SEXUAL MEDICINE
Sexual medicine is a medical specialty that deals with your sexual and reproductive health. This specialty encompasses diagnosing, assessing, and treating all aspects that relate to sexuality, including sexual health counseling. The Fosnight Center for Sexual Health can also provide basic general urology and gynecological services, which often overlaps with your sexual health. We work collaboratively with other local providers to meet all of your health care needs.
CONDITIONS
Also known as pleasure dissociative orgasmic disorder (PDOD). Individuals with PDOD know they are having an orgasm, however do not have the ability to experience pleasure from the orgasm. Causes can include medication side effects, nerve damage, hormonal imbalances, stress, and chronic fatigue. Diagnosis can be made from a thorough medical history and exam along with blood tests to assess hormone function. Treatment includes a multidisciplinary approach with medical interventions to adjust medications, pelvic floor physical therapy to explore anatomy and pelvic organ function, and sex therapy to set realistic expectations around satisfaction.
Also known as painful bladder syndrome, interstitial cystitis is a condition where the protective lining in the bladder thins or is nonexistent, causing severe inflammation to the bladder. Symptoms include urinary frequency, urinary urgency, pelvic pain, and dyspareunia in the absence of a true UTI or vaginal infection. The exact cause of IC is unknown however there are many factors that may contribute to the development of this condition. Diagnosis is made through questionnaires, medical history, extensive physical exam including a pelvic exam, and procedure/surgical interventions. There are varying degrees of IC and treatment options vary depending on the individual need of the patient. We often perform bladder instillations in the office to resolve bladder flares and/or rebuild the bladder lining. If you think you might have IC, visit www.ichelp.org to find out more information.
Whether you identify as genderqueer, gender non-binary, or gender fluid, we want to help you affirm your identity with hormone therapy. We approach hormone therapy on an individual basis to match the desired gender to each patient or client. Through a combination of estrogen, testosterone, and other hormone medications, we balance your hormones to meet your needs as an individual.
A newer sexual health concern, genito-pelvic dysesthesia (GPD) or persistent genital arousal disorder (PGAD) is associated with spontaneous, unwanted, persistent genital sensations. Symptoms can include pelvic pressure and/or discomfort, engorgement, pulsating, and throbbing that is not relieved with orgasm. Causes are multi-factorial and individually based on each person’s history. Treatment options include avoiding stress, relaxation techniques, medication adjustments, nerve blocks, neuromodulation, and pelvic floor physical therapy.
Cancer and its treatments have a wide range of effects on sexuality. Any type of cancer experience can influence your body image, emotions and relationships - all of which can change how you feel about sex. For many people, sex is the last thing they think about with a cancer diagnosis, however research shows that sexual health is a key player in optimizing wellness for cancer patients. Cancer treatments (surgery, radiation, chemotherapy, and hormone therapy) greatly impact sexual function and fertility. For younger women, cancer treatments may cause them to go into early menopause through premature ovarian failure. Ideally, having a sexual health consultation prior to cancer treatment can help troubleshoot potential sexual side effects and optimize your sexual healing after treatment. Loss of desire is the most common sexual health concern after cancer treatment. Together, we can develop a plan to rebuild your sexual self holistically with medical interventions, physical therapy, sex therapy, and other modalities.
At the center, we offer masculinization hormone affirming therapy for our transmale patients. The goal of therapy is to develop male secondary sex characteristics, and suppress female characteristics. We can use testosterone medications to support the masculinization process as well as add progesterone or other contraceptive methods to suppress the menstrual cycle. Masculinization hormone therapy also brings about changes in emotional and social functioning. We use a biopsychosocial approach during the transition process and provide informed consent that includes the discussion of risks and benefits of hormone therapy. Close follow up is important to maximize the effects during the transition process while minimizing the potential risk factors.
The pelvic floor is an intricate weave of muscles, ligaments, tendons, and fascia structures supporting the pelvic organs. When there is abnormal tone, pain, shortening, weakness, spasm, discoordination, and impaired contracile properties, the pelvic floor can become hypertonic (high-tone) or hypotonic (low-tone) leading to a wide array of pelvic floor concerns. Symptoms include urinary incontinence, fecal incontinence, dyspareunia (painful intercourse), decreased lubrication, and referred pain. Causes include but are not limited to pelvic/lower back trauma, medications, anxiety/depression, pregnancy, childbirth, pelvic and abdominal surgeries. Research shows that female athletes are at increased risk for high-tone pelvic floors. Diagnosis can be made on physical exam paying close attention to the core, pelvic floor, hips, and lower back. Often, a pelvic floor PT will use a surface electrode to assess the resting tone of the pelvic floor muscles and evaluate muscle coordination and contractility. Treatment options include pelvic floor physical therapy along with trigger point release, medications, mindfulness, and breathing techniques.
Also known as lack of lubrication and genital swelling in the presence of sexual stimulation. Some individuals report this as feeling as if they have “dead genitals.” Physical causes can include lack of blood flow, hormonal changes, medication side effects, and nerve injury. Psychological causes include anxiety/depression, trauma, relationship discord, body image concerns, and stress. Diagnosis and treatment vary on symptoms and individual profile.
At the center, we offer feminizing hormone affirming therapy for our transfemale patients. The goal of therapy is to develop female secondary sex characteristics, and suppress male characteristics. We can use estrogen and androgen blocking medications to support the feminization process as well as add progesterone as an adjunct therapy and potentiate breast development. Feminizing hormone therapy also brings about changes in emotional and social functioning. We use a biopsychosocial approach during the transition process and provide informed consent that includes the discussion of risks and benefits of hormone therapy. Close follow up is important to maximize the effects during the transition process while minimizing the potential risk factors.
Compulsive sexual behavior is sometimes called hypersexuality, hypersexuality disorder or sexual addiction. It's an excessive preoccupation with sexual fantasies, urges or behaviors that is difficult to control, causes you distress, or negatively affects your health, job, relationships or other parts of your life. Often, drugs and alcohol abuse overlap with compulsive sexual behaviors. Cognitive/behavioral therapy and self help organizations can improve behaviors as well as working with a therapist or counselor specializing in compulsive sexual behaviors.
A very common sexual health concern, premature ejaculation occurs when a man ejaculates sooner than he or his partner would like., typically within one to two minutes upon penetration. It is estimated that at least 1 in 3 men have experienced rapid ejaculation. Diagnosis of early ejaculation is made mostly through a medical history. Causes are thought to be mostly psychological, however hormone levels, concomitant erectile dysfunction, and aging are also contributions. Treatment options include medications (both oral and topical), disease management, behavior homework assignments, setting realistic expectations, pelvic floor physical therapy, and working collaboratively with a sexual health team.
During this transition period in a woman’s life can bring many emotions and feelings that impact her body image and sexuality. Many women continue sexuality activity throughout their pregnancy, however secondary to the growing uterus, may find some sexual activities painful or uncomfortable. Working with sexuality counselors and therapists can improve communication with your partner and seeking help from a pelvic floor physical therapist can improve lower back pain, hip pain, and dyspareunia. During the postpartum period, hormonal changes, lifestyle changes, and relationship changes greatly impact a woman’s sexuality. We recognize that having a strong support system is key to regaining your sexual self and building your relationship with your partner. Again, we work together as a multidisciplinary team to improve your overall sexual function through a biopsychosocial model ensuring optimal health and pleasure.
Anorgasmia is defined as long term inability to achieve orgasm after adequate sexual stimulation causing personal distress in women. Studies have revealed that approximately 15% of all women struggle with achieve orgasm and 10% report never achieving orgasm in their life. Diagnosis focuses on ruling out medical conditions and blood tests to determine how your body’s endocrine system is functioning. Treatment involves a multidisciplinary approach through medical interventions with vibration therapy, optimal sexual positioning/props, and medications; pelvic floor PT to increase blood flow, muscle relaxation, and rebuild nerve function; and sex therapy to initiate individual and partner behavioral assignments.
In adult males, hypogonadism or low testosterone, can impair the normal body hormonal functions. Early signs of low testosterone include depression, decreased energy, and decreased sexual desire. Over time, if not corrected, low testosterone can lead to erectile difficulties, development of breast tissue, obesity, decreased lean muscle mass, and even bone loss. There are various reasons for low testosterone, however more common secondary causes include medications, inflammatory diseases, obesity, HIV/AIDS, and normal process of aging. Diagnosis can be made via a thorough medical history and physical exam, along with blood, hormonal, and other diagnostic testing. Treatment includes correcting the underlying condition and/or testosterone supplementation through medications including topical patches/gels, injections, or pellets.
Vaginismus is vaginal tightness causing discomfort, burning, pain, penetration or insertion difficulties, or complete inability to have vaginal intercourse. The vaginal tightness results from a limbic system protective mechanism response that signals the body to brace and protect against potential harm. Vaginismus typically results secondary to a phenomenon called the cycle of pain. Treatments include a multidisciplinary approach through pelvic floor PT, vaginal dilator training, medications, vaginal inserts, biofeedback, and cognitive/behavioral therapy.
One of the most prevalent sexual health concern is hypoactive sexual desire disorder (HSDD), defined as chronic low sexual desire causing personal distress. Research estimates that 1 in 10 women has HSDD. Causes can include hormone changes, medication side effects, trauma, pain, and even stress. A thorough medical assessment including questionnaires, history taking, and physical exam are key in diagnosising HSDD. Treatment options include medications, behavior homework assignments, and working collaboratively with a sexual health team.
The menopause transition can be a time in a woman’s life where she may feel liberated or frustrated secondary to hormonal changes. This new phase in life can encompass several stages including perimenopause, menopause, and postmenopause. The average age for a woman to start menopause is 51, however hormonal changes can happen up to 10 years prior to her final menstrual period. Symptoms include irritability, fatigue, memory concerns, “brain fog,” hot flashes, night sweats, sleep disturbances, vulvovaginal concerns, and other physical changes. Although menopause is not a specific medical condition, this natural transition process can lead to personal distress and need for therapy options. Treatments include OTC medication, prescribed medications, as well as lifestyle and behavioral modifications.
For men with delayed ejaculation, there is a prolonged delay in reaching ejaculation/orgasm during sexual activity and stimulation. Many more men are dealing with delayed ejaculation than thought in the past. Causes include disease processes, medications, genital neuropathy, excessive alcohol use, hormone imbalances, depression, and pelvic floor concerns. Treatment approach to delayed ejaculation includes isolating the cause and using a multidisciplinary technique to improve erectile ability, increase blood flow and nerve sensitivity through pelvic floor physical therapy, and cognitive/behavioral therapy.
If you have internal pelvic organs that may put you at risk for pregnancy, it is important to understand what medical prevention options are out there for you. You can still get pregnant even if you are on testosterone and your periods have stopped. At the center, we want to talk to you about reliable contraception options if you do not wish to have a child. Implants and intrauterine devices (IUDs) are great options and available services at the center. Should you decide to become pregnant, either now or in the future, we can also discuss your fertility options. We work closely with Piedmont Reproductive Endocrinology Group (PREG) in Asheville, NC and Greenville, SC to help you explore ways to have a child with your own genetic material, either through freezing your eggs or ovarian tissue, and embryo freezing. These may be options for you if you want to become pregnant or if you want to have someone else, a surrogate, carry a child for you in the future.
Peyronie’s disease is caused by fibrous scar tissue involving the fascia structure surrounding the penile shaft. This palpable scar causes a penile deformity in the erect state, including bending, curvature, narrowing, hinging, and shortening of the penis. Painful erections and loss of sensation often occur which can lead to other sexual health concerns along with inability to penetrate during intercourse. The exact cause of Peyronie’s is still being investigated however we do have strong evidence that shows trauma or injury to the penis may cause a proliferate fibrous reaction in the fascia sheath leading to the formation of a plaque. Many other causes are being explored including genetics, inflammatory diseases, and autoimmune disorders. Diagnosis can be made through a medical history and thorough physical including a pelvic exam. An artificial erection and penile ultrasound may be performed in the office to isolate the plaque location and measure degree of curvature. Treatment options are based on several factors associated with the timing of the plaque, goal for penile function, and current comorbidities. Therapies include medications, intralesional injections, topical formulations, and surgical interventions.
Vulvodynia is an all-encompassing term associated with pain in the vulva and vestibule. Pain can occur anywhere on the vulva, either localized or generalized. The most common symptom is a burning sensation although other sensations such as a sharp, knife-like pain, dull ache, or pressure can happen as well. Causes can include inflammatory or infectious processes, neurogenic, genetic, stress, or hormonally mediated. A simple cotton swab test can be performed during a pelvic exam to assess the nerve sensitive of the vulvar skin. Treatment involves simplifying hygiene practices, avoiding irritants, topical corticosteroids, medications, pelvic floor physical therapy, procedures/surgical interventions, and cognitive/behavioral therapy.
Thinning of the vulvovaginal tissues can lead to pelvic pressure, burning, dryness, tearing, urinary symptoms, and pain with sexual activity. The most common cause is secondary to hormonal changes. This can be from medications, hormonal contraceptives, surgical removal of the ovaries, cancer treatments and medications, menopause, and other pelvic/abdominal surgeries. Diagnosis involves a thorough medical history, physical with pelvic exam, and diagnostic tests. Treatment typically involves medication adjustments, local topical vaginal hormone formulations, vibration therapy, and non-FDA approved procedures.
A relatively new term that encompasses all of the lower urogenital tract signs and symptoms associated with a low hormonal state. GSM describes the genital, urinary, and sexual changes that occur over the menopause transition. Diagnosis includes a thorough medical history and physical exam including a pelvic exam. Treatment options are based on replenishing the hormone imbalance in the urogenital tissues including vaginal moisturizers, local hormone formulations, vibration therapy, and pelvic floor physical therapy.
Millions of American men experience erectile difficulties and the most common sexual health compliant reported by men. Studies have shown that roughly 40% of men in their 40’s and 70% of men in their 70’s have erectile concerns. Ed is defined as the inability to achieve and/or maintain an erection sufficient for sexual activity. Causes can include physical, psychological, or both. The most common physical cause of ED includes blood flow insufficiency - coronary artery disease, hypertension, and hyperlipidemia. Other physical causes include diabetes, low testosterone, hormonal imbalances, Peyronie’s disease, tobacco use, sleep apnea, excessive alcohol use, obesity, medical treatments, Parkinson’s, and neurological disorders. Psychological causes include depression, anxiety, stress, performance pressures, and relationship discord. Treatment includes identification of the cause as well as optimizing blood flow and nerve sensitivity with medications and pelvic floor physical therapy. Cognitive/behavioral therapies work will as an adjunct therapy to improving medical comorbidities. Working together with a sexual team is essential to maximizing erectile potential. See Sexual Pelvic Rehabilitation Program for more information. There are experimental therapies that include low intensity shockwave therapy and plasma rich protein.
Bacterial vaginosis and recurrent vaginal yeast infections are two of the most common reasons for abnormal vaginal discharge. When the normal flora of the vagina becomes disrupted through hormonal changes, menses, douching, intercourse, this leads you more susceptible to yeast and bacterial infections. Abnormal vaginal discharge is the most common compliant, however other symptoms include a burning sensation, itching, pelvic pain and pressure. Confirming the correct diagnosis is key and includes pelvic exam with vaginal swabs to be tested for specific bacteria or yeast. Treatment is based on diagnostic test results and an individualized treatment plan is determined based on your needs and risk factors. Prevention is important as both bacterial vaginosis and vaginal yeast infections often recur.
Pain with intercourse is a common complaint for women of all ages. Research now shows that the majority of dyspareunia is caused by physical conditions that plays a large psychological influence on sexual health. Dyspareunia, itself is not merely a disease but rather a symptom with many different causes. Together, you and your sexual health care team will work collaboratively to develop an individual treatment plan to optimize your sexual health.
PROCEDURES
Vulvoscopy is procedure performed in the office to aid in a more detailed pelvic examination of the female external genitalia. This device allows the provider to see those structures in a magnified capacity through a special microscope, bringing out architecture that is not always visible with the eye. A special solution may be applied to the vulva during the vulvoscopy to help differentiate abnormal cells from normal ones. If a questionable area is seen during the vulvoscopy, a vulvar biopsy may be performed at the same time.
A duplex Doppler ultrasonography not only allows the provider to visualize the vascular structures within the pelvis, but ultrasonography also allows for evaluation of the pelvic floor musculature. This can aid in diagnostic of pelvic floor disorders and treatment options.
Trigger point injections are recommended as a treatment option for patients with pelvic floor muscle spasms that often cause pelvic pain and/or difficulties with sexual function. The injections are performed in the office and the majority of the time are used with ultrasound guidance in order to increase the effectiveness of the injection. Injection medications can include a local anesthetic, steroid, and/or botox. A series of injections in conjunction with pelvic floor physical therapy maximizes the effectiveness of the treatment and will be determine individually with the patient.
Evaluation of pelvic and penile tissues can aid in treatment options for those patients with erectile ability concerns. A penile doppler ultrasonography allows the provider and the patient to visualize blood flow to the pelvis and penile structures, isolating the cause for decreased vascularization. This is an in-office procedure and is performed in conjunction with an artificial erection injection.
Hormone pellet implants are used to restore hormonal balance in both men and women, as well as used for gender affirmation hormone therapy. This safe and simple procedure can be performed in the office with a local anesthetic every 3-6 months.
There are several neurologic diagnostic testing essential for evaluation of pelvic pain. These include magnetic resonance imaging (MRI), nerve blocks, and electromyography (EMG). Not all of these diagnostic tests will be required for each patient, however, a more focused, individual plan will be discussed and determined collaboratively with the provider and patient.
During a pelvic exam, the provider may perform a cotton swab test on the vulva and lower vaginal canal to determine sensations causing sexual or pain concerns. The test involves the use of a cotton swab placed on various sites on the female genitals and the patient sensations are recorded. This test is extremely helpful in diagnosing certain vulvar diseases. The provider will discuss with you in great detail the test before the exam begins.
One of the most effective treatment options for men with Peyronie’s has been intralesional injections. This allows for direct treatment of the plaque, resulting in reduction of the lesion size and decreased penile curvature. These injections are performed in the office under ultrasound guidance for optimal plaque visualization. A series of injections in conjunction with stretching and modeling exercises maximizes the effectiveness of the treatment. Other treatment modalities recommended include pelvic floor physical therapy and oral medications, and will be determined individually with the patient.
Interstim, or sacral neuromodulation, has been FDA approved to treat urge incontinence, fecal incontinence, and incomplete bladder emptying. A nerve evaluation test will first be performed in the office and if results are successful, we will discuss next best steps with the implantable device.
Evaluation of pelvic and penile tissues can aid in treatment options for those patients with erectile ability concerns. A penile doppler ultrasonography allows the provider and the patient to visualize blood flow to the pelvis and penile structures, isolating the cause for decreased vascularization. This is an in-office procedure and is performed in conjunction with an artificial erection injection.
A vulvar biopsy is a diagnostic procedure performed in the office to determine the cause of vulvar symptoms including irritation, lesion, suspected malignancy, auto-immune disorders, skin pigment changes, and conditions that are not resolving with standard treatment. A local anesthetic is used prior to taking a biopsy of the area and may require a suture for closure. Follow up will be scheduled to ensure proper wound healing, discuss biopsy results, and determine best course of treatment including referral to collaborating providers in the area.
This is a specialized surgical procedure to investigate symptoms associated with interstitial cystitis. A small scope will be inserted through your urethra while under general anesthesia to look at your bladder and distend the bladder with fluid. Occasionally, biopsies of the bladder wall may be taken. A cystohydrodistention can be both diagnostic and therapeutic, helping to alleviate some of the pelvic pain associated with interstitial cystitis.
Penile injections are a safe and effective method to improve blood flow to the penis. There are many health diseases that can impair the blood flow to the pelvic and penile tissues, limiting arousal and erections. These injections allow for dependable erections for sexual play. Education around how to perform self injections is vital to the safety and efficacy of the medications, and instructions will be provided to the patient in the office.
Bladder instillations or bladder cocktails are mixtures of medications put directly into the bladder in the office. We use a variety of medication combinations to meet the individual need of each patient. Bladder instillations can be used for patients with pelvic pain, interstitial cystitis, radiation cystitis, recurrent urinary tract infections, and other medical conditions.
