sexuality

Introduction to Sexuality

  • Erectile Dysfunction

  • Menopause

  • Pelvic Organ Prolapse

Definitions

  • Sexuality: A state of physical, emotional, mental, and social well-being related to sexuality; it is not merely the absence of disease, dysfunction, or infirmity.

  • Sexual Health: Requires a positive and respectful approach to sexuality and sexual responses, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence.

Scope of Sexuality

  • Ranges from sexual well-being to sexual ill-being.

  • Questions to Consider:

    • What contributes to sexual dysfunction?

    • What are examples of sexual ill-being or dysfunction?

    • In what way does culture impact this perspective?

General Phases of Sexual Response

  1. Motivation

  2. Arousal

  3. Genital Congestion

  4. Orgasm

  5. Resolution

  • Questions to Consider:

    • How do females respond during each of these stages?

    • How do males respond during each of these stages?

Variations and Context

  • Factors Affecting Sexual Dysfunction:

    • Physiological Factors

    • Psychological Factors

    • Maturational Factors

    • Environmental Factors

Etiology of Sexual Disorders

  • Sexually Transmitted Infections (STIs)

  • Female Sexual Disorders

  • Male Sexual Disorders

  • Questions to Consider:

    • Why can psychological factors (like anxiety, mood disorders, or stress) play a more significant role in sexual behavior than biological factors?

Consequences of Sexual Dysfunction

  • Physiological Consequences:

    • Unfulfilled sexual desire

    • Unsatisfactory sexual response

    • Pain

    • STIs

    • Infertility

  • Psychological Consequences:

    • Problems with relationships

    • Low self-esteem

    • Anxiety

    • Depression

Populations at Risk

  • Adolescents

  • Individuals with Disabilities:

    • Cognitive disabilities

    • Developmental disabilities

    • Physical disabilities

  • Newly Unpartnered Individuals

  • Sexual Orientation and Identification

Risk Factors for Sexual Dysfunction

  • High-risk Sexual Behavior:

    • Multiple and casual partners

    • Failure to practice safe-sex measures

  • Substance Use:

    • Alcohol, marijuana, or other illicit substances

  • Underlying Medical Conditions and Medications

  • Questions to Consider:

    • How does substance use impact high-risk sexual behaviors?

Assessment: Taking a Sexual History

  • Usual sexual patterns

  • Number of partners

  • Frequency of sexual activity

  • Level of satisfaction with sexual activity

  • Knowledge level of sexual functioning

  • Perceived problems

Assessment: Female Gynecological Examination

  • Components of Examination:

    • External genitalia and internal structures examination

    • Inspection and palpation:

    • External inspection and palpation

    • Internal inspection of vagina/cervix

    • Bimanual palpation (uterus and ovaries)

    • Collection of specimens as needed

  • Usually performed by physicians or nurse practitioners

Assessment: Male Examination

  • Components of Examination:

    • Examination of genitalia, testicles, and prostate

    • Inspection and palpation:

    • External inspection and palpation

    • Digital rectal examination

    • Collection of specimens as needed

  • Usually performed by physicians or nurse practitioners

Assessment: Common Diagnostic Tests

  • Papanicolaou Test (Pap Smear)

  • Prostate-Specific Antigen (PSA)

  • Testing for STIs

  • Genetic Screening

  • Hormonal Assays

  • Questions to Consider:

    • What would be included in client education for a Pap smear?

Clinical Management

Primary Prevention

  • Patient Education:

    • Condom use

    • Safe-sex practices

    • HPV vaccine

Secondary Prevention

  • Screening:

    • Screening for STIs

    • Screening for intimate partner violence

    • Cervical cytological screening (Pap test)

    • HIV screening

Collaborative Interventions

  • Pharmacological Agents:

    • Treatment of STIs, erectile dysfunction, menopausal symptoms

  • Devices:

    • Pessaries for pelvic organ prolapse

  • Surgery:

    • For pelvic organ prolapse and erectile dysfunction

  • Sexual Counseling

  • Questions to Consider:

    • Which pharmacological agents are recommended for treating erectile dysfunction and menopause symptoms?

    • What type of surgery may be used to treat erectile dysfunction and pelvic organ prolapse?

Interrelated Concepts

  • Anxiety

  • Gas Exchange

  • Reproduction

  • Stress

  • Sexuality

  • Pain

Review Quiz on Sexuality

  • True or False: Sexuality is a state of well-being that involves physical, emotional, mental, social, and spiritual dimensions across the life span.

  • True or False: Sexual identity is based on biological sexual characteristics, whereas gender identity is a psychosocial construct.

  • Select All That Apply: Which is not one of the 5 Ps of sexual health?

    • Partners

    • Parental Approval

    • Population at Risk

    • Protection

    • Past History

    • Practices

  • Question: Which patient is most at risk for sexual abuse?

  • Question: Statements about sexual dysfunction:

    • A. Biological factors play a more significant role than psychologic factors.

    • B. Sexual dysfunction is more prevalent among men than women.

    • C. The best predictor of sexual health is emotional well-being.

    • D. The patient with sexual dysfunction is at risk for anxiety and depression.

    • E. Sexual dysfunction remains uncommon.

Erectile Dysfunction

  • Definition: The inability to achieve and maintain an erection.

  • Types of Erectile Dysfunction:

    • Organic (Physiological)

    • Functional (Psychogenic)

Recognizing Cues: Risks Factors / Causes

  • Age

  • Vascular Diseases

  • Endocrine Diseases

  • Neurologic Diseases

  • Chronic Diseases

  • Penile Disease or Trauma

  • Surgery

  • Lifestyle Choices:

    • Obesity

  • Psychological Conditions

  • Medications

Diagnostic Testing

  • History & Physical Exam

  • Lab Testing:

    • Urine tests (urinalysis)

    • Penile Doppler ultrasonography test

    • Psychological assessment

Interventions: Take Action

  • Treatment Depends on the Underlying Cause

  • Lifestyle Modification

  • Medications:

    • Vacuum constriction device

    • Penile implants (prostheses)

    • Penile suppository

    • Penile injections

    • Counseling/Therapy

Case Study: Erectile Dysfunction

  • Case Overview:

    • A 42-year-old man with complaints of decreased erection.

    • No history of trauma or surgeries.

    • Medications: Antihypertensives and an oral hypoglycemic agent.

    • Alcohol use of 1-2 drinks, five days a week.

    • Vitals: Within Normal Limits; BP = 132/81

Attributable Causes for This Patient's ED

  • Analyze potential causes based on age, medications, and lifestyle.

Recommendations for the Patient

  • Education on lifestyle changes, medication adherence, and potential counseling.

Likely Diagnostic Tests for This Patient

  • Based on history and physical exam findings.

Other Standard Treatments for Erectile Dysfunction

  • Overview of all potential medication options.

Medications to Treat Erectile Dysfunction

  • Drug Class: Phosphodiesterase-5 Inhibitors (PDE-5)

    • Examples:

    • sildenafil (Viagra)

    • vardenafil (Levitra, Staxyn)

    • tadalafil (Cialis)

    • Route: Oral

    • Indication: Treat male erectile dysfunction and pulmonary arterial hypertension

    • Common Adverse Effects:

    • Headache

    • Flushing of the face and neck

    • Color vision impairment

    • Serious Adverse Effects:

    • Hypotension

    • Dizziness

    • Angina

    • Loss of vision

    • Sustained erection

    • Patient Education/Nursing Considerations:

    • Avoid using nitrate drugs while taking ED medications

    • Notify provider if erection lasts longer than 4 hours

Mechanism of Action

  • Enhances the effects of nitric oxide

  • Relaxes smooth muscle in the corpora cavernosa

  • Decreases usable testosterone

Patient Education

  • Medications can be taken up to 24 hours before sexual activity

  • Instructions vary depending on the medication taken

  • Taking a tablet will not automatically induce an erection

Key Points on Erectile Dysfunction

  • Also known as impotence, is the inability to achieve or maintain an erection.

  • Causes can be functional or organic.

  • First-line oral drugs used are phosphodiesterase-5 inhibitors.

  • Other treatment options: vacuum assist devices, penile injections, transurethral suppositories, or penile implants.

Menopause

  • Definition: The end of a woman’s menstrual cycles, dated with certainty 1 year after menstruation ceases.

  • Occurs between ages 35-60; average age is 51 years old.

Three Stages of Menopause

  1. Perimenopause:

    • Preceding menopause for about 4 years.

    • Decline in ovulation, progressing to anovulation.

    • Irregular/skipped menses to amenorrhea.

  2. Menopause:

    • Cessation of menses; a combination of endocrine, body, and psychological changes occurs at the end of the reproductive cycle.

  3. Post Menopause:

    • Time after being without a menstrual period for 12 months.

    • Symptoms like hot flashes may get milder or disappear; increased risk for health conditions such as osteoporosis and heart disease.

Recognizing Cues: Clinical Manifestations of Menopause

  • Vasomotor Symptoms:

    • Hot flashes, night sweats.

  • Genitourinary Symptoms:

    • Vaginal dryness, incontinence, pelvic organ prolapse, UTI/cystitis.

  • Skeletal Symptoms:

    • Decrease in bone density.

  • Cardiovascular Symptoms:

    • Increase in LDL, decrease in HDL.

  • Dermatological Symptoms:

    • Decreased skin elasticity, hair loss.

  • Reproductive Symptoms:

    • Decrease in libido, changes in breast tissue.

  • Psychological Symptoms:

    • Mood swings, sleep disturbances, body image disturbances.

Recognizing Cues: Diagnosis of Menopause

  • History: Comprehensive medical history.

  • Laboratory Tests:

    • Follicle-stimulating hormone level

    • Thyroid-stimulating hormone (TSH)

    • Estrogen, progesterone, & testosterone levels

  • Diagnostic Procedures:

    • Pelvic exam

    • Breast exam

    • Endometrial biopsy

    • Bone density study

Interventions: Take Action

Medications

  • Hormone Replacement Therapy (HRT)

  • Nonpharmacological Therapies:

    • Kegel exercises

    • OTC water-based lubricants

  • Lifestyle Modifications

  • Alternative & Complementary Therapies:

    • Yoga, acupuncture

    • Herbal remedies (phytoestrogens, vitamins E & B6)

Key Points on Menopause

  • Menopause results from a complex syndrome of physiological changes caused by declining ovarian function.

  • The cessation of menstruation occurs naturally or due to medical interventions (e.g., oophorectomy, chemotherapy).

  • Increased risk after menopause for medical conditions include heart/cardiovascular disease, osteoporosis, urinary incontinence, decreased sexual function/desire, and weight gain.

  • Menopause itself requires no medical treatment; treatments focus on symptom relief and managing chronic conditions associated with aging.

Pelvic Organ Prolapse

  • Definition: Refers to the drooping of pelvic floor organs, including the uterus (uterine prolapse), bladder (cystocele), and rectum (rectocele).

  • Diagnosis occurs when these organs descend into or outside the vaginal canal or anus.

  • Common Types Include:

    • Uterine Prolapse

    • Cystocele

    • Rectocele

Recognizing Cues: Risk Factors for Pelvic Organ Prolapse

  • Factors that increase pressure on the abdomen:

    • Pregnancy, labor, childbirth

    • Aging

    • Menopause

    • Long-term pressure on the abdomen (e.g., constipation)

    • Pelvic organ cancers

    • Pelvic surgery

    • Family history

Take Action: Nonsurgical Interventions

  • Interventions vary based on severity of POP:

    • Lifestyle modifications

    • Intravaginal estrogen therapy

    • Kegel exercises or physical therapy

    • Vaginal pessary

    • Bladder/bowel management

  • Surgical interventions considered for severe symptoms (e.g., transvaginal repair, anterior colporrhaphy)

Case Study: Pelvic Organ Prolapse (POP)

  • Case Overview:

    • A 65-year-old woman noted a feeling of fullness in the vaginal area, particularly when standing.

    • No urinary or fecal incontinence; pelvic exam findings include generalized atrophic changes and noted cystocele and rectocele.

    • Preferences lean towards non-surgical treatment, and a pessary is placed with a prescription for vaginal estrogen for atrophic changes.

Discussion Questions on POP

  • What increases this patient's risk for pelvic organ prolapse?

  • What are the different types of pelvic organ prolapse?

  • What are the symptoms of pelvic organ prolapse?

  • How is POP diagnosed?

  • What are nonsurgical treatment options?

  • What role does vaginal estrogen play in managing pelvic relaxation?

  • What education would you provide to your patient about POP?

  • What information should you include about Kegel exercises?

  • How to explain pelvic floor physical therapy to the patient?

Key Points on Pelvic Organ Prolapse

  • The pelvic organs are supported by a sling of muscles/tendons which may weaken, leading to organ prolapse.

  • Uterine prolapse is the most common type; cystocele and rectocele involve urinary and bowel functions respectively.

  • Conservative treatments preferred; surgical methods include anterior colporrhaphy for bladder support and posterior colporrhaphy for rectal bulging.

References

  • Giddens, J. (2021) Concepts for Nursing Practice (3rd ed.). St Louis, Missouri: Elsevier

  • Ignatavicius, D. & Workman, L. M. (2018). Medical-Surgical Nursing (10th ed.). St. Louis, MO: Elsevier, Inc.

  • Menopause. (2022, February 15). Retrieved from National Institutes of Health: http://www.nlm.nih.gov/medlineplus/menopause.html