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女性性功能障礙的評估與診斷

台大醫學院 畢業 前署立新竹醫院泌尿科 主治醫師 現任新竹陳志鴻泌尿科診所 院長 陳志鴻

  女性性功能障礙可分為四大類:性慾障礙(desire disorder)、喚醒障礙(arousal disorder)、高潮障礙(Orgasm disorder)及性疼痛(sexual pain,包括性交疼痛 dyspareunia及陰道痙攣vaginismus)。要正確的診斷女性性功能障礙首先要詳細詢問病史:包括一般內科性疾病(如糖尿病、心血管疾病、內分泌疾病、精神及神經性疾病等)及婦產科疾病、服藥狀態、性生活狀態、病史長短、持續性或情境性等。過去的性心理病史亦非常重要,尤其是過去有受過性侵害的病人,所受的影響特別深遠。由於常有二種以上的障礙同時存在,必須要一一的加以仔細辨別及釐清。

  因各種疾病及問題可能產生的女性性功能障礙為:

糖尿病:   可引發充血不足及神經性病變,造成喚醒障礙、潤滑不足、性交疼痛及高潮不能。

心血管疾病:   可能造成性交中氣喘及呼吸困難。

內分泌疾病:   男性荷爾蒙不足會造成性慾障礙,女性荷爾蒙不足則會造成陰道乾燥、潤滑不足、陰道萎縮及性交疼痛。

服藥狀態:   鎮定劑會阻礙性喚醒及高潮,而安眠劑也會抑制性慾望,抗憂鬱藥物(包括TCA,SSRI及鋰鹽等)會造成性高潮障礙等。

神經性疾病:   脊髓損傷可能引發陰道潤滑不足及高潮不能。

婦科疾病:   子宮切除術、婦科癌症及乳癌可能會造成性慾障礙及性交疼痛,而泌尿生殖器感染及手術後所造成之瘢痕及狹窄會引起性交疼痛。停經後則會造成陰道潤滑度降低、陰道萎縮、縮短、降低性慾、喚醒障礙及性交疼痛等。

  在女性性功能障礙問卷評估方面,有數個不同的版本,其中最常見及採用的為女性性功能指數(Female Sexual Function Index,FSFI),其分為六大部分(性慾、性喚醒、潤滑度、高潮、滿足及疼痛),共十九條問題(如附錄)。

  在女性性功能障礙的診斷上,詳細的身體理學檢查是必要且相當重要的。檢查的目的除了偵測出疾病外,在檢查當中亦可同時教育病人正確的解剖、性功能及在性交當中可能產生疼痛的因素。外陰部的檢查常常可以獲得非常多的資訊,且對治療有很大的幫助,但因其私密性很高,所以作此檢查時,必須有相當的理由,對於有性交疼痛及陰道痙攣的患者,作此檢查是有必要的,但對於喚醒及高潮障礙的患者來說,外生殖器的檢查所能得到的幫助就比較有限。

  在作女性外生殖器的理學檢查時,首先看外陰部的皮膚是否有萎縮或任何的病變(如皮膚炎、潰瘍等),觸診巴多林氏腺(Bartholin’s gland)是否有發炎的跡象。對於性交疼痛的患者先觀察陰道口及會陰部是否有手術疤痕或狹窄,然後再以手指觸診陰道周圍肌肉的鬆緊度、陰道的深度及是否有任何疼痛點。

  在實驗室檢驗方面,主要在評估是否有相關的內科性疾病及荷爾蒙的偵測,若有感染的因素而造成性交疼痛,就需要作相關的檢驗,包括細菌培養及性病檢測。陰道酸鹼度試驗對診斷也能有所幫助:感染或女性荷爾蒙分泌不足時,酸鹼度會增加(PH > 5)。

  其他輔助的檢查儀器有陰道光體積描記法(Vaginal photoplethysmography),此種裝置是將一個約6 x 1.5cm大的壓克力圓柱體,放入陰道外三分之一,它所發出的光照到周圍的組織,被血液所散射後,由裝置接收並產生訊號。此裝置可用來偵測陰道的充血狀態變化,用以診斷性喚醒障礙。

  女性性功能障礙和男性性功能障礙一樣,須經過仔細的評估後,才能作出正確的診斷,再根據診斷作有效的治療。在評估女性性功能障礙時,病人的性伴侶最好能同時參與,才能作更正確的診斷,包括伴侶是否同時有解剖上或功能上的異常,亦可能是造成患者性功能障礙的重要因素。目前女性性功能障礙的治療並無類似威而鋼等對男性性功能障礙有確定療效的藥物,因此在病史的詢問上,更須詳細且謹慎。

附 錄: Female Sexual Function Index (FSFI) and Scoringづ

Sexual desire or interest is a feeling that includes wanting to have a sexual experience, feeling receptive to a partner's sexual initiation, and thinking or fantasizing about having sex.

1. Over the past 4 weeks, how often did you feel sexual desire or interest?
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never


2. Over the past 4 weeks, how would you rate your level (degree) of sexual desire or interest?
5 = Very high
4 = High
3 = Moderate
2 = Low
1 = Very low or none at all


Sexual arousal is a feeling that includes both physical and mental aspects of sexual excitement. It may include feelings of warmth or tingling in the genitals, lubrication (wetness), or muscle contractions.

3. Over the past 4 weeks, how often did you feel sexually aroused ("turned on") during sexual activity or intercourse?
0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

4. Over the past 4 weeks, how would you rate your level of sexual arousal ("turn on") during sexual activity or intercourse?
0 = No sexual activity
5 = Very high
4 = High
3 = Moderate
2 = Low
1 = Very low or none at all

5. Over the past 4 weeks, how confident were you about becoming sexually aroused during sexual activity or intercourse?
0 = No sexual activity
5 = Very high confidence
4 = High confidence
3 = Moderate confidence
2 = Low confidence
1 = Very low or no confidence

6. Over the past 4 weeks, how often have you been satisfied with your arousal (excitement) during sexual activity or intercourse?
0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

7. Over the past 4 weeks, how often did you become lubricated ("wet") during sexual activity or intercourse?
0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

8. Over the past 4 weeks, how difficult was it to become lubricated ("wet") during sexual activity or intercourse?
0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult

9. Over the past 4 weeks, how often did you maintain your lubrication ("wetness") until completion of sexual activity or intercourse?
0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

10.Over the past 4 weeks, how difficult was it to maintain your lubrication ("wetness") until completion of sexual activity or intercourse?
0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult

11.Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?
0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

12.Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)?
0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult

13.Over the past 4 weeks, how satisfied were you with your ability to reach orgasm (climax) during sexual activity or intercourse?
0 = No sexual activity
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied

14.Over the past 4 weeks, how satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?
0 = No sexual activity
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied

15.Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner?
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied


16.Over the past 4 weeks, how satisfied have you been with your overall sexual life?
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied


17.Over the past 4 weeks, how often did you experience discomfort or pain during vaginal penetration?
0 = Did not attempt intercourse
1 = Almost always or always
2 = Most times (more than half the time)
3 = Sometimes (about half the time)
4 = A few times (less than half the time)
5 = Almost never or never


18.Over the past 4 weeks, how often did you experience discomfort or pain following vaginal penetration?
0 = Did not attempt intercourse
1 = Almost always or always
2 = Most times (more than half the time)
3 = Sometimes (about half the time)
4 = A few times (less than half the time)
5 = Almost never or never


19.Over the past 4 weeks, how would you rate your level (degree) of discomfort or pain during or following vaginal penetration?
0 = Did not attempt intercourse
1 = Very high
2 = High
3 = Moderate
4 = Low
5 = Very low or none at all
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