【医脉通】2015+第4届国际性医学会议共识：男性和女性性功能障碍的定义.pdf

INTERNATIONAL CONSULTATION ON SEXUAL MEDICINE REPORTSDefinitions of Sexual Dysfunctions in Women and Men:A ConsensusStatement From the Fourth International Consultation on Sexual Medicine2015Marita P.McCabe,PhD,1Ira D.Sharlip,MD,2Elham Atalla,MD,3Richard Balon,MD,4Alessandra D.Fisher,MD,PhD,5Edward Laumann,PhD,6Sun Won Lee,MD,7Ron Lewis,MD,8andRobert T.Segraves,MD9ABSTRACTIntroduction:Definitions of sexual dysfunctions in women and men are critical in facilitating research andenabling clinicians to communicate accurately.Aims:To present the new set of definitions of all forms of sexual dysfunction in women and men adopted by theFourth International Consultation on Sexual Medicine(ICSM)held in 2015.Methods:Classificationsystems,includingtheInternationalClassificationofDiseases,10thEditionandtheDiagnosticand Statistical Manual of Mental Disorders,Fifth Edition,and systems that focus on only specific types of sexualdysfunctions(eg,the International Society for Sexual Medicine definition for premature ejaculation)were reviewed.Main Outcome Measures:Evidence-based definitions were retained,gaps in definitions were identified,andoutdated definitions were updated or discarded.Where evidence was insufficient or absent,expert opinion wasused.Some definitions were self-evident and termed clinical principles.Results:The evidence to support the various classification systems was carefully evaluated.A more compre-hensive analysis of this evidence can be found in two other articles in this journal that consider the incidence andprevalence and the risk factors for sexual dysfunction in men and women.These data were used to shape thedefinitions for sexual dysfunction that have been recommended by the 2015 ICSM.Conclusion:The definitions that have been adopted are those that are most strongly supported by the literatureat this time or are considered clinical principles or consensus of experts opinions.As more research and clinicalstudies are conducted,there likely will be modifications of at least some definitions.J Sex Med 2016;13:135e143.Copyright?2016,International Society for Sexual Medicine.Published by ElsevierInc.All rights reserved.Key Words:International Consultation on Sexual Medicine;Definitions of Male and Female Sexual Dysfunction;DiagnosticandStatisticalManualofMentalDisorders,FifthEdition;InternationalClassificationofDiseases,10thEditionINTRODUCTIONThis article describes the different classification systems forsexual dysfunction that have been used to guide research andpractice in sexual medicine.Then,the definitions of sexualdysfunctions for men and women adopted by the Fourth In-ternational Consultation on Sexual Medicine(ICSM)areintroduced.Draft definitions of these sexual dysfunctions andthe rationale for their adoption were presented to the generalmeeting of the Fourth ICSM in June 2015.Comments fromdelegates were incorporated into a revised set of definitions,andthen these revised definitions were presented to the chairs of theother ICSM committees.The final definitions in this article arethose that were approved and adopted by the Fourth ICSM.Commonly accepted diagnostic criteria influence how clini-cians organize their thinking about clinical conditions,howReceived September 30,2015.Accepted December 20,2015.1Institute for Health and Ageing,Australian Catholic University,Melbourne,Australia;2University of California,San Francisco,CA,USA;3RCSI Medical University,Adilya,Bahrain;4Department of Psychiatry and Behavioral Neurosciences,Wayne StateUniversity,Detroit,MI,USA;5SODc Medicina della Sessualit e Andrologia,Florence,Italy;6Department of Sociology,University of Chicago,Chicago,IL,USA;7Department of Urology,Sungkyunkwan University School of Medicine,Seoul,Korea;8Georgia Regents University,Augusta,GA,USA;9Case Western Reserve University,Cleveland,OH,USACopyright 2016,International Society for Sexual Medicine.Published byElsevier Inc.All rights reserved.http:/dx.doi.org/10.1016/j.jsxm.2015.12.019J Sex Med 2016;13:135e143135 clinical activity is coded for reimbursement,and how populationsare defined in clinical research.Clinicians can use the experienceof other clinicians only to the extent that they agree on thedefinition of the condition being studied or treated.Data fromclinical trials and epidemiologic studies are relevant to theclinician only to the extent that they use similar definitions of thecondition being treated by the clinician.Commonly accepteddefinitions permit global information exchange and communi-cation among clinicians,their patients,and health care systems.These systems also facilitate the training of future clinicians andare used by other sectors such as health care policy makers,payersof health care,and pharmaceutical companies.1Various approaches to taxonomy are used in medicine.Aclassic approach in medicine is to define a disease by its etiology.Such an approach applies in certain bacteriologic infections andnutritional deficiencies.2However,the etiology of sexual dys-functions is often unknown or presumed to be multifactorial.Insuch cases,a descriptive taxonomy is used.Most current classi-fication systems for sexual dysfunctions are primarily descriptive.A problem with the most widely used current systems of classi-fication is the assumption of mind vs body dualism,with dis-orders being classified as psychiatric or medical in etiology.3Thisproblem is perhaps best appreciated in the definition of lifelongfemale orgasmic disorder.Although current research indicates aclear genetic contribution to orgasmic function,psychosocialinfluences are perhaps of equal or greater importance.In mostcases,one cannot easily separate organic from non-organic fac-tors.Part of this separation of diagnostic systems can be under-stood in historical context.With some exceptions,mosttreatments of sexual disorders before the advent of the phos-phodiesterase inhibitors were by psychiatrists or psychologistsand it was commonly assumed that the vast majority of sexualdisorders had psychological etiologies.4MAJOR CLASSIFICATION SYSTEMSAlthough different classification systems for sexual dysfunc-tions have been proposed,the International Classification ofDiseases,10th Edition(ICD-10)5by the World Health Organi-zation and the Diagnostic and Statistical Manual of MentalDisorders(fourth edition with text revision or fifth edition;DSM-1V-TR and DSM-5)6,7by the American PsychiatricAssociation have been the most widely used systems interna-tionally.Although the DSM system is a psychiatric system,someof its diagnostic criteria have been adopted to define conditionsthat are assumed to have an organic etiology.INTERNATIONAL CLASSIFICATION OF DISEASES,10TH EDITIONThe ICD-10 was approved by the World Health Associationin 1990 and published in 1992.5This system is in the process ofrevision.Completion of the ICD-11 is anticipated in 2017.In the ICD-10,one codes disorders as organic or as non-organic.The organic sexual dysfunction codes are erectile dysfunction(ED),vaginismus,and dyspareunia of organic etiology.Allorganic codes are contained in the chapter on diseases of thegenitourinary system.In contrast,there are 10 separate non-organic sexual dysfunction codes,including lack of sexualdesire,sexual aversion or lack of sexual enjoyment,failure ofgenital response,orgasmic dysfunction,premature ejaculation(PE),non-organic vaginismus,non-organic dyspareunia,exces-sive sexual drive,and two non-specific codes(similar to the“nototherwise specified”codes in the DSM-IV).The ICD-10 diag-nostic codes for sexual dysfunctions not caused by organic dis-orders or disease and their descriptions are listed below.ICD-10 Sexual Dysfunction Not Caused by anOrganic Disorder or DiseaseLack or Loss or Sexual DesireLoss of sexual desire is the principal problem and is not sec-ondary to other sexual difficulties,such as erectile failure or dys-pareunia.Lackofsexualdesiredoesnotprecludesexualenjoymentor arousal but makes the initiation of sexual activity less likely.Sexual AversionThe prospect of sexual interaction with a partner is associatedwith strong negative feelings and produces sufficient anxiety thatsexual activity is avoided.Lack of Sexual EnjoymentSexual responses occur normally and orgasm is experienced,but there is a lack of appropriate pleasure.This complaint ismuch more common in women than in men.Failure of Sexual ResponseIn men,the principal problem is ED(ie,difficulty in devel-oping or maintaining an erection suitable for satisfactory inter-course).If erection occurs normally in certain situations(eg,during masturbation or sleep or with a different partner),thenthe causation is likely to be psychogenic.Otherwise the correctdiagnosis of non-organic ED could depend on special in-vestigations(eg,of nocturnal penile tumescence)or the responseto psychological treatment.In women,the principal problem is vaginal dryness or failureof lubrication.The cause can be psychogenic or pathologic(eg,infection)or estrogen deficiency(eg,postmenopausal).It is un-usual for women to complain primarily of vaginal dryness exceptas a symptom of postmenopausal estrogen deficiency.Orgasmic DysfunctionOrgasm does not occur or is markedly delayed.This might besituational(ie,occurs only in certain situations),in which caseJ Sex Med 2016;13:135e143136McCabe et al the etiology is likely to be psychogenic,or invariable,whenphysical or constitutional factors cannot be easily excluded exceptby a positive response to psychological treatment.Orgasmicdysfunction is more common in women than in men.Premature EjaculationPE is the inability to control ejaculation sufficiently for bothpartners to enjoy sexual interaction.In severe cases,ejaculationmight occur before vaginal entry or in the absence of an erection.PE is unlikely to be of organic origin but can occur as a psy-chological reaction to organic impairment(eg,erectile failure orpain).Ejaculation also can appear prematurely if erection re-quires prolonged stimulation,causing the interval from satisfac-tory erection to ejaculation to be shortened;the primary problemin such a case is delayed erection.Non-Organic VaginismusVaginismus is spasm of the muscles that surround the vagina,causing occlusion of the vaginal opening.Penile entry isimpossible or painful.Vaginismus can be a secondary reaction tosome local cause of pain,in which case this category should notbe used.DyspareuniaDyspareunia(pain during sexual intercourse)occurs in womenand men.It often can be attributed to a local pathologic con-dition and then should be appropriately categorized.In somecases,no obvious cause is apparent and emotional factors mightbe important.This category is used only if there is no other moreprimary sexual dysfunction(eg,vaginismus or vaginal dryness).Excessive Sexual DriveMen and women occasionally complain of excessive sexualdrive as a problem in its own right,usually during the lateteenage period or early adulthood.When excessive sexual drive issecondary to an affective disorder or when it occurs during theearly stages of dementia,then the underlying disorder should becoded.DIAGNOSTIC AND STATISTICAL MANUAL OFMENTAL DISORDERS,FIFTH EDITIONThe DSM published by the American Psychiatric Associationhas been translated into more than 20 languages and has had amajor role in Europe and the United States in setting criteria forthe diagnosis of mental disorders.Specific criteria for sexualdysfunctions were introduced in the DSM-III in 1980 and thenmodified in subsequent versions(DSM-III-R in 1987,DSM-IVin 1994,and DSM-IV-TR in 2000).The DSM-5 was introducedin 2013.The DSM-57represents a major shift conceptually from theDSM-IV-TR in several ways.The DSM-5,in contrast to earlierversions of the DSM,no longer requires a parallelism betweenthe sexes and is no longer based on the sexual response cycle asproposed by Masters and Johnson.In contrast to the DSM-IV-TR,6the DSM-5 specifies duration and severity(frequency)criteria for most disorders.Most sexual dysfunction diagnosesrequire that the problems have persisted for at least 6 monthsand occur on approximately 75%of sexual occasions to bediagnosed as sexual dysfunctions.The etiologic subtypes havebeen deleted in the DSM-5.Eight specific diagnoses arespecified:delayedejaculation,erectiledisorder,femaleorgasmic disorder,female sexual interest-arousal disorder,genito-pelvic pain-penetration disorder,male hypoactive sex-ual desire disorder,premature(early)ejaculation,and sub-stance-or medication-induced disorder.There also are twonon-specific codes:other specified sexual dysfunction andunspecified sexual dysfunction.Sexual aversion disorder wasdeleted as a designated diagnosis because of its infrequent useand inconsistent definition.Genito-pelvic pain-penetrationdisorder combines elements of dyspareunia and vaginismusinto a single diagnosis.The basis for this change is that mostclinicians cannot reliably distinguish vaginismus from dys-pareunia.Female hypoactive sexual desire disorder and femalearousal disorder have been deleted from the DSM-5 andreplaced by female sexual interest-arousal disorder,whichcombines elements of subjective sexual desire and arousal intoone category.Female arousal disorder(defined in the DSM-IV-TR as the absence of genital arousal)was not included inthe DSM-5,because absence of genital arousal is rarely iden-tified independently of low sexual desire unless related tohypoestrogenism,which,by definition,is not a psychiatricdiagnosis.The DSM-5 definitions and criteria for sexual dysfunctions areincluded below.For each dysfunction,one should specifywhether the dysfunction is:?lifelong(the disturbance has been present since the individualbecame sexually active)or acquired(the disturbance beganafter a period of relatively normal sexual function)?generalized(not limited to certain types of stimulation,situations,or partners)or situational(occurs only with certaintypes of stimulation,situations,or partners)?mild,moderate,or severe in distress over symptoms incriterion A(a description of the distinguishing features of thedysfunction)All disorders except genito-pelvic pain-penetration disorderrequire that the symptoms meet the DSM-5 definition of thatcondition(criterion A),have been present for 6 months on atleast 75%of sexual occasions(criterion B),cause clinically sig-nificant distress(criterion C),are not a consequence of a non-sexual mental disorder or of a severe relationship distress orother significant stressors,and are not attributable to the effect ofa medication or illness(criterion D).J Sex Med 2016;13:135e143Definitions of Sexual Dysfunctions in Women and Men137 DSM-5 Definitions of Sexual Dysfunctions inWomenFemale Sexual Interest-Arousal DisorderLack of,or significantly decreased sexual interest or arousal ismanifested by at least three of the following characteristics:(i)ab-sent or decreased interest in sexual activity;(ii)absent or decreasedsexual or eroticthoughts or fantasies;(iii)no or decreased initiationofsexualactivityandtypicallyunreceptivetoapartnersattempt