AAFP REVIEW MARCH 1st

1. AAFP REVIEW MARCH 1st By: Tanya Oberoi Pandya D.O., M.B.A.

2. Objectives • Present topics including: Female Sexual Dysfunction, Urinary Retention & Ear Pain • Answer/Discuss CME questions • Q&A

3. Diagnosis & Treatment of Female Sexual Dysfunction

4. Prevalence • 40% of women have sexual complaints • Affects women of ALL ages • Most Common Complaint: Decreased Desire • Second: Orgasmic Dysfunction

6. Components: Physiologic Psychological Emotional Relational Effected By: Sex Hormones Neurotransmitters on central & peripheral nervous systems Female Sexuality

8. Classifications • Sexual Desire • Sexual Arousal • Orgasmic • Sexual Pain Disorders

9. Primary: lifelong • Acquired: secondary • Situational: occurs only in certain circumstances or with certain partners • Generalized: occurs in all situations and with all partners

10. Sexual Desire • May be the traditional spontaneous desire from sexual thoughts, dreams, and fantasies; or it may be secondary to cognitive motivation. • In some women, particularly those in long-term relationships, nonsexual motivators (e.g.,emotional closeness, feeling loved) may lead to sexual desire

11. Sexual Arousal Mechanism • Genitals experience vasocongestion, which promotes vaginal lubrication, engorgement, and lengthening; dilation of the vaginal wall; and engorgement of the clitoris and vestibulovaginalbulbs disorder

12. Sexual Arousal (cont’d) • CAN have sexual arousal disorder may have genital vasocongestion to stimuli but do not experience subjective sense of arousal • CAN have physical satisfaction without experiencing orgasm • Positive experience promotes future motivation

13. Evaluation • Use open ended questions • If sexual concern elicited ask: • Menstrual history • Obstetric History • Reproductive History • Sexual History • Status of current relationships • Sexual Activity • Family & Personal Beliefs about sexuality • History of Sexual Trauma or Abuse • Medical History • Surgical History • Medication use (OTC, herbal) • Alcohol, Tobacco, Illicit Drugs • Family History • Birth Control Used

14. Evaluation (cont’d) • CPE: often normal, except in older women, women without medical care, or with systemic disease • Pelvic Exam: low hormone levels, infection, hypo or hypertonicity of pelvic floor mm, adhesions, tenderness • Mental Status • Blood Pressure • Peripheral Pulses • MMSK • Thyroid • Breast • Neurologic

16. Labs • Rarely helpful • No labs unless a particular physical finding or diagnosis suggest

17. PLISSIT Permission Limited Information inform pt re nl sexual functioning Specific Suggestion re pt’s specific complaint Intensive Therapy with sexual health subspecialist ALLOW Ask Legitimize problem as clinical issue Limitations to eval of sex dysfx Open up discussion, including potential referral Work together to develop goals and management Models to Initiate Discussion

18. Psychiatric Comorbidities • Sexual dysfunction can be a manifestation of OR side effect of treatment • SSRI are common cause • ALL antidepressants classes can cause sexual dysfunction

19. SSRIs • 30 to 50% incidence of SSRI induced sexual dysfunction • Delayed or absent orgasm • Decreased libido

20. Treatment of medication-induced sexual dysfunction • Dosage reduction • Drug holidays • Switching to or adding a medication with a lower sexual adverse effects: Wellbutrin, Remeron • Behavior strategies • Waiting for tolerance to the medication to develop • Delaying medication administration until after sexual activity • Individual and couple therapy

21. Treatment • Patient education • “Normal” sexual cycle • Guided/interactive pelvic exam • Educating normal anatomy

22. Hypoactive Sexual Desire Disorder • Most common type • Nonpharm treatment: stress management, exercise, adequate rest • Patient education: normal sexual function, changing desire with age

23. Hypoactive Sexual Desire Disorder (cont’d) • RX: • *Testosterone 300 mcg daily transdermally (not approved in women) in postmenopausal women • *Topical & systemic estrogen improves vaginal lubrication in postmenopausal women with vaginal atrophy, but the therapy has not been shown to consistently increase desire or arousal • Phosphodiesterase inhibitors have not been shown to improve diminished desire

24. Sexual Arousal Disorder • Educate patient about physiologic & subjective arousal • Eros Clitoral Therapy Device, made by UroMetric: FDA approved • improve arousal by increasing blood flow to the clitoris with gentle suction • Lubrication • Phosphodiesterase inhibitor: limited benefit

25. Orgasmic Disorder • Directed masturbation • Cognitive behavior therapy • Decrease anxiety and promoting changes in attitudes & sexual thoughts: increase the ability to achieve orgasm & to gain satisfaction • Sensate focus: sexual therapy that guides a woman & her partner through a series of exercises, moving from nonsexual to sexual touching

26. Orgasmic Disorder (cont’d) • PDE inhibitor: small studies show maybe some help • Wellbutrin: pilot study shows benefit

27. Sexual Pain Disorder • Causes: • Infection • Vaginal atrophy • Endometriosis • Psychological

28. Sexual Pain Disorder (cont’d) • Vulvar Vestibulitis: physiotherapy, TCA, other antidepressants • Vaginismus: physiotherapy, psychotherapy • Physiotherapy (e.g., hands-on techniques, biofeedback, pelvic floor electrical stimulation, perineal ultrasonography, use of vaginal dilators) • Psychotherapy is tailored to the patient's individual issues, and inclusion of her sex partner should be encouraged.9

29. CME QUIZ

30. WHICH ONE OF THE FOLLOWING STATEMENTS ABOUT SEXUAL DYSFUNCTION IN WOMEN TAKING SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) IS CORRECT? • A. SSRIS ARE THE ONLY CLASS OF ANTIDEPRESSANTS THAT CAUSE FEMALE SEXUAL DYSFUNCTION. • B. SSRIS DO NOT INTERFERE WITH ORGASM. • C. DELAYING MEDICATION ADMINISTRATION UNTIL AFTER SEXUAL ACTIVITY IS A TREATMENT OPTION FOR SSRI-INDUCED DYSFUNCTION. • D. THE INCIDENCE OF SSRI-INDUCED DYSFUNCTION IS LOW.

31. WHICH ONE OF THE FOLLOWING STATEMENTS ABOUT SEXUAL DYSFUNCTION IN WOMEN TAKING SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) IS CORRECT? • A. SSRIS ARE THE ONLY CLASS OF ANTIDEPRESSANTS THAT CAUSE FEMALE SEXUAL DYSFUNCTION. • B. SSRIS DO NOT INTERFERE WITH ORGASM. • C. DELAYING MEDICATION ADMINISTRATION UNTIL AFTER SEXUAL ACTIVITY IS A TREATMENT OPTION FOR SSRI-INDUCED DYSFUNCTION. • D. THE INCIDENCE OF SSRI-INDUCED DYSFUNCTION IS LOW.

32. WHICH ONE OF THE FOLLOWING IS CONSIDERED THE FOUNDATION OF FEMALE SEXUAL DYSFUNCTION TREATMENT? • A. HORMONE THERAPY. • B. PATIENT EDUCATION. • C. PHOSPHODIESTERASE INHIBITORS. • D. CLITORAL SUCTION DEVICE

33. WHICH ONE OF THE FOLLOWING IS CONSIDERED THE FOUNDATION OF FEMALE SEXUAL DYSFUNCTION TREATMENT? • A. HORMONE THERAPY. • B. PATIENT EDUCATION. • C. PHOSPHODIESTERASE INHIBITORS. • D. CLITORAL SUCTION DEVICE

34. WHICH OF THE FOLLOWING PHYSICAL EXAMINATION FINDINGS IS/ARE ASSOCIATED WITH DYSPAREUNIA? • A.VAGINAL DISCHARGE • B. THYROID ENLARGEMENT • C. VULVAR SKIN ABNORMALITIES • D. VAGINAL ATROPHY

35. WHICH OF THE FOLLOWING PHYSICAL EXAMINATION FINDINGS IS/ARE ASSOCIATED WITH DYSPAREUNIA? • A. VAGINAL DISCHARGE • B. THYROID ENLARGEMENT • C. VULVAR SKIN ABNORMALITIES • D. VAGINAL ATROPHY

36. Urinary Retention in Adults: Diagnosis & Initial Management

37. Urinary Retention • Inability to voluntarily void urine • Acute urinary retention: sudden and often painful inability to void despite having a full bladder • Chronic urinary retention is painless retention associated with an increased volume of residual urine

38. Incidence • Dramatically increases with age • Age: 70s has a 10% chance • Age: 80s >30% chance of having an episode of acute urinary retention.

40. Obstructive • Intrinsic: BPH, bladder stones, uretheral stricture • Extrinsic: uterine or GI mass/impaction, reteroperitoneal mass • Women: Pelvic organ prolapse (cystocele or rectocele); uterine prolapse

41. Infectious/Inflammatory • Prostatitis: MCC • Urethritis • STI: uretheral edema • Genital herpes: local inflammation & sacral nn involvement (Elsberg syndrome)

42. Pharmacologic • Anticholinergics (TCA): decreasing detrusory mm contraction • Sympathomimetic drugs (decongestants): increase alpha-adrenergic tone in prostate & bladder neck • NSAIDs: twice as likely; d/t inhibition of prostaglandin mediated contraction of detrusor mm

45. Other Causes • Postoperative: narcotics, pain, traumatic instrumentation, bladder overdistention, type of anesthesia (pudendal block) • Pregnancy-associated: impacted retroverted uterus (16wks), post epidural • Trauma: to urethra, penis, bladder

46. H&P

48. BPH • Symptoms: frequency, urgency, nocturia, straining to void, weak urinary stream, hesitancy, sensation of incomplete bladder emptying, and stopping and starting of urinary stream.

49. Exam • Percussion: able to percuss if 150 ml urine in bladder • Palpate: palpable with >200ml of urine • Rectal Exam • UA • Post Void Residual: (?50 to 300ml)

50. Neurogenic Bladder • Consider in any of the following: • Hx of neurologic dz • Spinal trauma or tumor • Diabetes • Any change in baseline neurologic status