Clinical examinations

The etiopathogenesis of PSSD is not yet known, in other words, we do not know in which system and districts of the body the core of the problem lies. Many people with PSSD have had examinations of various kinds without any particular revelations. This should not be a reason to be held back by the idea that doing examinations is just time and money wasted. It makes sense to proceed with certain examinations (and not others) from the most standard to the least, in the presence of specific symptoms, also considering that: 

- post-SSRI syndromes have a variety of symptoms, and we don't know if the sufferer has the same underlying damage; each case could be its own case.

- alongside PSSD there could be problems that worsen its symptoms, which if diagnosed and treated could alleviate the symptoms. It cannot be ruled out that PSSD may make the reproductive system more vulnerable to genito-urological problems that should not be overlooked.

- those who are in doubt of having PSSD, especially if their symptoms and onset do not reflect the best-known features, may actually have problems of a different kind that can be detected and treated.

Similar symptomatologies

- post finasteride syndrome and post retinoid syndrome, as well as post antipsychotic syndromes, are persistent conditions that follow the use of different drugs but have considerable symptom overlap with PSSD. There are people who have taken more than one of these drugs at the same time and cannot accurately attribute their persistent symptoms to one or the other.

- Drugs currently taken that can give sexual side effects. The majority of psychotropic drugs can do this, for example, many antipsychotics raise prolactin and lower testosterone (verifiable by blood tests); finasteride, retinoids, contraceptive pill, anabolic steroids are other drugs to consider (not the only ones).

- Small fiber neuropathy: may include symptoms of sexual dysfunction, including genital hypoesthesia.

- Diabetes (high blood sugar/glucose) can cause sexual dysfunction and also genital hypoesthesia.

- Thyroid dysfunction (hypothyroidism, hyperthyroidism) and other hormonal imbalances.

Examinations that can be done and who to contact

For sexual dysfunction

Andrologist, Gynecologist, Urologist, Angiologist, Endocrinologist

- Analysis of hormones that typically can affect sexual response. 

In the case of high prolactin and low testosterone, a drug such as cabergoline may be prescribed to rebalance them.

The majority of people with PSSD do not have these hormonal imbalances, and some who have treated them have not seen the hoped-for improvements.

Here is a more extensive list of items to check in blood tests: 

CBC, DHT, SHBG, testosterone, free testosterone, prolactin, estradiol, progesterone, THS, T3, vitamin D, vitamin B12.

Even if the hormones in the blood are in ranges, this does not rule out the possibility of hormonal imbalances in the central nervous system (brain and spinal cord), which are not observable except by specific and delicate tests probably available only at the level of scientific research, such as CSF sampling, which allowed a deficiency of the neuroactive steroid allopregnanolone to be seen in a sample of patients with post-finasteride syndrome. In other words, it remains possible that PSSD is a neuroendocrine problem.

More specifically for erectile dysfunction:

- Examination of the prostate for prostatitis, i.e., inflammation of the organ: urinoculture and digito-rectal exploration (palpation of the prostate gland) by a urologist. Bacterial prostatitis is treated with antibiotics. Abacterial one can be chronic, and symptoms can present, subside, regress and then reappear; sometimes there is no decisive cure but a mix of different components, each targeted toward a specific mechanism of action involved in erection and libido. Among the most widely used are those based on L-arginine, Propionyl-L-carnitine and Vitamin B3, which are useful in supporting erectile function by contributing to physiological blood flow in the vessels. Prostate disorders can in fact negatively interfere with the sexual sphere leading to erectile dysfunction and premature ejaculation.

- Penile echocolor-doppler: resting and dynamic (with erection induced by injection into the penis of Prostaglandins or other vasoactive drug); checks the integrity of the corpora cavernosa and blood flow, i.e., whether mechanically induced erection is possible. It also examines penile morphology, e.g., whether there is obvious fibrosis.

- Penile and testicular ultrasound

- Rigiscan for monitoring nocturnal erections. A small instrument with two rings that attach under the glans will record the phases of penile stiffness during sleep, particularly to assess spontaneous erections occurring in the REM phase. Their absence indicates that the erectile dysfunction is anatomical in origin and not psychogenic.

- AngioTac: CT (X-ray) scan to observe blood vessels (arteries and veins) and blood flow.

- Elastography: ultrasound examination to see the degree of fibrosis of the corpora cavernosa of the penis. Fibrosis is scar tissue that limits tissue elasticity, worsening or causing erectile dysfunction. 

- Cavernosometry and other specific examinations for erectile dysfunction.

- Pelvic floor examination: this is the area in the small pelvis made up of ligaments, muscles and tendons that "support" the genito-urinary and anorectal systems; pelvic floor muscles can, especially in women, develop hypotonic and hypertone problems, which could affect sexual dysfunction; they are evaluated with digital exploration of the rectum and/or vagina. Specific exercises are prescribed as appropriate. For women, it may be advisable to consult specialists experienced in vulvodynia, which is a neuropathic pain disorder often involving pelvic floor problems.

Neurologist

Genital nerve reflexes

These are autonomic/involuntary responses of the nervous system.

- Bulbocavernous reflex, mediated by the spinal cord (S2-S4): the physician inserts a finger into the patient's anus and with a blunt tip stimulates the front of the penis, or lightly pricks the glans: normally there is a contraction of the bulbo-cavernous muscle at the base of the penis.

- Cremasteric reflex: this is a superficial reflex present in males. The female equivalent of this test is called Geigel reflex. The function of the cremasteric muscle, supplied by the genitofemoral nerve (L1, L2), is assessed by the autonomic testicular lifting response when the medial area of the thigh on the same side of the body is grazed downward.

Neuropathy (or neuralgia)

Some symptoms of PSSD, particularly genital anesthesia, could be caused by peripheral neuropathy.

- Electromyography (EMG) of the perineal muscles and pudendal nerve (right and left).

- Somatosensory evoked potentials (SEPs) of the pudendal nerve and sacral nerve.

- Laser-evoked potentials (LEPs), a more niche examination that in addition to the large nerves that can already be examined with SEPs also examines lower caliber nerve fibers.

The above three examinations are performed through sensors applied to the genitals (e.g., rings) and on the skin (e.g., electrodes or needles), signals are sent and electrical conduction through the peripheral nervous system is observed.

- Lumbosacral spine MRI: to see if there are mechanical reasons present that may generate pudendal neuralgia, such as compression of a nerve.

More specifically on the small nerve fibers:

- Skin biopsy: involves the removal of a tiny fragment of skin on which the density of nerve endings will be analyzed. Even finding a specialist willing to perform it in the genital area, there are to date no meters of comparison with a healthy specimen in the medical literature. One idea then is to do a skin biopsy at the thigh level, since the peripheral neuropathy might be notable in the genital area but not limited to it.

- Quantitative sensory testing (QST): the patient reports when a physical sensation becomes perceptible. For the symptom of genital hypoesthesia, it is easy for this test to deliver abnormal results, however, these are voluntary reports, so the results do not guarantee objectivity. Something comparable is the assessment of thermal and vibratory sensitivity using Genito Sensory Analyzer (GSA).

- Corneal confocal microscopy: a newer method than the previous two, it consists of scanning the eye; however, it may only be available in research settings.

Central nervous system (brain) examinations

When post-SSRI syndrome includes many severe symptoms, such as emotional dulling, anhedonia, cognitive dysfunction, sleep disturbances and others, concerns may more easily fall on brain problems. 

- Electroencephalogram (EEG) is an examination that monitors and graphs the functioning of the brain, its electrical activity, through sensors applied to the head. Any abnormalities should then be investigated.

- CT scan (computed axial tomography): is an examination that uses X-rays to provide three-dimensional images of internal tissues and can detect damage in the structure of the brain (but does not observe its functioning).

- Functional Magnetic Resonance Imaging (fMRI): is a type of magnetic resonance imaging that makes it possible to observe which areas of the brain are activated during the performance of a given task.

- Quantitative electroencephalography (QEEG): with electrodes placed on the scalp, it detects cortical electrical activity and traces any abnormalities to certain behaviors or disorders, including ADHD, schizophrenia, major depression, head trauma, and obsessive-compulsive disorder. If a significant alteration is detected, one type of treatment proposed is Neurofeedback: with the use of a computer and electrodes placed on the head, the patient will become able to consciously change the electrical activity of his or her brain. Neurofeedback is also proposed as an alternative to pharmacological methods for the treatment of numerous clinical conditions.

Gastroenterologist

About 90% of serotonin in the body is found in the gut. There are some indications, both in patient experiences and in the medical literature, that alterations in the gut microbiota may play a role in PSSD.

- Candida: important to perform this test before the gut microbiota test, because any antibiotic taken for SIBO could worsen candida.

- Glucose Breath Test for diagnosis of SIBO (intestinal bacterial overgrowth syndrome): after ingesting a solution containing glucose, for 2-3 hours, every 15 to 30 minutes the patient should blow into a machine. If there is bacterial overgrowth, there will be fermentation of the administered glucose with production of hydrogen that is measured in the exhaled air.

- Gut microbiota: the exam checks bacterial populations and whether or not there is dysbiosis (alterations in the intestinal flora) and what kind, with the possibility of treating it through diet and supplements. No prebiotics or probiotics should be taken before doing this exam. It will involve taking a stool sample in a special container to be tested in a laboratory (can be shipped), which will give you the report to be evaluated, possibly by a nutritionist.

Psychotherapist, sexologist

Regarding the need that some may have to clarify a psychogenic involvement on PSSD symptoms, this page provides an overview of reasons why it might be helpful to consult a sex therapist: Psychotherapies and Sex therapy