Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Sexual Dysfunction
F52.8: Other sexual dysfunction not due to a substance or known physiological condition
I. DEFINITION
Diminished desire or lack of libido (most common), orgasmic disorder; diminished sexual response or lack of arousal to sexual stimulation; sexual pain with dyspareunia or vaginismus, involuntary spasm, or constriction of the distal third of the vaginal musculature around the introitus on one or more occasions;
A. PLISSIT model (permission, limited information, specific sugges- tions, intensive therapy) is used to initiate discussion about sexual dysfunction and its management.
B. ALLOW model (ask, legitimize, limitations, open up, work together) facilitates completion of sexual history and initiation of treatment for further evaluation.
II. ETIOLOGY
A. Organic and physiologic disorders
1. Hormonal/endocrine imbalance
2. Injuries or anomalies of the genital tract
3. Infection of the genitalia
4. Lesions
5. Nerve impairment
6. Substance abuse: alcohol, recreational drugs
7. Recent pregnancy
8. Effects of medications (prescription or over the counter)
9. Chronic illness
10. Vasculogenic
B. Relationship disorders
1. Partner’s and/or patient’s lack of desire for sex
2. Medical conditions
3. Lack of privacy
4. Fear of failure in the sexual act; lack of knowledge about sexual response(s)
5. Shame, guilt
6. Expectations different from those of partner; miscommunication
7. Rape trauma; sexual assault or abuse at any age; domestic violence
8. Improper use of barrier or chemical contraceptives
9. Recent gynecologic event affecting sexuality, such as sterilization, pregnancy, tubal ligation or occlusion, abortion, hysterectomy, and mastectomy
10. Difficulties in sexual orientation; confusion over gender identity
11. Clinical depression of patient and/or partner
12. Spectatoring
III. HISTORY
A. What the patient may present with
1. Lack of sexual desire
2. Lack of response to stimulation
3. Inability to have an orgasm (primary or secondary)
4. Vaginal or vulvar irritation, bleeding, soreness
5. Lack of vaginal lubrication, dryness
6. Inability to have vaginal intercourse
7. Dyspareunia may be associated with vaginal dryness.
B. Other signs and symptoms
1. Rectal or perineal pain
2. Perineal lesions
3. Abdominal pain, pelvic pain
4. Fever
5. Bladder, urethral pain
C. Additional information to be considered
1. Sexual history: ever had intercourse; ever experienced orgasm; partners (men, women, both)
2. Contraceptive history and method presently using
3. Any gynecologic/obstetrical history, diethylstilbestrol exposure, perimenopausal problems, pelvic surgery, tubal ligation, carcinomas
4. Any recent contributing events: change of partner or new relationship, marriage, divorce, separation, sterilization, pregnancy, infection, surgery, sexual assault, incest, domestic violence, unemployment, other stressors
5. Any cultural or religious beliefs that relate to sexual activity
6. Alcohol, drug use; any changes
7. Expectations of self and partner, health of sexual partner
8. Any problems with privacy, time together, living arrangements
9. Use of sex toys
10. Pattern of sexual expression; availability of sexual partner
11. You might ask: “What do you do?” “How do you do it?” and “How does it make you feel?”
12. Sexual fantasies; preoccupations
13. Difficulties focusing on tactile or other sensations previously erotic
IV. PHYSICAL EXAMINATION
A. Vital signs
1. Blood pressure
2. Weight
B. General physical examination, including thyroid, breasts, costoverte- bral angle (CVA) tenderness (pyelonephritis), and neurologic
C. Abdominal examination with special attention to
1. Guarding
2. Pain
3. Masses
D. External examination
1. Anomalies
2. Skene’s glands
3. Clitoris
4. Status of hymen
5. Perineum
6. Bartholin’s glands
7. Urethra
8. Lesions, signs of infection, injury
E. Vaginal examination (speculum)
1. Vaginal walls: infection, anomalies, atrophy, injuries
2. Discharge, lesions
3. Cervix: lesions, signs of infection, anomalies, scarring
4. Tolerance of speculum and size accommodated, length of vagina
F. Bimanual examination
1. Pain on cervical manipulation
2. Uterus: tenderness, position
3. Adnexa: mass, tenderness
4. Vaginal lesions: tone or vaginismus
V. LABORATORY EXAMINATION
A. Appropriate cultures when evidence or risk of infection; wet mount; urinalysis
B. Consider thyroid panel; fasting blood sugar (FBS; liver, renal function tests; serum corticosteroids if history and/or clinical findings warrant
C. Hormone assays as indicated
VI. DIFFERENTIAL DIAGNOSIS
A. Hormonal imbalance: estrogen, androgens
B. Anomaly, injury
C. Infection
D. Substance abuse: drugs, alcohol, smoking, use of e-cigarettes
E. Nerve impairment: spinal cord injury, neurologic diseases
F. Changes caused by aging: slower responses
G. Adrenal, thyroid, liver, kidney problems
H. Diabetes, diabetic neuropathy
I. Medication side effects
J. Depression and/or anxiety
K. Psychosocial problems, eating disorders
L. Posttraumatic stress disorder (PTSD) secondary to incest, rape, sexual assault, and domestic violence
M. Vestibulitis, vulvodynia, vaginismus
N. Physical and/or intellectual disabilities
VII. TREATMENT
A. Medications
1. Treat any infection present (see Genitourinary Tract Conditions, Chapter 12; Miscellaneous Gynecologic Conditions, Chapter 17; and Vaginal Conditions, Chapter 21)
2. Consider hormones especially if perimenopausal or postmeno- pausal; new drugs for women, such as analogues to sildenafil
citrate (Viagra) when available; nonprescription dietary supple- ment Avlimil
3. At present, no testosterone preparation for women approved by the
U.S. Food and Drug Administration (FDA) is available. The use of bioidentical preparations or off-label use might be considered.
4. Nonprescription dietary supplement (i.e., Avlimil)
5. Vaginal estrogen
6. See Complementary and Alternative Therapies, Chapter 3
B. General measures
1. Education about changes in sexual response that accompany aging; need for privacy; making time for intimacy
2. Education about a woman’s sexual response and how it differs from that of a man; teach Kegel (pelvic floor) exercises; positions
3. Explore partner relationship: changes, previous responsiveness, sexual preference, communication, expectations, guilt; screen for abuse
4. Education on techniques for stretching hymen, vagina
5. Education and techniques for learning about sexual response and excitation, self and partner
6. Emphasize role of self-care: diet, exercise, vitamins, hygiene, and stress reduction
7. Education about water-soluble lubricants, nonhormonal agents to restore/maintain vaginal mucosa and moisture, other sexual aids
VIII. COMPLICATIONS
A. Long-term disruption of relationships
B. Exploitation in relationships: abuse, violence, infidelity
IX. CONSULTATION/REFERRAL
A. Physician for possible hormonal imbalance, genital anomaly, nerve impairment, medical conditions underlying problem
B. Counselor for rape trauma, PTSD, exploitative relationships, abuse, depression, gender identity, sexual preferences
C. Sex therapist—single or couples
D. Support group
X. FOLLOW-UP
A. Check if infection is present; reevaluate for further treatment
B. Arrange repeat visit as appropriate for discussion of relationship problems
C. Assess the success of vaginal, hymenal stretching; stimulation techniques
D. For medical/medication problems, laboratory results as appropriate
See Bibliographies. Website: www.avlimil.com