orgasm with ejaculation?
Next, perform a brief physical examination. Inspect and palpate the genitalia and prostate for structural abnormalities. Assess the patient's sensory function, concentrating on the perineal area. Next, test motor strength and deep tendon reflexes in all extremities, and note other neurologic deficits. Take the patient's vital signs and palpate his pulses for quality. Note any signs of peripheral vascular disease, such as cyanosis and cool extremities. Auscultate for abdominal aortic, femoral, carotid, or iliac bruits, and palpate for thyroid gland enlargement.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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