CLINICAL SCENARIOS ON SEXUAL

HEALTH DYSFUNCTIONS/DISORDERS

BY DR. ARIBA, AJ.

 Introduction
• A sexual problem may be defined as any problem that
occurs in the course of sexual activities. Sexual health
problems are common but they are under-diagnosed
and under-treated. They may have a prevalence of up
to 43% in women and 31% in men.
• Many patients who would require treatment for sexual
difficulties do not present directly. Some will present
with emotional and relationship dissatisfaction. Sexual
problems can manifest as well as mask in depression,
anxiety, failure to achieve, low self esteem, and
inability to engage in intimate relationships.
 Introduction-2
• Management of sexual health problems
requires paying attention to cultural, clinician
and patient related factors. However, for an
affected individual associated risk factors are:
Biological, Medical and Psychological.
• Assessment of sexual dysfunction requires a
careful history that should as much as possible
be corroborated from the partner.
 Introduction -3
• An important initial step in sexual history taking is to
identify patient’s concern with sexual function.
• Patients’ concerns: Males may feel ashamed as they
consider sexual failure as indicating loss a major part of
their masculinity.
• Physician’s attitude such as discomfort or non-
empathic responses are primary barriers to discussing
sexual health.
• Basically there are 2 categories of patients:
• i) those who are afraid they cannot perform or want
better performance
• ii) those who actually cannot perform
 Introduction-4
• Clinician’s concerns
• Poor training in taking sexual history
• Inadequate privacy in the clinics
• Physician embarrassment
• Time constraint
• Belief that sexual history is irrelevant to the chief
complaints
• Underestimation of the prevalence of sexual concerns in
their patients
• Physicians may not know what questions to ask. They may
feel awkward with sex languages and may have fears of
insulting their patients.
• Patients and their partners are often reluctant to
address sexual topics. Patients often cannot
mention terms of sexual organs or activities as
they find them as slangs and fear criticism by
others. They may regard them as obscene.
Hesitancy in mentioning these terms during the
interview may hinder its continuation.
• Clinician should be conversant with local terms
used to describe sexual activities /events or
problems.
• The Physician needs to understand his own view
of sexuality and should keep them out of
discussion with the patient. Avoid slangs or
excessive technical terminology. Avoid moral or
religious judgment of patient’s behavior. Don’t
forget that your patient may not be heterosexual.
Do not assume that a patient does not have a
specific sexual dysfunction. Explore it!
• Give assurance of confidentiality especially with
adolescent patients or patients with more than
one partner.
• During social history, life stressors such as divorce, death of
spouse, loss of job, change in social status and family
problems may have effect on sexuality.
• When the patient did not present with a sexual problem
as the primary complaint you can “link” into sexual history
at the “family and social history” segment, e.g: “sexual
health is important to overall health; therefore I always ask
patients about it. If it is okay with you i will ask you a few
questions about sexual matters now”
• “Are you currently sexually active?”
• “Are you or your partner experiencing any sexual
problems?”
• Open ended questions are better at the initial stage e.g
• “How would you describe your partner’s sexual
performance on a grading of 1-5, 1 being the poorest?”
• “We find that many sexual health problems when
identified can be solved medically even if it is the partner
that is affected. Do you think you and/or your spouse may
be experiencing any?”
• Another “link” is through reviewing the effects of chronic
medical problems or medication use. “E.g “many men
suffering from this condition or using this medication
experience sexual problems. Has this happened to you?”
 Taking detailed sexual history
• When the patient comes with a specific sexual problem or the physician
has identified one then the Current Sexual History should cover:
• Sexual complaints and duration
• Sexual practices
• Sexual frequency/ strength of sexual drive
• Sexual thought and feelings of sexual arousal
• Coping during separation
• Personal sexual goals and fantasies
• Premarital expectations and relationships
• Partners contribution to sexual distress
• Partners history of psychiatric illness, medications, alcohol, drugs, physical
illness
• Homosexual practices, group sex, paraphilia, orientation should be
assessed.
• Find out why patient is presenting now.
 Domains of sexual problems
• Frequent complaints include:
• Problems with desire:
• “I have no desire”; “I hate the thought of sex”; “I have too much
desire”; “My partner and I are incompatible in our desire for sex”
• Problems with arousal:
• In Men: “I cannot obtain and/or maintain an erection for long
under any circumstance”
• In Women: “I cannot become aroused and /or maintain arousal
under any circumstance”
• “I feel little or nothing when my partner or I touch my breasts or
genitals.”
• “I am never aroused enough to achieve an orgasm”
• “I can become aroused and maintain arousal with masturbation,
but never with my partner”
 Domains of sexual problems
• Problems with orgasm:
• Males: “I ejaculate too quickly when I am with my
partner” ; “I cannot ejaculate in the vagina”
• “I get little or no physical pleasure from orgasm”; “I
have an orgasm but do not ejaculate”
• Females;“I cannot achieve orgasm with intercourse”; “I
get little or no pleasure from intercourse”
• Penetration; “I find penetration/thrusting very difficult
or painful”
• Satisfaction; “I am not satisfied”; “My partner’s sexual
experience is not satisfying”
 CASE SCENARIO 1
• Mrs. J.A is a 35 year old trader, she presented to your
facility on account of recurrent headaches. She noted
that she had made several medical consultations and
had done numerous investigations yet the cause of her
headache remains a concern as she had always been
told that the results were normal. She brought along
results of some of the investigations she did.
• They were FBS= 93mg/dL, PCV = 40%, M.P – no
Malaria Parasite, CT of the Brain – Normal Study
• Her family had just relocated to an apartment close to
your facility. She presented because she needed help.
How would you go about managing her?
 CASE SCENARIO 1
• a. Show empathy and validate her concern (affirm
that you believe her story).
• b. Take further history, especially exploring the
headache problem further:
• Duration of headache, location, associated
factors (Fever, Vomiting, Lacrimation, etc), Is it
related to her menstrual cycle, Insomnia,
Aggravating or Relieving factors)
• Drug History, Family and Social history, Past
Medical history, Treatment received so far.
 CASE SCENARIO 1

• After your initial interaction she became more relaxed. To

answer your question on how her business was faring and
how her family was doing she further informs you that
despite the generally poor national economy her business
was doing well. But in a low tone she mentions that her
relationship with her husband had been strained for some
time now. She told you she had never spoken to any doctor
about her marriage because none of the ones she met so
far has ever asked her about it. She added that her
marriage had been under tension due to “sexual issues”
and she thinks the headache started around the same time.
• How would you handle this segment of the consultation?
 CASE SCENARIO 1
• Make her feel comfortable and be non-judgmental. Do not make her
feel awkward. Validate the fact that she brought up the issue.
Ensure her of confidentiality and support.
• Dialogue with the patient; Eg, “I appreciate the fact that you bring
this up. It takes being sincere and practical to do so. It also shows
your commitment to having a happy marriage”
• “I am going to ask you a few questions about your sexual health and
practices. I understand that these questions may be very personal
but they are very important for your overall health. I ask all my
adult patients similar questions about their sexual health. Like the
rest of our interaction the information will be kept in strict
confidence.”
• You now decide to take a full sexual history. What will be the
content of your conversation?
 CASE SCENARIO 1
• 1. Establish how the patient sees the problem and what she
considers to be the cause.
• 2. Determine the duration of the problem and whether it is related
to the time, place or partner.
• 3. Ask about loss of sex drive or dislike of sexual contact.
• 4. Explore sources of anxiety, guilt or anger
• 5. Ask about physical problem e.g pain
• 6. Carefully exclude areas that may affect sexual performance e.g
arthritis, trauma etc
• 7. Explore possible sexual abuse
• 8. Establish who the husband is: age, occupation, use of stimulants;
medication for a chronic illness; any preferred sex methods and
frequency, etc.
 CASE SCENARIO 1
• She opens up that she does not look forward
to intercourse with her husband because she
gets bruised after each episode. She added
that she gets home already fatigued because
of her job. She has refused to quit the
business because it is quite lucrative although
stressful. She is not sure if you can really help
with this.
• What will you do next?
 CASE SCENARIO 1
• Validate her concern.
• Tell her you can be of help.
• Inform her that if it becomes necessary you
may have to invite her husband.
• Fully explore the history of dyspareunia.
• What will you do next?
 CASE SCENARIO 1
• Get her consent for and perform a general and
gynaecological examination. In particular look
for pathology, anatomical distortions e.g
circumcision, check for sensation, etc.
 CASE SCENARIO 1
• You found no specific pathology but noted she
was very tense and rigid during vaginal
examination.
• How will you manage her further?
 END OF CASE SCENARIO 1
• Explain your findings to her. Give a brief
education/counsel about sexual dysfunction and
causes. Identify likely causes in her case, e.g stress
of work, house chores, and inadequate
lubrication. Suggest she may get a helper in the
shop. Advise to communicate with the husband to
allow adequate foreplay before penetration.
Advise on use of vaginal lubricants prior to
intercourse. Use the opportunity to educate on
screening for certain diseases such as DM, HT,
breast and cervical cancers. Give her an
appointment for follow-up.
 CASE SCENARIO 2
• One of your female clients who is 45-years old,
phoned to inform you that her 50 year old
husband Joseph will be coming to see you in the
clinic. When you asked what the problem was she
said she considered the matter to be serious
though there was no complaint of physical
ailment or immediate danger to his life
• While waiting for Joseph’s arrival, what are the
common health issues that will be running
through your mind?
 CASE SCENARIO 2
• He finally arrived and had this story to tell you: Joseph,
aged 50, developed ED three years ago. He has been
married to Martha, aged 45, for 20 years. Over the past
three years Martha has recognized that Joseph’s
erectile function is no longer reliable. Joseph has
difficulty acknowledging that something was
happening to his erections. He tells Martha that he is
too tired or too stressed at work. She however insisted
that he consult his primary care physician.
• How will you go about taking a detailed sexual
history?
 CASE SCENARIO 2
• This is a specific complaint on sexual problem (arousal
disorder).
• Praise him for coming and assure him of confidentiality
and support. Then proceed to take a detailed history
including:
• Sexual history- libido, erection adequacy, quality and
timing of orgasm, volume and appearance of ejaculate,
genital pain (sex-induced), penile
abnormalities/deformities, sexual partners (number of
partners, change of partners, partner dysfunction),
change in sexual preference/orientation.
 CASE SCENARIO 2
• Explore other symptoms to rule out differentials; low mood,
poor sleep, weight gain/loss, palpitations, excessive
sweating, tremors, dysuria, urethral discharge etc
• Past medical history- Diabetes Mellitus, Hypertension,
Testosterone deficiency, Prostate cancer treatment,
Depression, Anxiety disorder
• Medication history- e.g, Antidepressants, anti-
hypertensives, Substance use- Tobacco (smoking), Alcohol
• Psychosocial factors- Marital disharmony, performance
anxiety, depression, discord, stress, history of sexual abuse.
 CASE SCENARIO 2
• What clinical and laboratory investigations will you
request for?
• Check BMI and blood pressure on physical examination
• Do complete blood counts, ESR, urinalysis, Fasting
blood glucose/HBA1C, Serum lipids, serum electrolytes,
serum testosterone/hormonal assay, Thyroid function
test.
• List 5 differentials
• Hypertension; Type 2 Diabetes Mellitus; Widower
syndrome; Peyronie disease Pan-hypopituitarism;
Depression; Hypogonadism and Sickle cell anaemia
 CASE SCENARIO 2
• Laboratory result revealed a previously
undiagnosed Type 2 diabetes mellitus.

• What would be your next line of action?

 CASE SCENARIO 2
• This is bad news. Break it professionally and
assure him that diabetes can be controlled
using drugs and lifestyle changes.
• Treat the ED with PDE-5i
 END OF CASE SCENARIO 2
• Joseph and Martha came together for follow-
up visit a month later. They obviously looked
a happy couple as Martha beamed with smiles
and confirmed that they had recovered the
intensity of their sexual life. Joseph was
thankful to Martha for insisting that he seek
professional consultation for the problem.
 SCENARIO 3:

• Susan, aged 30 and John, aged 45 have been

married for seven years. One year ago John
developed ED, which had a tremendous impact
on his relationship with Susan. For the last three
months their sexual life has become almost non-
existent. Susan is certain that John is involved
with another woman and that this is the source
of his ED. She is angry when he attempts to
initiate lovemaking, believing that he is no longer
attracted to her.
 SCENARIO 3:

• John has no awareness of the foundation of

Susan’s extreme response. He seeks
consultation from his physician who diagnoses
hypercholesterolemia and prescribes a statin
and a PDE-5i. The PDE-5i does not work on
two consecutive attempts at lovemaking.
 SCENARIO 3:

• Susan cannot accept that the cause of John’s ED

was hypercholesterolemia. Furthermore she tells
John that she resents him using a pill to get
turned on, rather than being turned on by her
alone. After five unsuccessful attempts with a
PDE-5i John returns to his physician stating, “This
medication is not working, can you give me
something stronger?”
• List the other treatment options that this
patient may still benefit from.
 END OF SCENARIO 3:

• Couple counselling, CBT and relationship/couple

therapy
• Counselling on lifestyle modifications: Weight loss,
exercise, smoking cessation, reduce/stop alcohol,
• Screen for psychogenic causes, cardiovascular disease
• Testosterone supplementation ( in hypogonadism)
• 2nd line therapy: intraurethral/ intracavernosal
alprostadil;
• Vacuum pump devices.
• Penile prosthesis.
 CASE SCENARIO 4
• Mrs. Amaka is a 55year old P4, 4 alive woman who is 3
years post menopausal. She has come to see you
concerning her complaint of pain on sexual intercourse in
the last 1 year.
• This has resulted in discord between her and her husband,
due to her loss of interest and avoidance of sexual intimacy
with her husband due to the fear of pain.
• She is worried that she may have cancer and also anxious
about her marriage. She is afraid that her husband may
start to have affairs.
• She is also embarrassed about her complaint as she feels
that women her age are not expected to be concerned
about sex.
 CASE SCENARIO 4
• What other questions would you want to ask
her?
• What would you check for, or expect to find on
physical examination?
• What investigations will you request for?
• Outline your management plan for this patient
• What specific FM tools will you employ in the
management of this patient?
• What medications will you consider giving her?
 CASE SCENARIO 4
• The management must be patient-centered. This encounter
also provides an opportunity for appropriate health
education and screening. Hence you need to take a detailed
history of the complaint (dyspareunia) as well as a detailed
sexual history.
• Other symptoms to rule out differentials: Weight loss,
cough, anorexia, dysuria, frequency, urgency, low mood,
change in libido, anhedonia etc
• Gynaecological history- menarche, coitache, parity, route
of deliveries, complications post delivery, pelvic surgeries/
instrumentations/ procedures, contraceptive history, post-
coital/ vaginal bleeding, vaginal discharge, PAP smears-
time of last smear, abnormal reports e.g cervicitis, HSIL, CIN
 CASE SCENARIO 4
• Past medical history: UTI, STI, Ca cervix/ abnormal PAP
smear reports- e.g cervicitis, HSIL, CIN, Hypertension,
DM,
• Medication history: Oestrogen / hormonal
replacement therapy
• Psychosocial history- Depression, anxiety, sexual abuse
• Family and social history- Marital discord, family type
and dynamics, family history of gynaecological cancers.
• General examination:
• Absence/ presence of Pallor, Jaundice, weight and BMI,
finger clubbing, dehydration, pedal edema
 CASE SCENARIO 4
• Vaginal examination:
• Inspection- Appearance of external genitalia (hair distribution,
normal or pale mucosa, reduced ruggae, obvious bleeding or
discharge, obvious vulva mass or swelling).
• Speculum examination- Appearance of the cervix and cervical os:
discharge, erosion, contact bleeding, mass/polyp
• Digital/ bimanual examination: Uterine size or tenderness, adnexal
mass or tenderness, cervical excitation tenderness
• Abdomen: Distension, tenderness, palpable mass
• Systemic examination:
• Respiratory: Respiratory rate- tachypnea/normal, normal or
reduced chest expansion, air entry, breath sounds, lung bases
• CVS: Pulse rate- normal, tachycardia or bradycardia, blood pressure-
normal, elevated or low, heart sounds, apex beat
 CASE SCENARIO 4
• C) Individualized investigations depending on
findings from history and physical examination:
• Full blood count- anaemia, leucocytosis; ESR-
may be elevated or normal.
• Urinalysis- UTI, casts, protein (hypertensive/
diabetic nephropathy)
• Urine m/c/s- UTI; HVS for m/c/s (when
discharge is present)
• PAP smear/ culposcopy/ biopsy
• Abdomino-pelvic ultrasound
 END OF CASE SCENARIO 4
• Management plan: Detailed history and physical
examination; Investigations
• Treatment depending on results of investigations
(Likely diagnosis- Atrophic vaginitis); couple
counselling; lubricants; hormone replacement therapy
• - treat other conditions found (UTI, PID, Cervicitis, etc);
• Follow-up
• Family APGAR, Family cycle.
• Hormone replacement therapy
 CASE SCENARIO 5
• Joy and Daniel are newly married couple, who
have been unable to have sexual intercourse
since they got married 6 months ago. This has
been due to Joy’s anticipation and fear of the
pain that she expects to have as she has been
told by her friends.
• They have attempted several forms of lubricant
products and have discussed with their Pastor
who advised them to see you.
• How will you manage this case?
 CASE SCENARIO 5
• Sexual history of both partners (separately
unless consent is given) for past sexual
experiences, history of abuse, past and
present partners.
 CASE SCENARIO 5
• Gynaecological history- LMP, ketamenia,
menarche, coitache, dysmenorrhea,
contraception, vaginal discharge, abnormal
vaginal bleeding, dyspareunia, low abdominal
pain
 CASE SCENARIO 5
• FIFE of both partners-
• fears,
• ideas,
• function,
• expectation
 END OF CASE SCENARIO 5
• Counselling based on fears and ideas elicited,
use of lubricants, CBT
• Follow up
 CASE SCENARIO 6
• Mojisola is a 17 year old undergraduate who
has come to see you in the clinic as a result of
multiple growths that she observed around
her vagina for the last 3 months. She is also
afraid that she may be HIV positive and has
come to see you for treatment and HIV
screening,
• What additional history will you ask for?
 CASE SCENARIO 6
• Biodata
• History of presenting complaints- duration, site, initial size, any increase in
size, pain, ulceration, discharge, bleeding, similar growths in other parts of
the body?
• Other symptoms/ review of systems: Fever, dysuria, urgency, frequency,
abdominal pain, nausea, vomiting, diarrhoea, bleeding per rectum, anal
pain, throat pain, difficulty in swallowing, cough, breathlessness…
• Past medical history- STI, Retroviral status, TB, DM, Sickle cell etc
• Risk assessment and sexual history – number of partners (past and
present), routes of intercourse and sexual orientation, sharing/use of
unsterilized sharps, body tattoo or body piercing, blood transfusion.
• Family and social history: Parents, siblings, position in the family, source of
health care financing, alcohol intake, smoking and substance use.
• Medication history
 CASE SCENARIO 6
• She tells you that she is sexually active and has
multiple sexual partners. She has also had a foul
smelling copious yellowish vaginal discharge for
the last 6 months. She has no other significant
past medical or gynaecological history.
• After taking a detailed history, you proceed to
examine her and find multiple small flesh like
growths around the introitus, with a copious foul
smelling yellowish discharge.
• What would you want to do at this point?
 CASE SCENARIO 6
• Bimanual examination, check for cervical
excitation tenderness
• Take a high vaginal and endocervical swab for
m/c/s
• Full blood count; ESR; Urinalysis; Urine m/c/s ;
FBG; RVS; Abdominopelvic USS.
• Consider empirical treatment for PID based on
the colour, smell, and consistency of the
vaginal discharge.
 CASE SCENARIO 6
• What form of counselling will you give to this
patient at this point? And how will you
manage the genital growths?
 CASE SCENARIO 6
• HIV pre-test counselling
• Treatment options- serial podophylline
ointment application, imiquimod cream,
cryotherapy, laser treatment, surgical excision,
electrodesiccation, loop electrosurgical
excision.
 CASE SCENARIO 6
• You have screened her for HIV after a pre-test
counselling, and her result is negative.
• What will you tell her now?
 CASE SCENARIO 6
• Remind her about meaning of HIV, AIDS,
window period and the need to repeat the
test in 6 months. Remind about the routes of
HIV transmission.
• Counsel on safe sex practices and how to
reduce/avoid risk of transmission.
 CASE SCENARIO 6
• What are the 3 main differentials of the
vaginal discharge and how will you manage
each of them?
 CASE SCENARIO 6
• What are the 3 main differentials of the
vaginal discharge and how will you manage
each of them?
 CASE SCENARIO 6
• Bacterial vaginosis- Oral
metronidazole/clindamycin
• Trichomonas vaginalis- oral
metronidazole/tinidazole
• Candidiasis- oral/topical antifungal
 CASE SCENARIO 6
• What other screening tests would you
consider offering this lady in the future?
 CASE SCENARIO 6
• HBsAg
• HPV test
• PAP smear
 CASE SCENARIO 6
• List 8 problems peculiar to this age group that
you will try to identify and manage
 END OF CASE SCENARIO 6
• Substance use
• Alcohol use
• Cigarette smoking
• Educational problems
• Eating disorder
• Body dysmorphic disorder
• Suicide/self harm
• Violence/abuse
• Unsafe sexual activity