Introduction
A normal sexual function involves the activation of the neurovascular system, which leads to penile erection in males and clitorial engorgement in females. Some surgical treatments, examinations, and medication can cause damage to the neurovascular circuit, resulting in sexual dysfunction. Certain drugs, chemotherapy, radiotherapy, and surgical procedures on the vasculature, or their effect on sex hormones and inflammatory processes, can lead to biological effects of these interventions on sexual functions resulting in sexual dysfunctions. Males are four times more prone to iatrogenic dysfunction than females. Moreover, females experiencing iatrogenic sexual dysfunction have milder symptoms than males.
What Are the Symptoms of Iatrogenic Sexual Dysfunction?
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Low sexual desire.
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Delayed orgasm.
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Absence of orgasm.
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Absence of ejaculation.
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Decreased sexual arousal.
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Erectile dysfunction (ED).
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Dyspareunia (pain related to sexual intercourse).
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Vaginal dryness.
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Vaginal shortening and tightening.
What Are the Causes of Iatrogenic Sexual Dysfunctions?
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Medications.
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Surgical procedures.
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Radiotherapy.
What Are the Medications That Can Cause Sexual Dysfunctions?
1. Antidepressants:
They cause sexual side effects most commonly by inhibiting descending input to the sacral sex centers and inducing increased levels of serotonin in the blood, which affects other sex hormones and neurotransmitters such as testosterone and dopamine.
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Selective Serotonin Reuptake Inhibitors (SSRIs): Citalopram, Paroxetine, Escitalopram, Sertraline, and Fluoxetine.
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Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs): Venlafaxine, Desvenlafaxine, and Duloxetine.
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Monoamine Oxidase Inhibitors (MAOIs): Tranylcypromine, Isocarboxazid, and Phenelzine. However, Selegiline, an MAOI that works by sticking on the skin as a patch, has a low risk of sexual side effects.
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Tricyclic and Tetracyclic Antidepressants: Nortriptyline, Amitriptyline, and Clomipramine.
2. Anti Hypertensives:
They cause a decline in central dopamine levels, which is an essential mediator in neural inputs related to sexuality. In addition, they lower blood pressure, thus directly affecting the corpus cavernosum (two cylinder-like structures in the penis), and an increment in blood flow to this structure results in blood engorgement and rigidity in the penis causing an erection. They also exhibit effects on sexual neurotransmitters and hormones, such as an increase in the level of prolactin hormone, which leads to erection dysfunction in men. In addition, some diuretics, such as Spironolactone, block testosterone production and interfere with the functionality of sex hormones by competitively binding to androgen receptors.
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Beta-blockers such as Metoprolol and Atenolol.
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Clonidine, Reserpine, Alpha methyldopa.
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Some diuretics such as Hydrochlorothiazide, Bendrofluazide, and Furosemide.
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Spironolactone.
3. Other Cardiovascular Agents:
Drugs like Digoxin decrease testosterone and increase estrogen levels because it has a similar structure to sex steroids. They also decrease erection by increasing the smooth muscle tone of the corpus cavernosum, which in turn results in anti-erectile effects.
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Digoxin.
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Disopyramide.
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Antihyperlipidemic.
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Propranolol.
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Perhexiline.
4. Antipsychotics (Neuroleptics):
They decrease sexual functions by blocking dopamine receptors in the brain, which reduces levels of sex hormones. In addition, they also increase prolactin levels, which in turn give rise to erectile dysfunction. They also reduce sexual functions by indirect effects secondary to weight gain, central nervous system sedation, parkinsonism, and psychomotor retardation.
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Olanzapine.
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Risperidone.
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Aripiprazole.
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Alprazolam.
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Chlorpromazine.
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Fluphenazine.
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Haloperidol.
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Lithium.
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Risperidone.
5. Recreational Drugs:
They increase endothelial toxicity and adrenergic activity in chronic use.
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Alcohol.
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Marijuana.
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Nicotine.
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Heroine.
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Barbiturates.
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Amphetamines.
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Cocaine.
6. Antihistamines:
H2 blockers block androgen receptors and have anti-androgen activity, which affects sex hormone efficiency. It also increases prolactin levels which results in erectile dysfunction and directly affects the corpus cavernosum.
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Benadryl.
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Dramamine.
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Phenergan.
7. Anti-Androgens:
It blocks sex hormone synthesis and lowers testosterone levels in the blood. In addition, they competitively bind to androgen receptors, thus interfering with the functions of sex hormones.
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Finasteride.
8. Opioid Painkillers:
Chronic use of opioid painkillers inhibits the gonadal-pituitary-hypothalamic axis and decreases testosterone levels.
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Codeine.
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Fentanyl.
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Hydromorphone.
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Meperidine.
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Methadone.
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Morphine.
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Oxycodone.
9. Other Drugs:
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Cimetidine.
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Cyproterone.
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Disulfiram.
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Gonadotropin-releasing hormone agonists.
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Propantheline.
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Pseudoephedrine.
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Naproxen.
What Are the Surgical or Radiation Procedures That Can Cause Sexual Dysfunction?
Brachytherapy (for prostate cancer), radical prostatectomy, radical cystectomy, and low anterior or abdominoperineal resection for rectal cancer can reduce sexual functions in men. Pelvic organ prolapse, hysterectomy, bladder cancer, ovarian cancer, and surgery with radiotherapy in females can significantly deter sexual functions.
How Is Iatrogenic Sexual Dysfunction Diagnosed?
In case of experiencing any sexual dysfunction, one should consult their health care provider regarding symptoms of sexual dysfunctions. The clinician will take a detailed history and perform a clinical examination to rule out any underlying cause of sexual dysfunction. The history of performed surgery in the pelvic area, radiotherapy, or drug usage that may be the causative factor of sexual dysfunction is key in diagnosing iatrogenic sexual dysfunction.
How Is Iatrogenic Sexual Dysfunction Managed?
Management of sexual dysfunction depends on its causative factor.
1. In the Case of Medication-Related Sexual-Dysfunction:
The clinician primarily changes the medication to an alternative medication, which can treat the same disease or alter the dose of the drug of ongoing treatment to alleviate its effect on sexual functions. If alternative medicine is unavailable or unsuitable, medications to increase sexual functions and hormone therapy can help, such as estrogen, androgens, PDE4 inhibitors, testosterone, and dopamine receptor antagonist in women. In men, intracavernous injection or Intra ureteral injection of prostaglandin E1, oral medication such as Sildenafil, Tadalafil, and Vardenafil is widely used to improve erectile functions. During antidepressants, drug treatment decreases libido and orgasm, which may benefit from Cyproheptadine administration.
2. In the Case of Post-surgical and Radiation-Related Sexual Dysfunction:
A sexual rehabilitation program that consists of psychosexual counseling and the use of sexual aiding devices such as vaginal dilators and a penis pump can help to regain sexual function to some extent, in addition to pharmacological medications for sexual function improvement, physiotherapy, and exercises.
Conclusion
Despite the psychological aspect and diseases, some surgical treatments and medications can also bring about problems in sexual functions. This sexual dysfunction significantly affects the individual and their partner's quality of life. Therefore, properly managing these symptoms requires a multi-disciplinary approach, such as careful diagnosis, choosing alternative medications, pharmacological treatment to increase sexual functions, and sexual rehabilitation programs.
