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Fortschr Neurol Psychiatr 2004; 72(3): 121-135
DOI: 10.1055/s-2004-818357
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© Georg Thieme Verlag Stuttgart · New York

Weibliche sexuelle Funktionsstörungen: Klassifikation, Diagnostik und Therapie

Female Sexual Dysfunction: A Systematic Overview of Classification, Pathophysiology, Diagnosis and TreatmentH.  Marthol1 , M.  J.  Hilz1, 2
  • 1New York University School of Medicine, Department of Neurology, New York, USA (Edwin H. Kolodny, M.D., Professor and Chairman)
  • 2Neurologische Klinik mit Poliklinik der Universität Erlangen-Nürnberg (Direktor: Prof. Dr. med. B. Neundörfer)
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Publication History

Publication Date:
04 March 2004 (online)

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Zusammenfassung

Unter sexuellen Funktionsstörungen versteht man „Störungen im sexuellen Verlangen und psychophysiologische Veränderungen, die den sexuellen Reaktionszyklus charakterisieren und dadurch ein deutliches Leiden sowie zwischenmenschliche Schwierigkeiten hervorrufen”. Der sexuelle Reaktionszyklus wird in die drei Phasen, sexuelle Begierde, sexuelle Erregung und Orgasmus, unterteilt. An der Sexualfunktion der Frau sind die Vagina, Klitoris, Labia minora, Bulbus vestibuli sowie die Beckenbodenmuskulatur und der Uterus beteiligt. Während sexueller Erregung ist sowohl die Durchblutung als auch die Sensibilität im Bereich des weiblichen Genitales deutlich gesteigert. Darüber hinaus wird die Vaginalschleimhaut befeuchtet (Lubrikation). Schließlich kommt es während des Orgasmus zu rhythmischen Kontraktionen des Uterus und der Beckenbodenmuskulatur. Innerhalb des zentralen Nervensystems spielen Strukturen in Hypothalamus, Hippokampus und limbischem System eine zentrale Rolle. Man nimmt an, dass die sexuelle Erregung primär sympathisch vermittelt wird. Besonders sind aber so genannte nicht cholinerge, nicht adrenerge Neurotransmitter (NANC), z. B. vasoaktives intestinales Polypeptid (VIP) und Stickoxid (NO), von Bedeutung. Diese bewirken eine Relaxation der glatten Muskulatur und damit eine Steigerung der Durchblutung im Bereich des Genitales. Daneben beeinflussen verschiedene Hormone die Sexualfunktion der Frau. Östrogene sind für die Erhaltung der Vaginalschleimhaut sowie für die Sensibilität, Durchblutung und Lubrikation im Bereich des Genitale entscheidend. Androgene hingegen steigern vorwiegend die sexuelle Begierde, Erregung, Orgasmus und das allgemeine Wohlbefinden. Die international anerkannte Klassifikation weiblicher sexueller Funktionsstörungen unterscheidet zwischen Störungen der sexuellen Appetenz, Störungen mit sexueller Aversion, Störungen der sexuellen Erregung, Orgasmusstörungen und Störungen mit sexuell bedingten Schmerzen. Ursächlich sind vor allem vaskuläre Veränderungen, z. B. Arteriosklerose, und neurologische Erkrankungen, z. B. die diabetische Polyneuropathie, an der Entstehung sexueller Funktionsstörungen beteiligt. Daneben können aber auch hormonelle Veränderungen, Medikamente sowie psychische Belastungen die Sexualfunktion beeinträchtigen. Am Anfang der Diagnostik sollten eine ausführliche Anamneseerhebung und körperliche Untersuchung sowie Laborbestimmungen stehen. Organisch bedingte Störungen lassen sich zum Teil durch verschiedene Untersuchungsverfahren nachweisen. Messungen vor sowie nach sexueller Stimulation tragen dazu bei, pathologisch veränderte Reaktionen im Rahmen der sexuellen Erregungsphase aufzuzeigen. Mithilfe der Duplexsonographie, der Photoplethysmographie oder der Messung des transkutanen Sauerstoffpartialdruckes kann die Durchblutung im Bereich des weiblichen Genitale beurteilt werden. Daneben sollten der vaginale pH sowie die Compliance gemessen werden. Mittels neurophysiologischer Untersuchungsverfahren, z. B. dem Bulbokavernosus-Reflex, den somatosensibel evozierten Potenzialen des N. pudendus, der sympathischen Hautreaktion (SSR) und der Bestimmung der Warm-, Kalt- und Vibrationsempfindungsschwellen sowie der Empfindlichkeit gegenüber Druck und Berührung im Bereich des Genitales, können neurogene Ursachen teilweise ausgeschlossen werden. Bislang wurden überwiegend Hormonpräparate im Rahmen der Therapie weiblicher sexueller Funktionsstörungen eingesetzt. Östrogene können zur Linderung von Schmerzen und brennenden Missempfindungen während des Koitus beitragen. Die Wirksamkeit weiterer Medikamente, z. B. Sildenafil, L-Arginin, Yohimbin, Phentolamin, Apomorphin oder Prostaglandin E1, muss noch klinisch geprüft werden.

Abstract

Sexual dysfunction is defined as “disturbances in sexual desire and in the psychophysiological changes that characterize the sexual response cycle and cause marked distress and interpersonal difficulty”. The female sexual response cycle consists of three phases: desire, arousal, and orgasm. Various organs of the external and internal genitalia, e.g. vagina, clitoris, labia minora, vestibular bulbs, pelvic floor muscles and uterus, contribute to female sexual function. During sexual arousal, genital blood flow and sensation are increased. The vaginal canal is moistened (lubrication). During orgasm, there is rhythmical contraction of the uterus and pelvic floor muscles. Within the central nervous system, hypothalamic, limbic-hippocampal structures play a central role for sexual arousal. Sexual arousal largely depends on the sympathetic nervous system. Moreover, nonadrenergic/noncholinergic neurotransmitters (NANC), e.g. vasoactive intestinal polypeptide (VIP) and nitric oxide (NO), are involved in smooth muscle relaxation and enhancement of genital blood flow. Furthermore, various hormones may influence female sexual function. Estrogen has a significant role in maintaining vaginal mucosal epithelium as well as sensory thresholds and genital blood flow. Androgens primarily affect sexual desire, arousal, orgasm and the overall sense of well-being. The internationally accepted classification of female sexual dysfunction consists of hypoactive sexual desire disorders, sexual aversion disorders, sexual arousal disorders, orgasmic disorders and sexual pain disorders. Vascular insufficiency, e.g. due to atherosclerosis, and neurologic diseases, e.g. diabetic neuropathy, are major causes of sexual dysfunction. Additionally, sexual dysfunction may be due to changes in hormonal levels, medications with sexual side effects or of psychological origin. For the diagnosis of female sexual dysfunction, a detailed history should be taken initially, followed by a physical examination and laboratory studies. Physiologic monitoring of parameters of arousal potentially allows to diagnose organic diseases. Recordings at baseline and following sexual stimulation are recommended to determine pathologic changes that occur with arousal. Duplex Doppler sonography, photoplethysmography or the measurement of vaginal and minor labial oxygen tension may help to evaluate genital blood flow. Moreover, measurements of vaginal pH and compliance should be performed. Neurophysiological examination, e.g. measurement of the bulbocavernosus reflex and pudendal evoked potentials, genital sympathetic skin response (SSR), warm, cold and vibratory perception thresholds as well as testing of the pressure and touch sensitivity of the external genitalia, should be performed to evaluate neurogenic etiologies. Medical management of female sexual dysfunction so far is primarily based on hormone replacement therapy. Application of estrogen results in decreased pain and burning during intercourse. The efficacy of various other medications, e.g. sildenafil, L-arginine, yohimbine, phentolamine, apomorphine and prostaglandin E1, in the treatment of female sexual dysfunction is still under investigation.

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Prof. Dr. med. M. J. Hilz

Neurologische Klinik mit Poliklinik der Universität Erlangen-Nürnberg

Schwabachanlage 6

91054 Erlangen

Phone: 09131-853 4444

Fax: 09131-853 4328

Email: max.hilz@neuro.imed.uni-erlangen.de

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