General Management of Female Sexual Dysfunction for Urologists.

Sexual health and sexual dysfunction are the result of a complex interaction of biological, psychological, interpersonal, and social factors. These factors interact with each other and can have a differential impact on the female sexual function, causing dysfunction. 7 - 9

Basic counseling has several components, which have proven therapeutic effects. Emotional relief Give the patient, the opportunity to talk about his/her own sexuality Listen actively Patient feels accepted and understood Education and empowerment Inform about the reality of human sexuality Put the variety of personal experiences into perspective Frequency of problems Differences between female and male sexuality Dispel myths about male and female sexuality represented in social media about normal sexuality with different new norms and false information about “good sex.” “It rocks you and makes you feel like in heaven.” Sex is not penis in vagina, the usual program, but there is a large variety of sexual expression and preferences The pleasure of nongenital sex The use of sex toys is not pornographic Having sexual problems means that love has died The second step is establishing a treatment plan based on the understanding of the contributing factors (see above).

Based on the model of the human sexual response cycle described by Masters and Johnson and H S Kaplan, Female Sexual Dysfunctions (FSD) can be classified into 4 groups based on the different components of the response cycle. 1 – 4

Medical treatment Specific treatment for underlying disease Superficial dyspareunia (e.g., vulvovaginal infections and dermatologic diseases) Deep dyspareunia (e.g., endometriosis, adhesions, and irritable bowel syndrome) Normalize vaginal tropism and pH (by local hormonal treatment) Use of moisturizers Physiotherapy of pelvic floor Combined with imagination and relaxation techniques Psychosexual single and couple therapy Mindfulness Sensate focus Communication training to improve understanding of adequate stimulation Analgesic therapy Systemic: NSARs, antidepressants, and anticonvulsants (neuropathic pain) Local: Cortisone and injection of anesthetics Surgical interventions (vestibulectomy)

Hormonal therapy (see therapies above) Local estrogen therapy to improve vaginal tissue and vaginal blood flow Blood vessel dilators PDE-5 inhibitors have proven to be effective in women with diabetes Clitoral therapy device A Food and Drug Administration approved device such as a vibrator Physiotherapy of the pelvic floor Lifestyle changes Physical activities Body awareness methods (see above)

Medical therapy Optimize hormones Adjustment of orgasm-inhibiting medications Physiotherapy of the pelvic floor Psychosexual therapy Body awareness methods

Estrogens, androgens, and tibolone Hormone therapy in women with sex hormone deficiency, for example, during menopausal transition or in those women showing signs of Androgen Insufficiency Addressing co-morbid depression Depression is a frequent comorbidity and needs treatment eventually by adjustment of dosages or types of psychotropic drugs Individual Building on previous positive experiences and models of satisfying sexuality Addressing negative experiences Helping patients to find out what they really want in their sexual life Couple therapy Sensate focus (see above)

Chronic diseases Cancer, cardiovascular, and metabolic psychiatric diseases Diseases can impact sexual health in the following ways: tissue damage of the organs involved in the sexual response damage to the neuromuscular and neurovascular system influencing the endocrine response impairment of the brain neurotransmitter responses Cancer, cardiovascular, and metabolic psychiatric diseases Diseases can impact sexual health in the following ways: tissue damage of the organs involved in the sexual response damage to the neuromuscular and neurovascular system influencing the endocrine response impairment of the brain neurotransmitter responses Endocrine changes Postpartum Low estrogen, prolactin contributing to low desire, and painful intercourse Menopause Estrogen fluctuation, low estrogen, and testosterone insufficiency Contributing to low desire and arousal difficulties Diabetes Vascular changes in the genital organs of men and women can contribute to arousal problem (erectile dysfunction and arousal disorder in women) Postpartum Low estrogen, prolactin contributing to low desire, and painful intercourse Low estrogen, prolactin contributing to low desire, and painful intercourse Menopause Estrogen fluctuation, low estrogen, and testosterone insufficiency Contributing to low desire and arousal difficulties Estrogen fluctuation, low estrogen, and testosterone insufficiency Contributing to low desire and arousal difficulties Diabetes Vascular changes in the genital organs of men and women can contribute to arousal problem (erectile dysfunction and arousal disorder in women) Medications and recreational drugs Drugs influencing the peripheral response, such as antihypertensives Antidepressants having an impact on serotonin central action contributing to low desire Antihormones having an impact on the genital organs and on the brain regulation of the sexual response Drugs influencing the peripheral response, such as antihypertensives Antidepressants having an impact on serotonin central action contributing to low desire Antihormones having an impact on the genital organs and on the brain regulation of the sexual response

Immediate factors Sexual anxiety (not knowing what will happen, lack of knowledge) Performance anxiety Fear of getting hurt Sexual anxiety (not knowing what will happen, lack of knowledge) Performance anxiety Fear of getting hurt Personality traits Lack of self esteem Body image problem Lack of self esteem Body image problem Biographic factors Early neglect Sexual abuse Later traumatic experiences Separation, humiliation Sexual violence Lack of sexual education Early neglect Sexual abuse Later traumatic experiences Separation, humiliation Sexual violence Lack of sexual education

Sexual dysfunction partner Erectile dysfunction Premature ejaculation Erectile dysfunction Premature ejaculation Conflicts Jealousy and mistrust Differences in needs Imbalance of giving and taking Inability to compromise and forgive Jealousy and mistrust Differences in needs Imbalance of giving and taking Inability to compromise and forgive Routine Loss of tension Loss of seduction and fantasy Loss of tension Loss of seduction and fantasy Lack of communication Avoiding to talk about feelings Fear of hurting the partner Hidden stories Third-party involvement Internet pornography Avoiding to talk about feelings Fear of hurting the partner Hidden stories Third-party involvement Internet pornography

General living conditions Social distress Sociocultural norms

Examples Communication training for dysfunctions based on dysfunctional communication Listening to each other (facts, emotions, relationship messages, etc.) How to communicate yes and no How to communicate without hurting each other How to give feedback How to negotiate Sensate focus (Masters and Johnson) Masters and Johnsons developed a therapeutic concept, which combined different elements of body awareness, focal psychotherapy, and systemic therapy into one approach. The concept supports couples in “relearning the sexual encounter” by dividing the intercourse into different phases, which allow both partners to observe and communicate about their physical and emotional reactions, thus creating the conditions of an enjoyable sexual encounter without being under the pressure of success. Communication training for dysfunctions based on dysfunctional communication Listening to each other (facts, emotions, relationship messages, etc.) How to communicate yes and no How to communicate without hurting each other How to give feedback How to negotiate Listening to each other (facts, emotions, relationship messages, etc.) How to communicate yes and no How to communicate without hurting each other How to give feedback How to negotiate Sensate focus (Masters and Johnson) Masters and Johnsons developed a therapeutic concept, which combined different elements of body awareness, focal psychotherapy, and systemic therapy into one approach. The concept supports couples in “relearning the sexual encounter” by dividing the intercourse into different phases, which allow both partners to observe and communicate about their physical and emotional reactions, thus creating the conditions of an enjoyable sexual encounter without being under the pressure of success. Masters and Johnsons developed a therapeutic concept, which combined different elements of body awareness, focal psychotherapy, and systemic therapy into one approach. The concept supports couples in “relearning the sexual encounter” by dividing the intercourse into different phases, which allow both partners to observe and communicate about their physical and emotional reactions, thus creating the conditions of an enjoyable sexual encounter without being under the pressure of success.

Examples Body awareness methods for orgasmic and arousal difficulties related to insecurity, lack of knowledge about one’s own body Masturbation exercises Therapy sexocorporelle Physiotherapy for sexual pain disorders related to pelvic floor dysfunction Cognitive behavioral interventions for dysfunctions related to the following: irrational beliefs and thoughts leading to negative emotions by becoming aware of these patterns and actively changing perspectives and way of thinking distress and performance anxiety by learning relaxation and coping techniques Psychodynamic focal therapy for dysfunctions related to feelings of guilt, shame, and internal conflicts between sexual needs and sexual norms: making them aware of this dynamics and helping the patient to find a solution based on integration of both parts of his or her personality Mindfulness Body awareness methods for orgasmic and arousal difficulties related to insecurity, lack of knowledge about one’s own body Masturbation exercises Therapy sexocorporelle Masturbation exercises Therapy sexocorporelle Physiotherapy for sexual pain disorders related to pelvic floor dysfunction Cognitive behavioral interventions for dysfunctions related to the following: irrational beliefs and thoughts leading to negative emotions by becoming aware of these patterns and actively changing perspectives and way of thinking distress and performance anxiety by learning relaxation and coping techniques irrational beliefs and thoughts leading to negative emotions by becoming aware of these patterns and actively changing perspectives and way of thinking distress and performance anxiety by learning relaxation and coping techniques Psychodynamic focal therapy for dysfunctions related to feelings of guilt, shame, and internal conflicts between sexual needs and sexual norms: making them aware of this dynamics and helping the patient to find a solution based on integration of both parts of his or her personality making them aware of this dynamics and helping the patient to find a solution based on integration of both parts of his or her personality Mindfulness Mindfulness can be defined as a state of present-moment, nonjudgmental awareness Regulation of attention to keep it focused on the immediate experience. Approaching one’s experience with curiosity, openness, and acceptance. The here and now should be observed and experienced with all senses, thoughts and feelings should be perceived without judgment but with an open mind. Thus, every sexual experience is unique. Regulation of attention to keep it focused on the immediate experience. Approaching one’s experience with curiosity, openness, and acceptance. The here and now should be observed and experienced with all senses, thoughts and feelings should be perceived without judgment but with an open mind. Thus, every sexual experience is unique.