Heal with the mind Erectile Dysfunction (TAKe CoNTRoL Book 6)
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Disease-associated changes can have a negative impact on sexual functioning [ 1 , 2 ]. Generally, sexuality in systemic sclerosis has been a neglected area so far, especially female sexual dysfunction. Impaired sexual functioning in women was probably less studied due to the complexity and multifactorial nature of female sexual response.
A little bit more attention was paid to erectile dysfunction, where etiology is more pronounced even though women are affected by this disease more often [ 3 , 4 , 5 ]. The etiology of sexual dysfunctions in systemic sclerosis is not well known; the causes are multifactorial and are related to both the disease symptoms and the therapy.
Sex and relationships
Presence of depression, fear, changes in face and body appearance, and lack of self-esteem are the psychological aspects, which can play a key role in the pathogenesis of sexual dysfunction in systemic sclerosis patients [ 6 ]. The etiology of erectile dysfunction is a little bit more understood. It is considered to be a result of microangiopathic changes. Due to corporal fibrosis and myointimal proliferation, the blood flow in the penile arteries is reduced. Several studies have suggested that sexual dysfunction is a widespread problem in both men and women with SSc.
It is more prevalent than in general population and other chronic diseases [ 7 ]. The most common symptoms of female sexual dysfunction are vaginal tightness, dryness, and dyspareunia [ 7 , 8 ].
More severe sexual dysfunction is usually associated with depression symptoms, aging, and functional impairment [ 2 , 9 , 10 ]. In women, more than half of the SSc patients experience some sexual problems [ 7 , 8 ]. The management of erectile dysfunction has been more studied compared to female sexual dysfunction treatment. However, the number of publications regarding the efficacy of erectile dysfunction treatment in SSc patients is still very limited and further research is needed.
The treatment of female sexual dysfunction in SSc women has not been paid much attention so far. There are only general recommendations available. In order to better understand why and how systemic sclerosis may affect sexual functioning, there is an overview of sexual response models, developed over the past few years, which led to the current diagnostic and classification criteria for sexual dysfunction.
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The first model of female sexual response was described by Masters and Johnson in They published that a normal female sexual response consists of four consecutive phases including desire, plateau phase, orgasm, and resolution. It was supposed that in both women and men, the sexual response is commenced by desire which is influenced by the activity of two brain centers—dopamine sensitive excitatory center and serotonin sensitive inhibitory center.
These centers send a signal going through the descendent nervous system into the spinal cord from where the genital sexual reaction is triggered. The arousal phase is mediated by the parasympathetic nervous system, which leads to vascular and genital changes such as enlargement of the clitoris, dilatation of perivaginal arterioles, and lubrication and expansion of two-thirds of the vagina. The following level of excitement is referred to the plateau phase that lasts until the orgasm.
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The orgasm phase is accompanied by contractions of pelvic floor muscles, increased heart rate, respiratory rate, and blood pressure. After reaching orgasm, the body usually calms down and this phase is called the refractory or resolution phase Figure 1 [ 14 ]. Modified according to . In , this model was modified by Kaplan into a three-phase model, which consists of desire, arousal, and orgasm [ 15 ].
Based on this linear model, the diagnostic and classification system was developed. The ICD focused on how physical factors influenced sexual response, whereas DSM-IV classification emphasized more emotional and psychological aspects of female sexual dysfunction. Because both approaches followed the linear model of sexual response, which was later criticized for not taking into consideration the complexity of female sexual response, the new classification was needed [ 16 ]. In , the Sexual Function Health Council of the American Foundation for Urologic Disease AFUD convened an interdisciplinary congress, which was attended by 19 experts on female sexual dysfunction selected from five countries.
The new developed classification has been extended to include psychogenic and organic causes of desire, arousal, orgasm, and sexual pain disorders. An essential point of this classification is the personal distress criterion considering sexual complaint as a disorder only if it causes a subjective feeling of distress [ 17 ]. Studies reported that women often describe overlapping phases of sexual response in variable sequences.
For instance, the unfounded assumption that desire always precedes arousal has been mistaken, and based on the women self-report and research data, it was proven that arousal and desire co-occur and reinforce each other. It was also found that motivation for sexual activity is much more complex than the mere presence of sexual desire defined as thinking or fantasizing about sex.
Women in different surveys cited that increased desire for sexual activity may be caused by the emotional closeness of a partner or intimacy that increases female well-being and self-image, which may include the sense of feeling attractive, appreciated, loved, or desired. The type of stimulation, time needed, and interpersonal context are highly individual. Moreover, spontaneous desire can be affected by the menstrual cycle, which usually decreases with age and grows with a new relationship. In addition, it was confirmed that, unlike men, there is no correlation between female subjective excitement and genital congestion.
Subjective excitement could be influenced by interpersonal relationships, contextual factors, privacy, appropriateness, general emotional status, emotional relationships, biological factors, presence of depression, the influence of hormones dopamine, testosterone , and others. In , therefore, a revision of the current definition was done.
The International Definitions Committee consisting of 13 experts from seven countries convened and proposed new definitions, which take into account new findings in the field of female sexual response [ 18 , 19 , 20 ]. It was emphasized that innate sexual fantasies and thoughts are not necessary for healthy sexual functioning and that desire is the result of sexual incentive that may be physically or subjectively perceived.
Based on the previous findings, the arousal disorder was reclassified into subjective arousal disorder, genital arousal disorder, combined genital and subjective arousal disorder, and persistent genital arousal disorder. It was finally noted that sexual dysfunction is a result of both psychological and biological and many other contributing factors [ 15 , 21 ].
Nonlinear model of female sexual response cycle. The initial stage of female sexual response is sexual neutrality, but with positive motivation left. The reasons why a woman is willing to initiate or agree to sexual activity can be that she wants to feel loved, share physical pleasure or be emotionally closer to her partner, please her partner, or she wants to increase her own satisfaction. If sexual stimuli last sufficiently long, sexual arousal and enjoyment will intensify, and it can trigger a desire for further sexual activity. It is important to note that desire appears at this point, not in the initial phase.
When the stimulation continues and no negatives outcomes are involved, the process results in sexual satisfaction with or without orgasm. Modified according to . The nonorganic sexual diseases were classified as mental and behavioral disorders and organic belonged to diseases of the genitourinary system chapter. However, since ICD definition, lots of evidences have been accumulated regarding the causes of sexual dysfunction, which often involve a combination of physical and psychological factors.
The ICD classification was therefore not consistent with clinical approaches in sexual health. ICD diagnostic guidelines organize sexual dysfunctions into four main groups: sexual desire and arousal dysfunctions;. Moreover, a separate grouping of sexual pain disorders has been established.
Where possible, categories in this new classification of sexual dysfunctions apply to both men and women even though the differences in sexual response are known.
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On the other hand, the neural pathways and neurotransmitters mediating sexual response are the same for both men and women. Separate sexual dysfunction categories are provided where clinical manifestations differ [ 24 ]. The overview of current diagnostic criteria of sexual dysfunctions is presented below in Table 1.
Sexual response is a complex interaction of psychological, interpersonal, social, cultural and physiological processes and one or more of these factors may affect any stage of the sexual response. Adapted from [ 25 , 26 ]. Persons with systemic sclerosis can experience a variety of symptoms that may affect all aspects of life, including sexual functions. The exact etiopathogenesis of sexual dysfunctions in systemic sclerosis is not well known; the causes are multifactorial and are related to both the disease symptoms and the therapy.
Medical, pathophysiological, psychological, and social components may be involved in sexual dysfunction. Both physical and psychological problems arising from disease-related condition contribute to partnership difficulties, less active and less enjoyable sexual life [ 3 , 27 , 28 ]. The most common physical symptom is skin tightness. Due to skin tightness, the fingers becomes fixed in bent position, which could interfere with sexual foreplay, touch, and masturbation.