![]() However, there are presently very few data regarding the use of sildenafil in women and the results are still conflicting. 8 The analogies between male and female physiological response to sexual stimuli have prompted studies over its efficacy in FSAD. 7 Sildenafil citrate (Viagra), a PDE5 inhibitor, has been successfully used for the treatment of male erectile dysfunction since the late 1990s. ![]() Thus, PDE5 inhibitors could be used as an easily available medical treatment for genital FSADs. According to emerging data, PDE5 is expressed in vaginal, clitoral, and labial smooth muscles. 6 Phosphodiesterase type 5 (PDE5) inhibitors (eg, sildenafil, tadalafil, vardenafil) physiologically enhance the production of guanosine monophosphate from cyclic guanosine monophosphate, thus contrasting the above-mentioned effects ( Figure 1). ![]() Furthermore, the ultrafiltration of plasma through capillary vaginal vessels contributes to vaginal lubrication. The engorgement of penile corpora cavernosa in men and clitoris and labia minora in women are the main modifications of genital organs during sexual arousal. This molecule promotes the relaxation of the smooth muscle cells, causes vasodilatation, and increases blood flow in genital organs. In smooth muscle cells, nitric oxide activates the guanylate cyclase enzyme which converts guanosine triphosphate into cyclic guanosine monophosphate. Rationale for the use of sildenafil in the treatment of FSAD However, in most cases, both factors contribute to FSAD (combined). In subjective FSAD, the woman’s emotional response to sexual stimuli is altered but the physical response still occurs, while genital phenomena are impaired in objective FSAD. 4 To sum up, Basson et al 5 categorized FSAD into three main classes: subjective, genital, and combined ( Table 1). ![]() Moreover, FSADs are frequently associated with other FSDs concerning desire, orgasm, and pain. Thus, such factors as sexual inhibition, depression or anxiety, inadequate sexual stimulation, or interpersonal problems may impair women’s arousal. In fact, women very often relate arousal to the subjective feeling of been “sexually involved” more than to the physiological response to erotic stimuli (ie, vaginal lubrication and engorgement of sexual tissues such as nipples, vulva, clitoris, and vaginal walls). However, a modern definition of FSDs should not focus only on genital phenomena without considering the psychological aspect of arousal. 4 Thus, iatrogenic factors (eg, chronic antidepressant treatments, surgical procedures, radiotherapy of the pelvis), along with endocrine, vascular, and neurological disorders can cause female sexual dysfunction. In fact, genital congestion and lubrication strictly depend on the hormonal balance (ie, arousal disorders during the menopausal transition) and require adequate vascular function and an efficient nerve transmission of mechanical stimuli. 3 Such a clinical condition may depend either on local or general factors. FSAD is traditionally defined as a persistent or recurrent inability to attain or maintain adequate lubrication and genital swelling until completion of sexual activity. In particular, female sexual arousal disorder (FSAD) belongs to the so-called “female sexual interest/arousal disorder” and is one of the most prevalent subcategories of FSDs. The Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-V) 2 defines FSDs as disturbances in the female sexual response cycle, resulting in marked distress and interpersonal difficulties. Clinical features of female sexual arousal disorder
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