Definitions of Sexual Dysfunctions in Women and Men: A Consensus Statement From the Fourth International Consultation on Sexual Medicine 2015.

INTRODUCTION: Definitions of sexual dysfunctions in women and men are critical in facilitating research and enabling clinicians to communicate accurately. AIMS: To present the new set of definitions of all forms of sexual dysfunction in women and men adopted by the Fourth International Consultation on Sexual Medicine (ICSM) held in 2015. METHODS: Classification systems, including the International Classification of Diseases, 10th Edition and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and systems that focus on only specific types of sexual dysfunctions (e.g., the International Society for Sexual Medicine definition for premature ejaculation) were reviewed. MAIN OUTCOME MEASURES: Evidence-based definitions were retained, gaps in definitions were identified, and outdated definitions were updated or discarded. Where evidence was insufficient or absent, expert opinion was used. Some definitions were self-evident and termed clinical principles. RESULTS: The evidence to support the various classification systems was carefully evaluated. A more comprehensive analysis of this evidence can be found in two other articles in this journal that consider the incidence and prevalence and the risk factors for sexual dysfunction in men and women. These data were used to shape the definitions for sexual dysfunction that have been recommended by the 2015 ICSM. CONCLUSION: The definitions that have been adopted are those that are most strongly supported by the literature at this time or are considered clinical principles or consensus of experts' opinions. As more research and clinical studies are conducted, there likely will be modifications of at least some definitions.

Incidence and Prevalence of Sexual Dysfunction in Women and Men: A Consensus Statement from the Fourth International Consultation on Sexual Medicine 2015.

INTRODUCTION: The incidence and prevalence of various sexual dysfunctions in women and men are important to understand to designate priorities for epidemiologic and clinical research. AIM: This manuscript was designed to conduct a review of the literature to determine the incidence and prevalence of sexual dysfunction in women and men. METHODS: Members of Committee 1 of the Fourth International Consultation on Sexual Medicine (2015) searched and reviewed epidemiologic literature on the incidence and prevalence of sexual dysfunctions. Key older studies and most studies published after 2009 were included in the text of this article. MAIN OUTCOME MEASURES: The outcome measures were the reports in the various studies of the incidence and prevalence of sexual dysfunction among women and men. RESULTS: There are more studies on incidence and prevalence for men than for women and many more studies on prevalence than incidence for women and men. The data indicate that the most frequent sexual dysfunctions for women are desire and arousal dysfunctions. In addition, there is a large proportion of women who experience multiple sexual dysfunctions. For men, premature ejaculation and erectile dysfunction are the most common sexual dysfunctions, with less comorbidity across sexual dysfunctions for men compared with women. CONCLUSION: These data need to be treated with caution, because there is a high level of variability across studies caused by methodologic differences in the instruments used to assess presence of sexual dysfunction, ages of samples, nature of samples, methodology used to gather the data, and cultural differences. Future research needs to use well-validated tools to gather data and ensure that the data collection strategy is clearly described.

Risk Factors for Sexual Dysfunction Among Women and Men: A Consensus Statement From the Fourth International Consultation on Sexual Medicine 2015.

INTRODUCTION: This article presents a review of previous research concerning risk factors for sexual dysfunction in women and men. AIM: The aim is to evaluate past research studies to determine the contribution of all risk factors to the development and maintenance of sexual dysfunction among women and men. METHODS: Studies were organized under a biopsychosocial framework, with the bulk of studies of women and men having investigated the role of biological factors. MAIN OUTCOME MEASURES: The outcome measures were the data on factors for sexual dysfunction. RESULTS: Many more studies investigated risk factors for sexual dysfunction in men than in women. For women and men, diabetes, heart disease, urinary tract disorders, and chronic illness were significant risk factors for sexual dysfunction. Depression and anxiety and the medications used to treat these disorders also were risk factors for sexual dysfunction in women and men. In addition, substance abuse was associated with sexual dysfunction. Many other social and cultural factors were related to sexual dysfunction in women and men. CONCLUSION: Psychosocial factors are clearly risk factors for sexual dysfunction. Women and men with sexual dysfunction should be offered psychosocial evaluation and treatment, if available, in addition to medical evaluation and treatment. The impact of social and cultural factors on sexual function requires substantially more research. The evidence that erectile dysfunction is a harbinger of other forms of cardiovascular disease is strong enough to recommend that clinical evaluation for occult cardiovascular disease should be undertaken in men who do not have known cardiovascular disease but who develop organic erectile dysfunction, especially in men younger than 70 years.

Antidepressant-induced sexual dysfunction in men.

Most of the available antidepressant medications, including tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, and dual noradrenergic/serotonergic reuptake inhibitors have been reported to be associated with sexual dysfunction in both sexes. This manuscript reviews evidence concerning the relative incidence of treatment emergent sexual dysfunction in men being treated with antidepressant drugs. Both double-blind controlled trials and large clinical series report a high incidence of sexual dysfunction, especially ejaculatory delay, with serotonergic drugs. The incidence of sexual dysfunction in men appears to be much lower with drugs whose primary mechanism of action involves adrenergic or dopaminergic systems.

International Society for Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation.

INTRODUCTION: Over the past 20 years our knowledge of premature ejaculation (PE) has significantly advanced. Specifically, we have witnessed substantial progress in understanding the physiology of ejaculation, clarifying the real prevalence of PE in population-based studies, reconceptualizing the definition and diagnostic criterion of the disorder, assessing the psychosocial impact on patients and partners, designing validated diagnostic and outcome measures, proposing new pharmacologic strategies and examining the efficacy, safety and satisfaction of these new and established therapies. Given the abundance of high level research it seemed like an opportune time for the International Society for Sexual Medicine (ISSM) to promulgate an evidenced-based, comprehensive and practical set of clinical guidelines for the diagnosis and treatment of PE. AIM: Develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts. Method. Review of the literature. RESULTS: This article contains the report of the ISSM PE Guidelines Committee. It affirms the ISSM definition of PE and suggests that the prevalence is considerably lower than previously thought. Evidence-based data regarding biological and psychological etiology of PE are presented, as is population-based statistics on normal ejaculatory latency. Brief assessment procedures are delineated and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients. CONCLUSION: Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. Therefore, it is strongly recommended that these guidelines be re-evaluated and updated by the ISSM every 4 years.

Encompassing sexual medicine within psychiatry: pros and cons.

OBJECTIVE: This article examines the positive and negative aspects of psychiatry encompassing sexual medicine within its purview. METHODS: MEDLINE searches for the period between 1980 to the present were performed with the terms "psychiatry," "sexual medicine," and "sexual dysfunction." In addition, sexual medicine texts were reviewed for chapters relevant to this topic. RESULTS: Psychiatry, the only medical discipline trained to integrate both biological and psychological factors in making treatment decisions, has been minimally involved in the evolution of the multidisciplinary field known as sexual medicine. CONCLUSION: If psychiatry is to maintain a role in the diagnosis and treatment of sexual disorders, it is critical that its training programs include training in sexual medicine.

Cutoff score of the sexual interest and desire inventory-female for diagnosis of hypoactive sexual desire disorder.

OBJECTIVE: To determine the most appropriate cutoff value for the Sexual Interest and Desire Inventory-Female (SIDI-F) score to discriminate between women with hypoactive sexual desire disorder (HSDD) and those with no female sexual dysfunction (FSD). The SIDI-F is a clinician-rated instrument consisting of 13 items designed to assess HSDD severity in women. The total score ranges from 0 to 51, with higher scores indicating better sexual function. METHODS: Data from patients enrolled in a North American nontreatment study and a European nontreatment study were analyzed. Both studies were 4-week, prospective, multicenter trials designed to assess the reliability and validity of the SIDI-F. Only patients with HSDD or no FSD were included in this analysis. Receiver operating characteristics (ROC) analysis was used to determine the ability of the SIDI-F to differentiate between patients with HSDD and those with no FSD at baseline. RESULTS: A total of 428 women were included in this analysis: 174 from North America (HSDD 113, no FSD 61) and 254 from Europe (HSDD 130, no FSD 124). In the North American study, a SIDI-F cutoff score of 33 minimized the difference between sensitivity (94.7%) and specificity (93.4%). In the European study, SIDI-F cutoff scores of both 33 and 34 minimized the difference between sensitivity (95.2%) and specificity (94.4%). CONCLUSIONS: In appropriately screened women, a SIDI-F score of ≤33 indicates the presence of HSDD.

Considerations for diagnostic criteria for erectile dysfunction in DSM V.

INTRODUCTION: The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., text revision (DSM-IV-TR) criteria for erectile disorder have been criticized as multiple grounds including that the criteria lack precision, that the requirement of marked distress is inappropriate, and that the specification of etiological subtypes should be deleted. AIM: The goal of this manuscript is to review evidence relevant to diagnostic criteria for erectile disorder published since 1990. METHOD: Medline searches from 1990 forward were conducted using the terms erectile disorder and impotence. Early drafts of proposed alterations in diagnostic criteria were submitted to advisors. MAIN OUTCOME MEASURE: Evidence regarding modification of criteria for DSM V diagnostic criteria for erectile dysfunction was judged by whether existing data justified the adoption of precise criteria which would lead to homogenous groups for research. Another outcome measure was whether data exist to reliably differentiate fluctuations in normal function from pathological states. RESULTS: The literature review revealed a large literature concerning erectile disorder but minimal evidence concerning an operational definition for this disorder. CONCLUSIONS: It is recommended that erectile disorder be precisely defined in order to clearly differentiate alterations in normal function from a condition requiring medial intervention and to facilitate clinical research. It is specifically proposed that erectile dysfunction be defined as failure to obtain and maintain an erection sufficient for sexual activity or decreased erectile turgidity on 75% of sexual occasions and lasting for at least 6 months. It is also recommended that erectile disorder be defined independently of distress.

Considerations for an evidence-based definition of premature ejaculation in the DSM-V.

INTRODUCTION: The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., text revision (DSM-IV-TR) criteria for premature ejaculation (PE) have been criticized on multiple grounds including that the criteria lack precision, that the requirement of marked distress is inappropriate, and that the specification of etiological subtypes should be deleted. Since these criteria were originally adopted, there has been a tremendous gain in knowledge concerning PE. AIM: The goal of this manuscript is to review evidence relevant to diagnostic criteria for PE published since 1990. METHOD: Medline searches from 1990 forward were conducted using the terms PE, rapid ejaculation, ejaculatory disorder, and intravaginal ejaculatory latency. Early drafts of proposed alterations in diagnostic criteria were submitted to advisors. MAIN OUTCOME MEASURE: Expert opinion was based on review of evidence-based medical literature. RESULTS: The literature search indicated possible alterations in diagnostic criteria for PE. CONCLUSIONS: It is recommended that the Diagnostic and Statistical Manual committee adopt criteria similar to those adopted by the International Society of Sexual Medicine. It is proposed that lifelong PE in heterosexual men be defined as ejaculation occurring within approximately 1 minute of vaginal penetration on 75% of occasions for at least 6 months. Field trials will be necessary to determine if these criteria can be applied to acquired PE and whether analogous criteria can be applied to ejaculatory latencies in other sexual activities. Serious consideration should be given to changing the name from PE to rapid ejaculation. The subtypes indicating etiology should be eliminated.

Considerations for a better definition of male orgasmic disorder in DSM V.

INTRODUCTION: All of the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., text revision (DSM-IV-TR) criteria for sexual disorders have been criticized on multiple grounds, including that the criteria lack precision, that the requirement of marked distress is inappropriate, and that the specification of etiological subtypes should be deleted. AIM: The goal of this article is to review evidence relevant to diagnostic criteria for male orgasmic disorder published since 1990. METHODS: Medline searches from 1990 forward were conducted using the terms male orgasmic disorder, anorgasmia, delayed ejaculation, retarded ejaculation, ejaculatory delay, and ejaculatory disorder. Early drafts of proposed alterations in diagnostic criteria were submitted to advisors. MAIN OUTCOME MEASURE: Evidence reviewed was judged by current usage of terminology, evidence allowing precise definition of the syndrome, and evidence concerning separation of the syndrome from distress. RESULTS: The literature search indicated minimal use of the term male orgasmic disorder and minimal knowledge concerning psychogenic ejaculatory problems. CONCLUSIONS: It is recommended that the term male orgasmic disorder be replaced with the term delayed ejaculation. Duration and severity criteria are recommended. Since many ejaculatory problems are idiopathic, it is recommended that the etiological subtypes due to psychological or due to combined factors be eliminated.

An evidence-based definition of lifelong premature ejaculation: report of the International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation.

OBJECTIVE: To develop a contemporary, evidence-based definition of premature ejaculation (PE). METHODS: There are several definitions of PE; the most commonly quoted, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders - 4th Edition - Text Revision, and other definitions of PE, are all authority-based rather than evidence-based, and have no support from controlled clinical and/or epidemiological studies. Thus in August 2007, the International Society for Sexual Medicine (ISSM) appointed several international experts in PE to an Ad Hoc Committee for the Definition of PE. The committee met in Amsterdam in October 2007 to evaluate the strengths and weaknesses of current definitions of PE, to critically assess the evidence in support of the constructs of ejaculatory latency, ejaculatory control, sexual satisfaction and personal/interpersonal distress, and to propose a new evidence-based definition of PE. RESULTS: The Committee unanimously agreed that the constructs which are necessary to define PE are rapidity of ejaculation, perceived self-efficacy, and control and negative personal consequences from PE. The Committee proposed that lifelong PE be defined as a male sexual dysfunction characterized by ejaculation which always or nearly always occurs before or within about one minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy. This definition is limited to men with lifelong PE who engage in vaginal intercourse. The panel concluded that there are insufficient published objective data to propose an evidence-based definition of acquired PE. CONCLUSION: The ISSM definition of lifelong PE represents the first evidence-based definition of PE. This definition will hopefully lead to the development of new tools and patient-reported outcome measures for diagnosing and assessing the efficacy of treatment interventions, and encourage ongoing research into the true prevalence of this disorder, and the efficacy of new pharmacological and psychological treatments.

An evidence-based definition of lifelong premature ejaculation: report of the International Society for Sexual Medicine (ISSM) ad hoc committee for the definition of premature ejaculation.

INTRODUCTION: The medical literature contains several definitions of premature ejaculation (PE). The most commonly quoted definition, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision, and other definitions of PE are all authority based rather than evidence based, and have no support from controlled clinical and/or epidemiological studies. AIM: The aim of this article is to develop a contemporary, evidence-based definition of PE. METHODS: In August 2007, the International Society for Sexual Medicine (ISSM) appointed several international experts in PE to an Ad Hoc Committee for the Definition of Premature Ejaculation. The committee met in Amsterdam in October 2007 to evaluate the strengths and weaknesses of current definitions of PE, to critique the evidence in support of the constructs of ejaculatory latency, ejaculatory control, sexual satisfaction, and personal/interpersonal distress, and to propose a new evidence-based definition of PE. RESULTS: The committee unanimously agreed that the constructs that are necessary to define PE are rapidity of ejaculation, perceived self-efficacy and control, and negative personal consequences from PE. The committee proposed that lifelong PE be defined as ". . . a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy." This definition is limited to men with lifelong PE who engage in vaginal intercourse. The panel concluded that there are insufficient published objective data to propose an evidence-based definition of acquired PE. CONCLUSION: The ISSM definition of lifelong PE represents the first evidence-based definition of PE. This definition will hopefully lead to the development of new tools and Patient Reported Outcome measures for diagnosing and assessing the efficacy of treatment interventions and encourage ongoing research into the true prevalence of this disorder and the efficacy of new pharmacological and psychological treatments.

Management of hypoactive sexual desire disorder.

Epidemiological studies have found that problems with sexual desire are one of the most common sexual complaints in females. Such complaints are far less common in males. In women, problems with sexual desire have been found to be associated with age, relationship duration, relationship distress, and complaints of anxiety and depression. Evidence-based interventions include cognitive behavioral therapy and androgen therapy. Endocrinopathies are common causes of male problems with libido. There is minimal evidence available concerning the treatment of psychological etiologies of low sexual desire in men.

Sexual dysfunction associated with antidepressant therapy.

Increasing numbers of patients are on psychiatric drugs, especially antidepressants. When patients complain of sexual dysfunction, it is important that the clinician take a careful history concerning psychopharmacologic agents. It is possible that simple interventions may maintain the desired effect of the psychiatric drugs while also eliminating sexual side effects caused by these agents.

Proposal for changes in diagnostic criteria for sexual dysfunctions.

INTRODUCTION: Officially sanctioned diagnostic criteria have a major influence on treatment decisions and on how populations are defined for clinical research. The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association has had a major influence on research concerning the treatment of sexual disorders and has been criticized on numerous grounds. AIM: The purpose of this article is to describe the evolution of criteria sets in the DSM and to critically evaluate suggestions for modification of this system. METHOD: All living members of the DSM work groups on sexual dysfunction were contacted regarding their recollections of the evolution of criteria sets. Literature concerning diagnostic criteria for the sexual dysfunctions in the DSM, as well as literature suggesting modification of this system, was reviewed. MAIN OUTCOME MEASURE: Recommendations for changes in the DSM-V system were based upon a review of the evidence concerning optimal criteria for each diagnostic entity. RESULTS: The original diagnostic system from sexual disorders in the DSM was developed by expert opinion, literature searches, and solicitation of feedback for other experts in the field. There have been minimal changes in the DSM criteria for sexual dysfunctions because of the requirement that there be substantial empirical data before modification of the system would be considered. An international consensus group has suggested major modification in criteria concerning female sexual dysfunctions. There is a growing database that documents the need to change criteria for premature ejaculation. CONCLUSIONS: It is recommended that some of the suggested modifications to the criteria sets for sexual dysfunctions be adopted by the DSM-V committee. It is also recommended that specific criteria related to duration and severity be adopted, in order to clearly distinguish sexual disorders from transient alterations in sexual function related to life stress and relationship discord.

Tadalafil for treatment of erectile dysfunction in men on antidepressants.

OBJECTIVE: The objective of this post hoc analysis was to evaluate tadalafil, a treatment indicated for erectile dysfunction (ED), in men on antidepressants. METHOD: A retrospective, pooled analysis of 19 double-blind, placebo-controlled trials (N = 3864) identified 205 men with ED, mean age of 55 years (range, 27-79 years) receiving antidepressants and tadalafil 10 mg (n = 38), tadalafil 20 mg (n = 113), or placebo (n = 54). Efficacy was measured by the International Index of Erectile Function erectile function domain score, the Sexual Encounter Profile diary, and a Global Assessment Question. Tolerability was assessed via collection and analysis of treatment-emergent adverse events. RESULTS: Patients on antidepressants who were treated with tadalafil showed significantly greater baseline-to-end point improvement on the International Index of Erectile Function score compared with placebo (end point: tadalafil 10 mg, 21.7; tadalafil 20 mg, 21.8; placebo, 14.5; both P < 0.01). The mean per-patient percent successful intercourse postbaseline was also greater with tadalafil 10 mg (54%) and tadalafil 20 mg (59%) than placebo (29%, both P < 0.05). Patients taking tadalafil 10 (72%) and 20 (76%) mg both reported significant improvement in erections on the Global Assessment Question compared with placebo (33%, both P < 0.01). The incidence of treatment-emergent adverse events was low in all treatment groups with the most common being headache, dyspepsia, and back pain. CONCLUSION: Tadalafil was well tolerated and improved erectile function in patients taking antidepressant medications.

Comparison of androgens in women with hypoactive sexual desire disorder: those on combined oral contraceptives (COCs) vs. those not on COCs.

INTRODUCTION: Approximately one out of four sexually active women in the United States uses some form of hormonal contraceptive method because they provide the most effective reversible method of birth control available. However, little attention has been paid to possible adverse effects of combined oral contraceptives (COCs) on sexual functioning. AIM: The aim of this study was to examine the potential effects of COCs on women with hypoactive sexual desire disorder (HSDD). It was hypothesized that female patients with generalized, acquired HSDD on COCs have lower androgen levels than those not on COCs. METHODS: The patients were healthy premenopausal women with HSDD, aged 22-50 years. Subjects had a history of adequate sexual desire, interest, and functioning. Participants were required to be in a stable, monogamous, heterosexual relationship and were screened for any medication or medical or psychiatric disorders that impact desire. The patients met operational criteria for global, acquired HSDD. The 106 patients were divided into two groups: those on COCs (N = 43) and those not on COCs (N = 63). A two-tailed t-test comparison was made between the two groups comparing free and total testosterone and sex hormone-binding globulin (SHBG). MAIN OUTCOME MEASURES: The main outcome measures are the differences between the two groups comparing free testosterone, total testosterone, and SHBG. RESULTS: These patients with HSDD on COCs had significantly lower free and total testosterone levels compared with those who were not on COCs. The SHBG was significantly higher in the group on COCs compared with those who were not on COCs. CONCLUSION: The result of this study suggests that COCs in premenopausal women with HSDD are associated with lower androgen levels than those not on COCs. Further research is required to determine if low androgen levels secondary to COCs impact female sexual desire.