From an article by Naveed Saleh, MD, MS, for MDLinx | January 2020/ Edited by JP Saleeby, MD
Talking to patients about erectile dysfunction (ED) used to be taboo when I was in medical school in the 1980s. Now, even men without ED ask for prescriptions to try Viagra or one of the knockoffs. But asking about the “little blue pill” is the exception when talking—or, more likely, not talking—about sexual dysfunctions and disorders to their doctor.
Because patients don’t like to bring them up and doctors sometimes don’t ask about them. Sexual health is an important part of wellness and quality of life. Much like sleep and health diet and exercise, these are topics a good Functional Medicine doctor will openly discuss with patients. This means those less-common sexual problems go undiagnosed, and therefore untreated out there in the conventional world of medicine.
To shed light on these, let’s take a look at five uncommon sexual disorders that deserve greater attention.
This condition is a specialized non-REM parasomnia, in which affected patients vocalize, masturbate, fondle, or attempt intercourse while sleeping. When these people wake up, they don’t remember anything. If your spouse enjoys uninterrupted sleep at night and you suffer from this, you may wake up with a black-eye.
According to limited research, this condition preferentially affects men (67%-81% male predominance) and begins between 26 and 33 years on average. Unsurprisingly, this condition may lead to interpersonal, clinical, and criminal repercussions. Sexsomnia likely exists on a continuum starting with sleepwalking.
Interestingly, obstructive sleep apnea (OSA) is a recognized precipitant of sex-arousal disorders. In a handful of those treated for sleep apnea, these disorders abated. Other possible treatments include maintaining sleep hygiene, antidepressants, and refraining from drugs and alcohol. CHM has just updated its “Better Sleep Handout” and for those interested please stop by the office for a copy.
Post-orgasmic illness syndrome
Sex is supposed to be enjoyable, which is why this next rare disorder is so strange.
Post-orgasmic illness syndrome (POIS) is an illness that causes a patient to experience flu-like and allergy symptoms post-orgasm. It mostly affects men, but women can also experience POIS, too. Symptoms develop soon after orgasm. These include fatigue, weakness, fever, mood changes, memory problems, concentration problems, sore throat, and itchy eyes, and commonly last between 2 and 7 days.
The etiology of POIS remains unknown, but some experts think that in men it could be an autoimmune or allergic reaction to semen. Other experts hypothesize that it could be due to a chemical imbalance in the brain.
POIS can be extremely distressing for patients and their partners. Although no definitive treatment for this condition exists, some men have tried SSRI antidepressants, benzodiazepines, or antihistamines. When all else fails, abstinence is an option. Alternatively, sex can be scheduled for when a person has enough time to cope and recover.
Persistent genital arousal disorder
Talk about uncomfortable… A recent case reported in PAIN Reports (https://journals.lww.com/painrpts/Abstract/latest/Persistent_genital_arousal_disorder__a_special.99822.aspx) expounded on persistent genital arousal disorder (PGAD), a syndrome marked by spontaneous sexual arousal or orgasm primarily affecting women. These orgasms are unpleasant, and some women found relief via masturbation. Most of these patients are sent for psychiatric treatment, although there appears to be a neurological underpinning.
“We hypothesize that many cases of PGAD are caused by unprovoked firing of C-fibers in the regional special sensory neurons that subserve sexual arousal,” the authors wrote. “Some PGAD symptoms may share pathophysiologic mechanisms with neuropathic pain and itch.”
Bolstering the position that PGAD is more neurological in nature is the observation that psychiatric treatment is ineffective, and that neurological tests in several patients found spinal nerve root lesions, nerve conduction abnormalities, and sensory nerve disorders. Neurological treatment following neurological evaluation has helped some. Interventions that have shown efficacy in individual patients include surgery to remove sacral nerve cysts and administration of IV immune globulin, as well as tapering doses of antidepressants.
When a man has an orgasm, a sphincter muscle shuts off access to the bladder so that semen can propel through the urethra. With retrograde ejaculation, a disorder of this muscle causes semen to divert into the bladder. Common causes include complications from prostate surgery, adverse effects of drugs such as SSRIs or medications used to treat enlarged prostate, and nerve damage caused by multiple sclerosis (MS) or uncontrolled diabetes (T2DM).
For most men, the symptoms of retrograde ejaculation are benign. Treatment can consist of medication discontinuance if drugs are the cause. If due to nerve or muscle damage of the bladder, pseudoephedrine or imipramine could ameliorate muscle tone at the bladder entrance. Finally, in vitro fertilization may be an option for those interested in having children who have unresolved issues about proper ejaculations.
Sexual desire disorders
The sexual response cycle is impacted by biopsychosocial factors and comprises four phases including desire, arousal, orgasm, and resolution. Desire, in turn, consists of three parts: sexual drive, sexual motivation, and sexual wish. Sexual drive results from psychoneuroendocrine mechanisms.
Sexual desire disorders may be more prevalent than you might expect: An estimated 32% of women and 15% of men lacked sexual interest in the previous 12 months, according to researchers.
Hypoactive sexual desire disorder (HSDD) and sexual aversion disorder (SAD) are two types of sexual desire disorders. These conditions likely exist on a spectrum, with SAD being more severe.
HSDD is defined as a persistent deficiency or lack of sexual fantasy or desire for sex. SAD involves aversion and avoidance of sexual contact with a partner. Subtypes include generalized, acquired, lifelong, situational, secondary to psychological factors, and secondary to combined factors.
Treatment for sexual desire disorders includes analytically-oriented sex therapy and psychotherapy, such as cognitive behavioral therapy. Of note, SAD is often progressive and refractory to treatment. Additionally, various hormone replacement treatments, as well as bupropion, herbal remedies, and even amphetamine and methylphenidate have been tried, with mixed success.
Addressing a patients’ sexual problems
“Sexual desire disorders are underrecognized, under-treated disorders leading to a great deal of morbidity in relationships,” wrote Keith A. Montgomery, MD, in the journal Psychiatry (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695750/). Dr. Montgomery asks physicians and other healthcare providers to become more familiar with prevalence, etiology, and treatment of sexual desire disorders. He urges physicians and patients alike to be more open and more comfortable with the topic so that they can be adequately addressed.