One of the ways to broach the subject of sexual function is to educate the patient about the cycle of normal female sexual response. In a sexual and sexual dysfunction tutorial, Davis describes the following stages: desire, arousal, plateau phase, orgasm, and resolution phase.
Desire is the motivation and inclination to be sexual. It is dependent on internal (fantasies) and external sexual cues and also on adequate neuroendocrine functioning.
Arousal is characterized by erotic feelings and vaginal lubrication as blood flow increases to the vagina. In addition to feelings of sexual tension, the sexually excited woman may experience tachycardia, rapid breathing, elevated blood pressure, breast engorgement, muscle tension, nipple erection, and other physical signs of arousal such as a flush. This is the stage where the vagina lengthens, distends, and dilates, and the uterus elevates partially out of the pelvis.
During the plateau phase, sexual tension, erotic feelings, and vasocongestion reach maximum intensity. The labia become more swollen and turn dark red, and the lower third of the vagina swells and thickens to form the orgasmic platform. The clitoris becomes more swollen and elevated, and the uterus elevates fully out of the pelvis. Eventually, women reach the threshold point of orgasmic inevitability. Orgasm is a myotonic response mediated by the sympathetic nervous system and is experienced as a sudden release of the tension built up during previous phases. Women, unlike men, experience no refractory period but can experience multiple
orgasms during a single cycle. They can also experience orgasms before, during, and after intercourse provided they receive enough clitoral stimulation.
The last phase is called the resolution phase. Women experience a feeling of relaxation and well-being. The body returns to a resting state. Complete uterine descent, detumescence of the clitoris and orgasmic platform, and decongestion of the vagina and labia take about 5 to 10 minutes.
Sexual Dysfunction
Over 50% of all women are affected at one time or another by female sexual dysfunction (FSD). The Women's Health Foundation lists seven classifications for FSD disorders:
Hypoactive sexual desire Sexual aversion
Sexual arousal Orgasmic Dyspareunia Vaginismus
Noncoital sexual pain
Feldhaus-Dahir reports on the many barriers to helping patients with sexual dysfunction, which is multifactorial
P.38 and abysmally misunderstood. Since the FDA has approved nothing to treat premenopausal or postmenopausal women's sexual dysfunction, the menopausal woman and her physician have limited choices, but they do have a few.
A well-estrogenized vagina is essential for normal sexual function, but many women still believe estrogen therapies (discussed in more detail below) will harm them. Clinicians in the United States who prescribe
androgen therapy use testosterone marketed for hypogonadal men, but at 10% of the dosage. A premenopausal woman naturally produces 10% of the amount produced by a normal male.
Some neurotransmitters, widely in use for other reasons, show promise treating sexual dysfunction. Simon lists bupropion, nefazodone, and buspirone as effective agents for desire, arousal, and orgasm. SSRIs have a negative effect on sexual desire.
Sexual Function after Surgery
Patients who talk about their sex lives frequently describe four pleasures associated with sexuality. These universal elements are touching, genital caressing, orgasm, and gratifying a partner. When a patient is recovering from surgery or has experienced surgical loss of coital function, genital caressing as a receiver or giver can be satisfying. Once a woman learns early in life how to be orgasmic, she can often learn to be so again despite major genital loss, including of her clitoris. When the ability to experience orgasm by one favorite means is destroyed by disease, the patient can be encouraged to experiment with alternative methods that do not conflict with her value system. Women who will never experience vaginal intercourse again can discover they are able, with education and imagination, to fulfill their feminine role as givers of pleasure if they choose to do so.
When a patient's psychosexual rehabilitation after surgery seems to be impaired and she fails to make steady progress toward resumption of her usual role, appropriate self-esteem, energy, identity, and ability to handle stress, she should be offered help. Help should be offered as soon as she mentions the problem. Early
intervention is often easy and brief. The surgeon should be the first person to help the patient, with counseling and, if necessary, suitable medications.
A postsurgical patient may expect too much too soon from herself, or she may head off in the opposite direction and begin to assume the role of invalid. In most cases, however, she will be caught somewhere in between these two extremes. Once she begins to exhibit her normal patterns of relating to others, you will know she has
officially begun the process of genuine healing.
You will be able to tell when she enters the healing phase because she will become less dependent on you, the nurses, and even her family members. As her strength increases, she will want to resume her usual activities.
The inevitable, normal, uncomfortable grief process will commence. Encourage the patient to talk about her feelings rather than repressing them or brooding, because worry and rumination are forms of repetitive thought that are concomitant with and predictive of depressed mood. Dreary thoughts fuel a depressed mood and turn it into something ugly and dangerous; this has the potential to cause long-term or permanent psychological damage.
The patient has the power within to effect change in herself. Family members and friends should be cautioned, at this point, to allow verbal ventilation. It's a form of healthy discontent that frequently provides the impetus to hurry up and lose the sick image and begin to see herself as well and strong again.
Cosmetics, dress, and grooming are important parts of the rehabilitation process. When a postoperative patient combs her hair, puts on lipstick, and demands her own nightgown instead of hospital garb, she has begun to heal. When a patient feels that the surgery was disfiguring, she needs to compensate by learning new ways to dress or groom. She needs to feel whole and complete and responsible again as quickly as possible.
Most of the time, the mate or lover of the woman is caring and considerate of her. There is genuine concern for her health, hope for a quick recovery, and the willingness to assume many aspects of her role until she is well.
Often there is a deepening of affection between the partners as gifts of love and concern are given and received.
That special someone is in the waiting room during the surgical ordeal and by the patient's bedside when she awakes. There are flowers and gifts and promises made and kept. There is an abundance of reciprocal love.
Adjustment to new roles is relatively smooth, causing new bonds to form and old ones to strengthen.
The surgical patient begins to see herself as a sexual person when her sexual identity is validated by her sexual partner, friends, family, and even admiring strangers she passes on the street. The woman who has had a mastectomy or other body-altering surgery needs to know her partner still finds her attractive and desirable.
Without this affirmation, she may have a great deal of trouble seeing herself as a sexual being.
A potential roadblock to healing, however, is the fact that some sexual partners cannot accept an incomplete person. Some surgical procedures result in the loss of vulva, clitoris, or vagina. Radical pelvic surgery can leave a woman with a colostomy or urinary diversion. A severely altered body image concurrent with loss of health and vigor poses a serious threat to a woman's self-esteem. The woman who has lost her sexual identity feels
damaged beyond repair. Some complain of continuing pelvic pain without obvious structural cause. Interest in sex vanishes, and the patient may actually leave her sexual partner or force the partner to abandon her. As she terminates her sexual identity, she feels old before her time and begins to draw in the edges of her life. These women need intense psychosexual therapy if they are ever to heal emotionally. Table 3.1 outlines the major factors that occur with psychosexual dysfunction.
In some cases, the woman's partner becomes a bigger problem than her physical disability. It is possible her significant other constructed a fragile emotional bond with body parts rather than with the actual woman. If she had or has cancer, the partner may irrationally feel that the cancer is contagious. If she is receiving radiation treatment, he may feel that if he resumes sexual relations with her, he, too, might absorb radiation from her body and be burned. The couple may be accustomed to frequent sex, and any change in the woman's availability stresses the relationship. The fear of causing pain also has an inhibiting effect. Emotional isolation and loss of nurturing occur in both partners when the woman experiences physical disability. As surgeon to the
postoperative patient, you are her first line of psychosexual defense, and yours will not be an easy job.
TABLE 3.1 Major Factors in Psychosexual Dysfunction
Symptomatic
Interpersonal (discord with significant other)
Organic (disease, malnutrition, malfunction of body organs) Psychiatric (anxiety, depression, schizophrenia)
Alcohol or drug abuse
Iatrogenic (suggestions, medication, surgery) Learned
Family (childhood negative sexual associations, experiences)
Religion (imposed prohibitions internalized) Early unpleasant sexual experiences
Gynecologic disorders (damaged genitalia, loss of breasts, uterus) Intrapsychic conflict
Failure to develop psychosexually
Restrictive childrearing Religious influences
Sexual adjustment is often significantly impaired in women after pelvic exenteration and gracilis myocutaneous vaginal reconstruction. In one of the few studies that exist, 84% of the patients resumed sexual activity within the first year after surgery. A modified version of the Sexual Adjustment Questionnaire was used; the responses outlined the most common problems patients face after the surgery: self-consciousness about a urostomy or colostomy, being seen in the nude by their partner, vaginal dryness, and vaginal discharge. It is hoped that future modifications in surgical technique, more realistic patient counseling, and aggressive postoperative support will minimize these problems in the future. Less serious matters can cause self-esteem and body image problems, too, if their aftermath includes or leads to bowel incontinence, urinary incontinence, vaginal vault prolapse, and scarring.
Bowel incontinence is rarely discussed even with a woman's physician because it is so embarrassing. Whether from obstetric injuries, injury to the anal muscles, infections, or diminished muscle strength from aging, once the cause and severity are determined, treatment can begin. This might include dietary changes, constipating medications, muscle strengthening exercises, biofeedback techniques, and sometimes surgical repair of the muscle. Some or all of these remedies help the woman control the discharge of embarrassing gas or stool. It is most important to discuss possible remedies because many women feel there is nothing that can be done for them but the frightening colostomy, when in actual fact, colostomy is a procedure that is rarely required.
As many as 50% of all women experience occasional urinary incontinence. In an attempt to lessen the blow to a woman's ego and make the event more socially acceptable, manufacturers hire movie stars to make commercials about the effectiveness of diapers for grown women. Diapers do treat the symptoms and allow for more freedom of movement, but not in an intimate setting. For many years, gynecologists have instructed patients about Kegel exercises to tighten the muscles of the pelvic floor, but this may not be enough to stop the embarrassing leakage of urine. The patient needs to know that there are tests that can determine the exact cause of the problem, and treatments using bladder retraining therapy, medications, and surgery. Urinary incontinence may be more socially acceptable today, but it is never normal, no matter what the woman's age.
Both bowel and urinary incontinence can be caused by vaginal vault prolapse, and this condition must be ruled out because it drastically affects sexual functioning. The presence of a mass can cause painful intercourse, difficulty accepting penetration, and a great deal of psychological anxiety when the tissue can be seen in the vaginal opening. This condition, if left untreated, only worsens with time, but techniques that correct female
P.39 organsupporting defects in the pelvis can restore sexual functioning and with it, a woman's sense of vitality and feminine allure.