The modern era in sexual medicine started in the
1970s when a few devoted pioneers and visionaries
began to revolutionize our thinking and understanding
in this field.
Prior to that time, sexual dysfunctions in men,
particularly erectile disorders, were thought to be
purely psychogenic or in rare cases caused by testosterone
deficiency. Treatment of sexual disorders was
considered to be predominantly the business of sextherapists
or rarely of endocrinologists.
Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 18)
Table 124-8 Initial Management of Genital or Perianal Ulcer
Herpes simplex virus (HSV)
Treponema pallidum (primary syphilis)
Haemophilus ducreyi (chancroid)
Usual initial laboratory evaluation Dark-field exam, direct FA, or PCR for T. pallidum; RPR or VDRL test for syphilis (if negative but primary syphilis suspected, repeat in 1 week); culture,
direct FA, ELISA, or PCR for HSV; consider HSV-2-specific serology. In chancroid-endemic area: PCR or culture for H.
Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 19)
Ulcerative Genital or Perianal Lesions: Treatment
Immediate syndrome-based treatment for acute genital ulcerations (after collection of all necessary hdiagnostic specimens at the first visit) is often appropriate before all test results become available, because patients with typical initial or recurrent episodes of genital or anorectal herpes can benefit from prompt oral antiviral therapy (Chap.
Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 20)
Proctitis, Proctocolitis, Enterocolitis, and Enteritis: Treatment
Acute proctitis in persons who have practiced receptive anorectal intercourse is usually sexually acquired. Such patients should undergo anoscopy to detect rectal ulcers or vesicles and petechiae after swabbing of the rectal mucosa; to examine rectal exudates for PMNs and gram-negative diplococci; and to obtain rectal swab specimens for testing for rectal gonorrhea, chlamydial infection, herpes, and syphilis.
Take molecular genetics and
bioinformatics for example; these are perhaps two of the most exciting areas of biology and
are beginning to have an impact on other areas of medical therapeutics such as cancer and
diabetes, and provide a signpost to ‘personalised medicine’. Yet recent genome wide
association (GWAS) studies of large samples, have demonstrated that in schizophrenia
around 1000 or more genetic variants of low penetrance may be implicated in the
heritability of schizophrenia.
This report, published by the UN Millennium Project, examines the global burden of diseases and
risks related to sexual and reproductive health (SRH), analyses the implications for the
Millennium Development Goals, and asks what needs to be done. Key findings include that
millions of women lack access to family planning services they need and want. The unmet need
for contraception is especially acute among adolescents in the developing world. One in 16
women in sub-Saharan Africa dies from complications of pregnancy and childbirth, compared with
one in every 2800 in...
What is alternative medicine? Attempts to define what is conventional
and what is not conventional introduce a bias, no matter
who the arbiter is who sets up the definitions (Table 1). Many
alternative therapies pre-date conventional medicine by hundreds
or thousands of years. Some are quite well known, others
seem mysterious or strange, and some pose serious risks (Murray
and Rubel 1992). Many of us use unconventional therapies acquired
from grandparents, parents, or friends (chicken soup is
perhaps the most famous) in our personal lives without a second
Approach to the Patient: Erectile Dysfunction
A good physician-patient relationship helps to unravel the possible causes of ED, many of which require discussion of personal and sometimes embarrassing topics. For this reason, a primary care provider is often ideally suited to initiate the evaluation. A complete medical and sexual history should be taken in an effort to assess whether the cause of ED is organic, psychogenic, or multifactorial (Fig. 492). Initial questions should focus on the onset of symptoms, the presence and duration of partial erections, and the progression of ED.
Female Sexual Dysfunction: Treatment
General An open discussion with the patient is important as couples may need to be educated about normal anatomy and physiologic responses, including role of orgasm in sexual encounters. Physiologic changes associated with aging and/or disease should be explained. Couples may need to be reminded that clitoral stimulation rather than coital intromission may be more beneficial.
Behavioral modification and nonpharmacologic therapies should be a first step. Patient and partner counseling may improve communication and relationship strains.
Male Sexual Dysfunction: Treatment
Patient Education Patient and partner education is essential in the treatment of ED. In goaldirected therapy, education facilitates understanding of the disease, results of the tests, and selection of treatment. Discussion of treatment options helps to clarify how treatment is best offered and stratify first- and second-line therapies. Patients with high-risk lifestyle issues, such as smoking, alcohol abuse, or recreational drug use, should be counseled on the role these factors play in the development of ED.
Physiology of the Female Sexual Response
The female sexual response requires the presence of estrogens. A role for androgens is also likely but less well-established. In the CNS, estrogens and androgens work synergistically to enhance sexual arousal and response. A number of studies report enhanced libido in women during preovulatory phases of the menstrual cycle, suggesting that hormones involved in the ovulatory surge (e.g., estrogens) increase desire.
Sexual motivation is heavily influenced by context, including the environment and partner factors.
Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 17)
Although most genital ulcerations cannot be diagnosed confidently on clinical grounds alone, clinical findings plus epidemiologic considerations (Table 124-7) can usually guide initial management (Table 124-8) pending results of further tests.
Clinicians should order a rapid serologic test for syphilis in all cases of genital ulcer and a dark-field or direct immunofluorescence test (or PCR test, where available) for T.
Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 21)
Although gonorrhea is now substantially less common than chlamydial infection in industrialized countries, screening tests for N. gonorrhoeae are still appropriate for women and teenage girls attending STD clinics and for sexually active teens and young women from areas of high gonorrhea prevalence. Multiplex NAATs that combine screening for N. gonorrhoeae and C. trachomatis in a single low-cost assay now facilitate the prevention and control of both infections in populations at high risk.
Harrison's Internal Medicine Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach
Classification and Epidemiology
Worldwide, most adults acquire at least one sexually transmitted infection (STI), and many remain at risk for complications. Each year, for example, an estimated 6.2 million persons in the United States acquire a new genital human papillomavirus (HPV) infection, and many of these individuals are at risk for genital neoplasias.
This syndrome (formerly termed nonspecific vaginitis, Haemophilus vaginitis, anaerobic vaginitis, or Gardnerella-associated vaginal discharge) is characterized by symptoms of vaginal malodor and a slightly to moderately increased white discharge, which appears homogeneous, is low in viscosity, and evenly coats the vaginal mucosa. An interesting observation is that new genital HPV infection in young women is associated with increased subsequent risk of developing bacterial vaginosis.
Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 12)
Gram's stain of cervical mucus, showing a strand of cervical mucus
containing many polymorphonuclear leukocytes. This picture is typical of mucopurulent cervicitis. Note that leukocytes are not seen in areas of the slide containing vaginal epithelial cells, adjacent to the mucus strands.
Pelvic Inflammatory Disease: Treatment
The 2006 CDC guidelines recommend initiation of empirical treatment for PID in sexually active young women and other women at risk for PID if they are experiencing pelvic or lower abdominal pain, if no other cause for the pain can be identified, and if pelvic examination reveals one or more of the following criteria for PID: cervical motion tenderness, uterine tenderness, or adnexal tenderness.
Women with suspected PID can be treated as either outpatients or inpatients.
The appropriate time to start contraception depends on the contraceptive method and may
also depend on medical and social factors. Traditionally, initiation of hormonal and
intrauterine methods of contraception has been delayed until the onset of the next menstrual
period in order to avoid inadvertent use during pregnancy. Starting early in the cycle also
avoids the need for additional contraception. The manufacturers’ Summaries of Product
Characteristics (SPCs) vary in their advice on contraceptive start dates and the need for
Treat urethritis promptly, while test results are pending.
Table 124-4 summarizes the steps in management of sexually active men with urethral discharge and/or dysuria.
Table 124-4 Management of Urethral Discharge in Men
Usual initial evaluation
Chlamydia trachomatis pyuria Neisseria gonorrhoeae
Demonstration of urethral discharge or
Mycoplasma genitalium complications
Urethral Gram's stain to confirm urethritis, detect gram-negative diplococci
Test for N. gonorrhoeae, C.