Psychiatry EOR: Paraphilic Disorders; Sexual Dysfunctions (Pearls) (Smarty PANCE)

What defines a paraphilic disorder?

Recurrent, intense sexually arousing fantasies, urges, or behaviors involving atypical objects/situations causing distress or impairment for ≥6 months

What is voyeuristic disorder?

Recurrent sexual arousal from observing unsuspecting person who is naked, disrobing, or engaging in sexual activity - must cause distress or involve non-consenting person

What is exhibitionistic disorder?

Recurrent sexual arousal from exposing one's genitals to an unsuspecting person - must cause distress or involve non-consenting person

What is frotteuristic disorder?

Recurrent sexual arousal from touching or rubbing against a non-consenting person, typically in crowded public places

What is sexual masochism disorder?

Recurrent sexual arousal from being humiliated, beaten, bound, or made to suffer - must cause significant distress or impairment

What is sexual sadism disorder?

Recurrent sexual arousal from physical or psychological suffering of another person - particularly concerning when involves non-consenting victims

What is fetishistic disorder?

Recurrent sexual arousal from non-living objects (shoes, underwear) or non-genital body parts causing distress or impairment for ≥6 months

What is pedophilic disorder?

Recurrent sexual arousal involving prepubescent children (generally ≤13 years) in person ≥16 years old and ≥5 years older than child

What is transvestic disorder?

Recurrent sexual arousal from cross-dressing in heterosexual males causing significant distress or impairment

What are the general treatment approaches for paraphilic disorders?

Cognitive-behavioral therapy, SSRIs (reduce sexual drive), antiandrogens (severe cases), psychoeducation, relapse prevention

What medication class is used to reduce sexual drive in paraphilic disorders?

SSRIs (first-line), antiandrogens like medroxyprogesterone or leuprolide (for severe/dangerous behaviors)

What is delayed ejaculation?

Marked delay in or inability to achieve ejaculation during sexual activity for ≥6 months (occurs in 75-100% of occasions)

What is erectile disorder?

Marked difficulty obtaining or maintaining erection or decreased erectile rigidity for ≥6 months (occurs in 75-100% of occasions)

What are the organic causes of erectile disorder? Use mnemonic DIVAS

Diabetes, Ischemic vascular disease, Venous leak, Alcohol/drugs, Surgery/trauma

What is the first-line treatment for erectile disorder?

PDE-5 inhibitors (sildenafil, tadalafil, vardenafil) - increase cGMP leading to smooth muscle relaxation and increased blood flow

What are contraindications to PDE-5 inhibitors?

Concurrent nitrate use (risk of severe hypotension), recent MI/stroke, severe cardiac disease, hypotension

What is female orgasmic disorder?

Marked delay, infrequency, or absence of orgasm, or reduced orgasmic intensity for ≥6 months (occurs in 75-100% of occasions)

What is female sexual interest/arousal disorder?

Lack of or significantly reduced sexual interest/arousal with absent/reduced sexual thoughts, initiation, excitement, pleasure, or genital sensations for ≥6 months

What is genito-pelvic pain/penetration disorder?

Persistent difficulties with vaginal penetration, vulvovaginal/pelvic pain, fear/anxiety about pain, or pelvic floor muscle tension for ≥6 months

What conditions should be ruled out in genito-pelvic pain disorder?

Vaginismus, endometriosis, pelvic inflammatory disease, vulvodynia, vestibulodynia, atrophic vaginitis

What is male hypoactive sexual desire disorder?

Persistently deficient or absent sexual thoughts, fantasies, and desire for sexual activity for ≥6 months causing distress

What is premature (early) ejaculation?

Ejaculation within approximately 1 minute of vaginal penetration and before person wishes it for ≥6 months (occurs in 75-100% of occasions)

What are treatment options for premature ejaculation?

SSRIs (paroxetine, sertraline - delay ejaculation), topical anesthetics, behavioral techniques (stop-start, squeeze method), counseling

What medications commonly cause sexual dysfunction? Use mnemonic SASH

SSRIs (most common), Antipsychotics, Stimulants (amphetamines), Hypertensives (beta-blockers, thiazides), alcohol

What is the most common sexual side effect of SSRIs?

Delayed or absent orgasm (anorgasmia), decreased libido, erectile dysfunction in men

How is substance/medication-induced sexual dysfunction diagnosed?

Sexual dysfunction develops during or soon after substance/medication use and is not better explained by non-substance-induced sexual dysfunction

What is the general approach to treating sexual dysfunctions?

Address underlying medical conditions, review medications, psychotherapy (CBT, sex therapy), treat relationship issues, consider medication changes

What laboratory tests should be ordered for erectile dysfunction workup?

Morning testosterone, glucose/HbA1c, lipid panel, TSH, prolactin (if low testosterone or decreased libido)

What non-pharmacologic treatments help with sexual dysfunctions?

Couples/sex therapy, sensate focus exercises, communication training, address performance anxiety, lifestyle modifications

What is the difference between lifelong vs acquired sexual dysfunction?

Lifelong: present since sexually active; Acquired: develops after period of normal sexual function