Sexual Dysfunction — MCQs
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A 22-year-old nulliparous woman, recently sexually active, presents with dyspareunia localized to the vaginal introitus, accompanied by involuntary pelvic muscle contractions. Her pelvic examination is otherwise normal. What is the most common cause of this condition?
Which of the following statements about erectile dysfunction are false?
A 25-year-old woman presents with complaints of pain during intercourse for 2 months, which occurs with initial penetration and continues throughout the entire episode. She reports a previously pleasurable, pain-free relationship with her husband. Her prior investigations, including pelvic examination, Pap smear with cultures, and pelvic sonogram, were normal. She also admits to vaginal dryness and low libido during the same timeframe. She reveals that she discovered her husband's infidelity 2 months ago. What is the most appropriate recommendation for this patient?
Which of the following may be used in erectile dysfunction except?
What is the most accurate treatment for erectile dysfunction?
A 23-year-old nulliparous woman complains of painful coitus, with the pain located at the vaginal introitus. This is accompanied by painful involuntary contractions of the pelvic muscles. Pelvic examination is normal, and no obvious local pathology is seen. What is the most common cause of this condition?
A 30-year-old male presents with erectile dysfunction. Basic screening evaluation is unremarkable. What is the next step in evaluation or management?
A postoperative male client with diabetes mellitus reports impotence and expresses concern about its effect on his marriage. In planning this client's care, what is the most appropriate intervention?
Flibanserin is used in the treatment of:
Which of the following agents is most specifically used for the treatment of erectile disorder in males?
Sexual Dysfunction Indian Medical PG Practice Questions and MCQs
Question 1: A 22-year-old nulliparous woman, recently sexually active, presents with dyspareunia localized to the vaginal introitus, accompanied by involuntary pelvic muscle contractions. Her pelvic examination is otherwise normal. What is the most common cause of this condition?
- A. Endometriosis
- B. Psychogenic causes (Correct Answer)
- C. Bartholin's gland abscess
- D. Vulvar atrophy
Explanation: ### Explanation The clinical presentation of involuntary pelvic muscle contractions (specifically the pubococcygeus muscle) and localized introital dyspareunia in a young, nulliparous woman is classic for **Vaginismus**. **1. Why Psychogenic Causes are Correct:** Vaginismus is primarily a psychophysiological condition. While physical triggers can exist, the **most common underlying cause is psychogenic**, often rooted in "fear-avoidance" cycles. Factors include sexual trauma, negative attitudes toward sex, or fear of pain/pregnancy. This leads to a conditioned reflex where the pelvic floor muscles contract involuntarily in anticipation of penetration, making entry painful or impossible despite normal anatomy. **2. Why Other Options are Incorrect:** * **Endometriosis (A):** Typically causes **deep dyspareunia** (pain on deep thrusting) rather than introital pain, and is often associated with dysmenorrhea and chronic pelvic pain. * **Bartholin’s Gland Abscess (C):** This presents as an acute, extremely painful, fluctuant swelling at the 4 or 8 o'clock position of the vaginal vestibule. It is an inflammatory/infectious condition, not a muscle contraction disorder. * **Vulvar Atrophy (D):** This is a common cause of dyspareunia in **postmenopausal** women due to estrogen deficiency. It is highly unlikely in a 22-year-old with a normal pelvic exam. **3. NEET-PG High-Yield Pearls:** * **Definition:** Vaginismus is the involuntary spasm of the outer third of the vaginal muscles. * **Diagnosis:** It is a clinical diagnosis. The pelvic exam is typically normal except for the induced spasm during attempted digital examination. * **Management:** The first-line treatment is **behavioral therapy and vaginal dilators** (Heigar’s dilators) to desensitize the reflex, often combined with counseling. * **Distinction:** Always differentiate between **Introital Dyspareunia** (Vaginismus, Vulvar Vestibulitis) and **Deep Dyspareunia** (Endometriosis, PID, Pelvic Adhesions).
Question 2: Which of the following statements about erectile dysfunction are false?
- A. Psychogenic erectile dysfunction is distinguished from organic erectile dysfunction by PIPE therapy. (Correct Answer)
- B. Sildenafil is used for treatment.
- C. Nocturnal penile tumescence is maintained in psychological erectile dysfunction.
- D. Sensate focus therapy aims at sensitizing nongenital areas.
Explanation: **Explanation:** The correct answer is **A**. This statement is false because **PIPE (Papaverine Induced Penile Erection)** therapy is used to assess the vascular integrity of the penis, but it **cannot** reliably distinguish between psychogenic and organic erectile dysfunction (ED). A positive response (erection) occurs in both psychogenic ED and mild vasculogenic ED, making it non-specific for differentiation. **Analysis of other options:** * **Option B (Sildenafil):** This is a Phosphodiesterase-5 (PDE-5) inhibitor and is the first-line pharmacological treatment for ED. It works by increasing cGMP levels, leading to smooth muscle relaxation and increased blood flow. * **Option C (Nocturnal Penile Tumescence - NPT):** This is the **gold standard** for differentiating psychogenic from organic ED. Healthy men have 3–5 spontaneous erections during REM sleep. These are **maintained** in psychogenic ED but absent or diminished in organic ED. * **Option D (Sensate Focus Therapy):** Developed by Masters and Johnson, this behavioral technique involves a series of touching exercises. It aims to reduce performance anxiety by focusing on non-genital physical sensations before progressing to genital stimulation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of ED:** Organic (Vascular/Diabetes) in older men; Psychogenic in younger men. * **NPT Monitoring:** Often performed using a **Rigiscan** device. * **Sildenafil Contraindication:** Must never be co-administered with **Nitrates** due to the risk of severe, life-threatening hypotension. * **Alprostadil:** A PGE1 analogue used as second-line therapy (intracavernosal injection).
Question 3: A 25-year-old woman presents with complaints of pain during intercourse for 2 months, which occurs with initial penetration and continues throughout the entire episode. She reports a previously pleasurable, pain-free relationship with her husband. Her prior investigations, including pelvic examination, Pap smear with cultures, and pelvic sonogram, were normal. She also admits to vaginal dryness and low libido during the same timeframe. She reveals that she discovered her husband's infidelity 2 months ago. What is the most appropriate recommendation for this patient?
- A. Marriage counseling (Correct Answer)
- B. Estrogen vaginal cream for vaginal dryness
- C. Vaginal dilators for treatment of vaginismus
- D. Antidepressant therapy
Explanation: ### Explanation The patient is presenting with **secondary dyspareunia** (painful intercourse) and **acquired Female Sexual Interest/Arousal Disorder (FSIAD)**. The temporal relationship between the onset of symptoms and the discovery of her husband’s infidelity points toward a **psychogenic etiology** rather than a physical one. **1. Why Marriage Counseling is Correct:** In this clinical scenario, the physical examination and investigations (Pap smear, cultures, sonogram) are entirely normal, ruling out organic causes like infections, endometriosis, or atrophy. The psychological trauma of infidelity has led to a lack of emotional intimacy, resulting in decreased arousal, inadequate vaginal lubrication (dryness), and subsequent pain during penetration. **Marriage counseling** is the most appropriate first-line intervention to address the underlying relational conflict and emotional distress causing the sexual dysfunction. **2. Why Other Options are Incorrect:** * **B. Estrogen vaginal cream:** This is indicated for vulvovaginal atrophy (Genitourinary Syndrome of Menopause). This patient is 25 years old with normal anatomy; her dryness is due to lack of arousal, not estrogen deficiency. * **C. Vaginal dilators:** These are the treatment of choice for **vaginismus** (involuntary contraction of pelvic floor muscles). While she has pain, the history suggests it is secondary to a lack of lubrication and emotional factors rather than primary muscle spasms. * **D. Antidepressant therapy:** While she is distressed, there is no clinical diagnosis of Major Depressive Disorder. Furthermore, SSRIs often cause sexual side effects (delayed orgasm, decreased libido), which could worsen her condition. ### Clinical Pearls for NEET-PG: * **Primary vs. Secondary:** Primary dyspareunia occurs from the first sexual encounter; secondary occurs after a period of pain-free function. * **Vaginismus vs. Dyspareunia:** Vaginismus is a *conditioned reflex* causing muscle spasm; Dyspareunia is the *sensation* of pain. * **The Arousal-Pain Cycle:** Psychological distress leads to decreased arousal $\rightarrow$ decreased lubrication $\rightarrow$ friction/pain $\rightarrow$ anticipatory anxiety $\rightarrow$ further decreased arousal. * **Rule of Thumb:** If a patient has a sudden onset of sexual dysfunction coinciding with a major life stressor and has a normal physical exam, prioritize **psychotherapy or counseling**.
Question 4: Which of the following may be used in erectile dysfunction except?
- A. Phenylephrine (Correct Answer)
- B. Apomorphine
- C. Alprostidil
- D. All
Explanation: In the management of erectile dysfunction (ED), the goal is to promote vasodilation and smooth muscle relaxation in the corpus cavernosum. **Phenylephrine** is the correct answer because it is a selective **alpha-1 adrenergic agonist** that causes vasoconstriction. ### Why Phenylephrine is the Exception: Phenylephrine is actually used to **treat priapism** (a prolonged, painful erection), not erectile dysfunction. By stimulating alpha-receptors, it induces contraction of the cavernous smooth muscle and vasoconstriction of the arterioles, effectively terminating the erection. ### Explanation of Other Options: * **Apomorphine:** This is a dopamine (D2) receptor agonist that acts centrally on the hypothalamus to trigger the erectile response. It was historically used as a sublingual treatment for ED. * **Alprostadil:** This is a synthetic **Prostaglandin E1 (PGE1)**. It acts locally by increasing cAMP levels, leading to smooth muscle relaxation and increased blood flow. It is administered via intracavernosal injection or intraurethral pellets. ### NEET-PG High-Yield Pearls: * **First-line treatment for ED:** Oral PDE-5 inhibitors (e.g., Sildenafil, Tadalafil). * **Mechanism of Sildenafil:** Inhibits PDE-5, preventing the breakdown of cGMP, which maintains smooth muscle relaxation. * **Contraindication:** PDE-5 inhibitors must never be used with **Nitrates** due to the risk of severe, life-threatening hypotension. * **Priapism Management:** Aspiration of blood followed by intracavernosal injection of **Phenylephrine** is the standard emergency management for ischemic priapism.
Question 5: What is the most accurate treatment for erectile dysfunction?
- A. Sildenafil (Correct Answer)
- B. Master and Johnson technique
- C. Beta blockers
- D. Papaverine
Explanation: **Explanation:** **Erectile Dysfunction (ED)** is defined as the persistent inability to attain or maintain a penile erection sufficient for satisfactory sexual performance. **Why Sildenafil is correct:** Sildenafil is a selective **Phosphodiesterase-5 (PDE-5) inhibitor**. It works by inhibiting the enzyme PDE-5, which normally breaks down cyclic Guanosine Monophosphate (cGMP) in the corpus cavernosum. By preventing cGMP degradation, it enhances nitric oxide-mediated smooth muscle relaxation and increases blood flow to the penis. It is currently the **first-line pharmacological treatment** for ED due to its high efficacy and oral route of administration. **Analysis of Incorrect Options:** * **Master and Johnson technique:** This refers to behavioral therapy (e.g., "sensate focus" exercises). While useful for psychogenic sexual dysfunction or premature ejaculation, it is not the primary or most accurate treatment for organic ED. * **Beta-blockers:** These are actually a **cause** of erectile dysfunction (a known side effect), not a treatment. * **Papaverine:** This is a vasodilator that can be used via intracavernosal injection. While effective, it is considered a second-line treatment due to the risk of priapism and the invasive nature of administration compared to oral PDE-5 inhibitors. **High-Yield Clinical Pearls for NEET-PG:** * **Contraindication:** Sildenafil must **never** be co-administered with **Nitrates** (e.g., Nitroglycerin), as it can lead to life-threatening hypotension. * **Side Effects:** Common side effects include headache, flushing, and **cyanopsia** (blue-tinted vision) due to cross-reactivity with PDE-6 in the retina. * **Tadalafil vs. Sildenafil:** Tadalafil has a much longer half-life (approx. 17.5 hours) compared to Sildenafil (4 hours), earning it the nickname "the weekend pill."
Question 6: A 23-year-old nulliparous woman complains of painful coitus, with the pain located at the vaginal introitus. This is accompanied by painful involuntary contractions of the pelvic muscles. Pelvic examination is normal, and no obvious local pathology is seen. What is the most common cause of this condition?
- A. Endometriosis
- B. Psychological causes (Correct Answer)
- C. Bartholin's gland abscess
- D. Vulvar atrophy
Explanation: **Explanation:** The clinical presentation described—pain at the vaginal introitus accompanied by involuntary contractions of the pelvic floor muscles (specifically the pubococcygeus muscle) during attempted penetration—is the classic triad of **Vaginismus**. **Why Psychological Causes are correct:** Vaginismus is primarily a psychophysiological condition. While it can be triggered by physical pain, the most common underlying etiology involves **psychological factors** such as fear of pain, sexual trauma, strict religious upbringing, or anxiety regarding intercourse. This leads to a conditioned reflex where the body "protects" itself via involuntary muscle spasms, despite a normal physical anatomy. **Analysis of Incorrect Options:** * **Endometriosis:** Typically causes **deep dyspareunia** (pain deep in the pelvis) rather than introital pain, and is often associated with dysmenorrhea and pelvic masses. * **Bartholin’s Gland Abscess:** This would present with a visible, exquisitely tender, fluctuant swelling at the 4 or 8 o'clock position of the labia majora. The question states the pelvic examination is **normal**. * **Vulvar Atrophy:** Common in postmenopausal women due to estrogen deficiency. It is highly unlikely in a 23-year-old nulliparous woman and would show physical signs like thinning of the mucosa. **Clinical Pearls for NEET-PG:** * **Vaginismus vs. Dyspareunia:** Vaginismus is the *involuntary contraction* preventing entry; Dyspareunia is *pain* during intercourse. * **Management:** The first-line treatment for Vaginismus is **behavioral therapy** and the use of **graded vaginal dilators** (Hegar’s dilators) combined with relaxation techniques. * **Primary vs. Secondary:** Primary vaginismus occurs when a woman has never been able to achieve penetration; secondary occurs after a period of normal function.
Question 7: A 30-year-old male presents with erectile dysfunction. Basic screening evaluation is unremarkable. What is the next step in evaluation or management?
- A. Oral sildenafil trial (Correct Answer)
- B. Cavernosometry
- C. Doppler study
- D. Neurological testing
Explanation: **Explanation:** The management of erectile dysfunction (ED) follows a stepwise approach. In a 30-year-old patient where the basic screening (history, physical exam, and baseline labs like glucose and testosterone) is unremarkable, the most likely etiology is either psychogenic or early vasculogenic. **1. Why Oral Sildenafil is the correct next step:** Current clinical guidelines (AUA/EAU) recommend a **trial of Oral Phosphodiesterase-5 (PDE5) inhibitors**, such as Sildenafil, as both a first-line treatment and a diagnostic tool. If the patient responds well to Sildenafil, it confirms that the corporal tissue is functional and the blood supply is sufficient, often obviating the need for invasive, expensive, or specialized testing. **2. Why other options are incorrect:** * **Doppler study (Option C):** Penile Duplex Ultrasound is indicated only if the patient fails oral therapy or if there is a history of pelvic trauma/Peyronie’s disease. It is not a first-line investigation. * **Cavernosometry (Option B):** This is a highly invasive procedure used to diagnose venous leak (venous-occlusive dysfunction). It is reserved for surgical candidates and is never a primary step. * **Neurological testing (Option D):** This is indicated only if there is a specific history of spinal cord injury, pelvic surgery, or abnormal findings on neurological examination (e.g., decreased perianal sensation). **Clinical Pearls for NEET-PG:** * **First-line treatment for ED:** Lifestyle modifications + PDE5 inhibitors. * **Mechanism of Sildenafil:** Inhibits PDE5, increasing **cGMP** levels, leading to smooth muscle relaxation and increased blood flow. * **Contraindication:** Never co-administer PDE5 inhibitors with **Nitrates** (risk of severe hypotension). * **Psychogenic ED:** Characterized by sudden onset and the presence of **nocturnal/morning erections**.
Question 8: A postoperative male client with diabetes mellitus reports impotence and expresses concern about its effect on his marriage. In planning this client's care, what is the most appropriate intervention?
- A. Encourage the client to ask questions about personal sexuality.
- B. Provide time for privacy.
- C. Provide support for the spouse or significant other.
- D. Suggest referral to a sex counselor or other appropriate professional. (Correct Answer)
Explanation: **Explanation:** **1. Why Option D is Correct:** Impotence (Erectile Dysfunction) in a diabetic patient is often multifactorial, involving **organic causes** (diabetic neuropathy and microvascular disease) and **psychological factors** (postoperative stress and anxiety regarding marital impact). Managing sexual dysfunction requires specialized knowledge to differentiate between these causes and to provide targeted therapies (e.g., PDE5 inhibitors, vacuum devices, or psychosexual therapy). A referral to a sex counselor or a urologist specializing in sexual medicine is the most appropriate intervention because it ensures the patient receives expert, comprehensive care beyond the scope of general postoperative nursing or medical management. **2. Why Other Options are Incorrect:** * **Option A & B:** While encouraging communication and providing privacy are essential components of therapeutic communication, they are **supportive measures** rather than definitive interventions. They do not address the underlying physiological or complex psychological roots of the dysfunction. * **Option C:** Supporting the spouse is important for holistic care, but the primary focus must remain on diagnosing and treating the patient’s clinical condition first. **3. Clinical Pearls for NEET-PG:** * **Diabetes & ED:** Diabetes is the most common organic cause of Erectile Dysfunction. It involves a combination of decreased nitric oxide bioavailability (endothelial dysfunction) and autonomic neuropathy. * **Screening:** Always rule out reversible causes like medications (Beta-blockers, SSRIs) or hormonal imbalances (Hypogonadism/Hyperprolactinemia). * **First-line Treatment:** Lifestyle modifications and oral PDE5 inhibitors (e.g., Sildenafil), provided there are no contraindications like nitrate use. * **Psychogenic vs. Organic:** If a patient maintains nocturnal penile tumescence (morning erections), the cause is likely psychogenic rather than organic.
Question 9: Flibanserin is used in the treatment of:
- A. Female hypoactive sexual desire disorder (Correct Answer)
- B. Erectile dysfunction
- C. Anorgasmia
- D. Dyspareunia
Explanation: **Explanation:** **Flibanserin** is the first FDA-approved medication specifically indicated for the treatment of **Hypoactive Sexual Desire Disorder (HSDD)** in premenopausal women. HSDD is characterized by a persistent or recurrent deficiency of sexual fantasies and desire for sexual activity that causes marked distress. **Mechanism of Action:** Flibanserin is a **multifunctional serotonin agonist-antagonist (MSAA)**. It acts as a **5-HT1A receptor agonist** and a **5-HT2A receptor antagonist**. By modulating these receptors, it decreases serotonin (which inhibits sexual desire) and increases dopamine and norepinephrine (which promote sexual excitation) in the prefrontal cortex. **Analysis of Incorrect Options:** * **B. Erectile dysfunction:** This is primarily treated with Phosphodiesterase-5 (PDE-5) inhibitors like Sildenafil or Tadalafil, which act on the nitric oxide pathway. * **C. Anorgasmia:** While sometimes associated with HSDD, anorgasmia is a separate orgasmic disorder. There is currently no FDA-approved drug specifically for anorgasmia. * **D. Dyspareunia:** Painful intercourse in postmenopausal women is typically treated with lubricants, local estrogen therapy, or **Ospemifene** (a selective estrogen receptor modulator). **High-Yield Clinical Pearls for NEET-PG:** * **Trade Name:** Addyi (often called the "Female Viagra," though its mechanism is central, not peripheral). * **Dosing:** It must be taken **daily at bedtime** to mitigate side effects like somnolence and dizziness. * **Black Box Warning:** Significant risk of **severe hypotension and syncope** when taken with **alcohol**. It is also contraindicated with strong CYP3A4 inhibitors. * **Bremelanotide:** Another drug for HSDD, but unlike Flibanserin, it is a melanocortin receptor agonist administered via subcutaneous injection on an as-needed basis.
Question 10: Which of the following agents is most specifically used for the treatment of erectile disorder in males?
- A. Sildenafil (Correct Answer)
- B. Diazepam
- C. Fluoxetine
- D. Zolpidem
Explanation: **Explanation:** **Sildenafil** is the correct answer as it is a potent and selective inhibitor of **phosphodiesterase type 5 (PDE5)**. In the presence of sexual stimulation, nitric oxide (NO) is released in the corpus cavernosum, which activates guanylate cyclase to produce cyclic guanosine monophosphate (cGMP). cGMP causes smooth muscle relaxation and increased blood flow to the penis. Sildenafil prevents the degradation of cGMP by PDE5, thereby enhancing and sustaining an erection. It is considered the first-line pharmacological treatment for erectile dysfunction (ED). **Analysis of Incorrect Options:** * **Diazepam:** A benzodiazepine used primarily for its anxiolytic, sedative, and muscle-relaxant properties. It has no role in treating ED and may actually cause sexual dysfunction as a side effect. * **Fluoxetine:** An SSRI used for depression and OCD. It is notorious for causing sexual side effects (decreased libido, delayed ejaculation). Interestingly, it is sometimes used off-label to treat *premature ejaculation*, but not erectile disorder. * **Zolpidem:** A non-benzodiazepine sedative-hypnotic used for the short-term treatment of insomnia. It has no therapeutic effect on erectile function. **High-Yield Clinical Pearls for NEET-PG:** * **Contraindication:** Sildenafil must **never** be co-administered with **nitrates** (e.g., Nitroglycerin) as it can cause life-threatening hypotension. * **Side Effects:** Common side effects include headache, flushing, dyspepsia, and "blue-tinted vision" (cyanopsia) due to weak inhibition of PDE6 in the retina. * **Timing:** It should be taken approximately 30–60 minutes before anticipated sexual activity. * **Other PDE5 Inhibitors:** Tadalafil (longer half-life, "the weekend pill") and Vardenafil.
Practice by Chapter
Female Sexual Response Cycle
Practice Questions
Desire Disorders
Practice Questions
Arousal Disorders
Practice Questions
Orgasmic Disorders
Practice Questions
Sexual Pain Disorders
Practice Questions
Impact of Gynecologic Conditions on Sexual Function
Practice Questions
Psychological Aspects of Female Sexuality
Practice Questions
Hormonal Influences on Sexual Function
Practice Questions
Evaluation of Female Sexual Dysfunction
Practice Questions
Treatment Approaches to Sexual Dysfunction
Practice Questions
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