Sexual Dysfunction and Disease

Sexual functioning is important to a person’s quality of life. Problems with sexual function can have a negative effect on mood, interpersonal relationships and overall well-being.

The term "sexual dysfunction" describes a number of conditions that harm a person's ability to have an enjoyable sex life. Sexual dysfunction includes problems that affect a person’s desire for sex, ability to become sexually aroused and ability to reach orgasm, as well as problems resulting in pain during intercourse.

Sexual dysfunction can be caused by physical and emotional factors, or a combination of both. Certain medical conditions are associated with an increased risk of sexual dysfunction. Most common of these conditions are:

• Cardiovascular disease, including hypertension (high blood pressure) and peripheral vascular disease (a circulation disorder that affects blood vessels away from the heart)
• Diabetes
• Prostate cancer
• Depression
• Menopause

How does cardiovascular disease affect sexual function?
Many cardiovascular diseases, especially hypertension and peripheral vascular disease, involve changes to the small blood vessels that supply areas of the body away from the heart, such as the legs, feet and genitals. Poor blood flow to the penis or vagina can impact a person’s ability to become aroused and engage in sexual intercourse. Some studies suggest that 30 percent to 50 percent of cases of erectile dysfunction (the inability to achieve or maintain an erection suitable for intercourse) are the result of blood vessel disease.

Further, any medical condition that causes a general feeling of weakness and disability has the potential to decrease sexual desire and performance. For example, the fatigue, shortness of breath, chest pain and muscle weakness that may accompany cardiovascular disease also may be responsible for problems with sexual function. The fear that sexual activity may trigger a severe cardiac event, such as a heart attack, also may be a factor in decreasing sexual function in people with cardiovascular disease. In addition, some medications used to treat cardiovascular disease, particular hypertension, can have negative sexual side effects, including loss of desire, erectile dysfunction and problems with ejaculation.

In many cases, individuals with cardiovascular disease can resume sexual activity and be treated for sexual dysfunction, when appropriate, if they follow their doctors’ recommendations and cardiovascular disease treatment plan. Certain lifestyle changes—such as quitting smoking, reducing alcohol intake, eating a healthy diet, and engaging in regular exercise and physical activity—also can help improve blood flow and reduce the risk of sexual dysfunction.

How does diabetes affect sexual function?
Diabetes also can affect the blood vessels. In addition, a condition called diabetic neuropathy—which involves damage to the nerves—may contribute to problems with sexual function.

In men, diabetes can lead to a hardening and narrowing of the blood vessels that supply the erectile tissue of the penis. This can cause problems achieving an erection. In addition, the penis may be less firm during an erection. In women, diabetes can lead to hardening of the blood vessels of the vaginal wall. Decreased blood flow can affect vaginal lubrication, causing the vagina to be too dry for comfortable intercourse. This condition also seems to put woman at greater risk for recurring yeast infections.

For people with diabetes, the first step in treating sexual dysfunction is to control their blood glucose levels. When the diabetes is well-controlled, there is a decreased risk for many complications, including sex-related problems.

There are other treatments for sexual dysfunction that may be used for people with diabetes. These include the use of medication, specifically sildenafil citrate (Viagra™), varderafil (Levitra™), or tadalafil (Cialis™) to treat erectile dysfunction, mechanical devices (vacuum devices, penile implants, etc.) and counseling. For women with vaginal dryness, a water-soluble lubricant (such as Astro-Glide or K-Y Jelly) may be helpful.

How does prostate cancer affect sexual function?
Although prostate cancer is not a cause of erectile dysfunction, treatments for the disease can cause erectile dysfunction. All current treatments for prostate cancer can be associated with erectile dysfunction, although the onset of dysfunction can vary, depending on the treatment.

The current methods of treating prostate cancer include:

• Surgery with radical prostatectomy (removal of the entire prostate gland) — Erectile dysfunction can begin immediately following a radical prostatectomy, whether the nerve-sparing or non-nerve-sparing technique is used. The nerves are those that control erections and they are very close to the prostate. If the nerve-sparing technique is used, recovery from erectile dysfunction may occur within the first year following the procedure. Recovery of erectile function after a non-nerve-sparing technique is possible, but unlikely.
• Radiation therapy by external beam or brachytherapy (seed implant) — The onset of erectile dysfunction following radiation therapy is gradual and usually begins about six months following radiation therapy.
• Hormone therapy (to decrease androgens, as in testosterone) — When hormone therapy is used, erectile dysfunction may occur approximately two to four weeks following the initiation of the therapy and usually is accompanied by a decreased libido (desire for sex).

The treatment options for erectile dysfunction for patients who have received treatment for prostate cancer include sildenafil (Viagra), intracavernous injection therapy (injection of medication into the penis), vacuum constriction devices, intraurethral therapy (medication taken as a suppository placed in the urinary tube) and penile prostheses (implanted devices).

How does depression affect sexual function?
The brain is the body’s most sensitive "sex organ." Sexual desire starts in the brain and works its way down. Chemicals called neurotransmitters help brain cells (neurons) communicate to stimulate blood flow to the sex organs.

In a person with depression, a clinical mood disorder, these chemicals are out of balance. As a result, sexual desire is low or non-existent. In addition, low levels of certain neurotransmitters can dull the feelings of pleasure. The strain that a depressive illness can place on a patient’s relationship can further interfere with sexual functioning and pleasure. For both men and women, being unable to initiate, participate in or enjoy sex can lead to a crippling loss of self-confidence, which—in turn—can undermine recovery from the depression.

Ironically, some medicines used to treat depression—particularly a group of medicines called selective serotonin reuptake inhibitors (SSRI)—can further affect sexual functioning. An estimated 33 percent of people taking antidepressants experience decreased desire and difficulty in achieving orgasm. Some antidepressants also may cause problems with erections in men. As the dosage of antidepressants increases, the sexual side effects increase, as well.

There are ways to help manage the sexual side effects associated with many antidepressant medicines, without compromising treatment. These include taking brief drug "holidays" and switching to a drug that has less effect on sexuality. Keep in mind that no medication should be discontinued or stopped briefly without discussing it with your doctor. Some newer medicines—such as amineptine, Wellbutrin, Remeron and Serzone—are shown to cause fewer or no sexual side effects.

In order to better cope with the debilitating effects of depression, as well as the sexual side effects of treatment, patients must be open and honest with their doctors and their partners. Most patients choose to continue treatment once they realize that the sexual problems they are experiencing are associated with the medicines and are reversible, and do not reflect a problem with themselves or their relationships.

Menopause
The loss of estrogen following menopause can lead to changes in a woman’s sexual functioning. Lower levels of estrogen can result in a significant decrease in blood supply to the vagina. As with diabetes, this decreased blood flow can affect vaginal lubrication, causing the vagina to be too dry for comfortable intercourse. Menopausal women may notice that they are not as easily aroused, and may be less sensitive to touching and stroking—which can result in decreased interest in sex. Further, the emotional changes that often accompany menopause can add to a woman’s loss of interest in sex and/or ability to become aroused. For women with vaginal dryness, a water-soluble lubricant (such as Astro-Glide or K-Y Jelly) may be helpful.

Hormone replacement therapy may improve certain conditions, such as loss of vaginal lubrication and genital sensation, that can create problems with sexual function. However, hormone replacement therapy poses certain risks, including uterine bleeding and an increased risk of breast cancer. For that reason, the use of hormone replacement therapy must be evaluated on an individual basis.

It should be noted that some post-menopausal women report an increase in sexual satisfaction. This may be due to decreased anxiety associated with a fear of pregnancy. In addition, post-menopausal woman often have fewer child-rearing responsibilities, allowing them to relax and enjoy intimacy with their partners.

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