Lifestyle factors, including smoking and substantial alcohol consumption, are also risk factors for sexual morbidity. In men, cigarette smoking may induce vasoconstriction and penile venous leakage. In large amounts, alcohol is a strong sedative-hypnotic, producing decreased libido and transient erectile dysfunction.
Pharmacologic treatment for cancer and chronic illness in general is often a necessary and integral component of health maintenance. Some pharmacologic treatments, however, may have direct or indirect deleterious effects on sexual function through multiple physiologic and psychologic pathways. Pharmacologic agents that may negatively affect sexual response are addressed in the section on pharmacologic effects. A number of resources provide further delineation of the mechanisms for changes in sexual function associated with these agents and include listings of specific medications and known effects on sexual function.[4,24,25,26]
Brief questionnaires that measure sexual dysfunction may be helpful, particularly when screening larger groups of cancer patients for sexual dysfunction or when conducting research on sexuality as an aspect of quality of life. The International Index of Erectile Function (IIEF, 15 items) and the Brief Male Sexual Function Inventory (BMSFI, 11 items) are well-validated scales measuring aspects of sexual function and satisfaction in men.[27,28] Sexual problems can also be identified with a briefer five-item scale, the Sexual Health Inventory for Men (SHIM), which is a validated self-report scale that can be used to identify erectile dysfunction in a variety of clinical settings. For women, there are several brief measures with established psychometric properties that assess sexual functioning and satisfaction: the Brief Index of Sexual Functioning for Women (BISF-W, 22 items), the Sex History Form (SHF, 46 items), the Changes in Sexual Functioning Questionnaire (CSFQ, 35 items), the Derogatis Interview for Sexual Functioning (DISF/DISF-SR, 25 items), the Female Sexual Function Index (FSFI, 19 items), and the Golombok-Rusk Inventory of Sexual Satisfaction (GRISS, 28 items).[13,29,30] These scales vary in their reliability, validity, method of attainment (i.e., patient vs. clinician rates; structured vs. semistructured), type and number of symptoms assessed, and time frame of assessment. To accurately reflect changes over time, one must obtain systematic assessment of premorbid, baseline, and follow-up levels of sexual function and satisfaction.
In addition to paper-and-pencil self-report measures of sexuality, some medical evaluations of the adequacy of the physiological response are available. For men, some of the more useful evaluations include the Rigiscan, a computerized electronic instrument that measures the adequacy of nocturnal erections; penile ultrasound studies to document hemodynamics of erection; and hormonal assays. In women, the use of the vaginal maturation index to measure estrogenization, a careful pelvic examination to identify sources of pain that occur during sexual activity, and hormonal assays are most common. More sophisticated measures of vaginal blood flow or sensory thresholds have been studied but have not gained wide acceptance.