Sexual Medicine

Introduction. It has been reported that lack of sexual activity due to erectile dysfunction (ED) may be associated with testosterone (T) decline. Aim. To investigate whether the known changes in sex hormones associated with resumption of sexual activity are sustained in the long term. Main Outcome Measures. Primary endpoints were variations from baseline of steroid hormones: total T, free T (f T), and estradiol (E). Secondary endpoints were variations of erectile function domain scores at International Index of Erectile Function-5 (IIEF-5).

INTRODUCTION Despite the serious behavioral consequences faced by individuals with sexual compulsivity, related neuropsychological studies are sparse. AIM To compare decision making and cognitive flexibility at baseline and after exposure to an erotic video in sexually compulsive participants and non-sexually compulsive controls. METHODS The sample consisted of 30 sexually compulsive men and 30 controls. Cognitive flexibility was investigated through the Wisconsin Card Sorting Test and decision making was examined through the Iowa Gambling Task. MAIN OUTCOME MEASURES Wisconsin Card Sorting Test categories, correct responses, and perseverative errors and Iowa Gambling Task general trends and blocks. RESULTS Sexually compulsive subjects and controls performed similarly at baseline. After watching an erotic video, controls performed better in block 1 of the Iowa Gambling Task (P = .01) and had more correct responses on the Wisconsin Card Sorting Test (P = .01). CONCLUSIONS The controls...

Introduction.  Controversy exists regarding testosterone replacement therapy (TRT) in men following radical prostatectomy (RP). Many clinicians are hesitant to offer patients TRT after an RP, out of concern that the increased androgen levels may promote tumor progression or recurrence from residual tumor. Recently, several small studies have demonstrated the use of TRT in men following an RP and have shown an improvement in serum testosterone levels with no increase in prostate-specific antigen (PSA) values.Aims.  The aim of this article is to assess changes in PSA and testosterone values in hypogonadal patients on TRT after RP and also to evaluate the impact of pathologic Gleason grade on ultimate PSA values.Methods.  All hypogonadal men who were treated with TRT by members of our department following RP were retrospectively reviewed. PSA values before RP, after RP, and after TRT were evaluated. Serum testosterone levels before and after TRT were also examined. Only patients with undetectable PSA values and negative surgical margins on pathologic specimen were offered TRT and included in the study.Main Outcome Measures.  Main outcome measures were changes in PSA and testosterone values after initiation of TRT.Results.  Fifty-seven men, ages 53–83 years (mean 64), were identified as having initiated TRT following RP. Men received TRT for an average of 36 months following RP (range 1–136 months). Patients were followed an average of 13 months after initiation of TRT (range 1–99 months). The mean testosterone values rose from 255 ng/dL before TRT to 459 ng/dL after TRT (P < 0.001). There was no increase in PSA values after initiation of TRT and thus no patient had a biochemical PSA recurrence.Conclusion.  TRT is effective in improving testosterone levels, without increasing PSA values, in hypogonadal men who have undergone RP. Khera M, Grober E, Najari B, Colen J, Mohamed O, Lamb D, and Lipshultz L. Testosterone replacement therapy following radical prostatectomy. J Sex Med **;**:**–**.

Introduction. Urinary incontinence impairs sexual functioning and sexual satisfaction. Traditional artificial urinary sphincter (AUS) implantation requires perineal incision for cuff placement and a second inguinal incision for reservoir and pump placement. We believed AUS could be placed easier and quicker through one scrotal incision. Aim. In an effort to effect more proximal placement of the cuff while keeping the advantages of the one scrotal incision technique, we report enhancements to the original surgical technique. Methods. Thirty patients have been operated upon using the enhanced technique. A modification of the SKW retractor system (AMS) facilitates deep bulbar exposure. Twenty patients were first time implantations and 10 were revisions with five of the revisions having had the original AUS placed by traditional two-incision technique. Two of the first time AUS patients received an inflatable penile prosthesis through the same incision. Main Outcome Measures. We evaluated site of cuff placement, sizes of cuffs used, postoperative continence status. Results. All of the virgin AUS required dissection of the bulbocavernosus muscle prior to cuff placement. In scrotally placed revisions, replacement cuffs were situated considerably proximal (4.5-7.5 cm) to the original cuff site. The perineal placed revisions were accomplished through a scrotal incision with replacement of two cuffs in the same site and the three other patients immediately distal. No intraoperative complications were seen. One patient developed scrotal hematoma requiring drainage. Only 15 patients are available for follow-up and all are socially continent (one pad or less). Conclusions. Transscrotal approach is used safely and efficiently for penile implants and AUS implantation. The new enhancements to the one-scrotal incision technique allow more proximal cuff placement as evidenced by the bulbocavernosus muscle dissection and use of larger cuffs. Continence rate is similar to rates achieved with perineal placement of cuff found in the literature. Wilson SK, Aliotta PJ, Salem EA, and Mulcahy JJ. New enhancements of the scrotal one incision technique for placement of artificial urinary sphincter allow proximal cuff placement. J Sex Med 2010;7:3510-3515.

Introduction. Physical examination and laboratory evaluation of men with erectile dysfunction (ED) are opportunities to identify potentially life-threatening etiologies and comorbid conditions. Aim. To review genital anatomy, identify any physical abnormalities, assess for comorbid conditions, and reveal significant risk factors for ED. Methods. Expert opinion was based on evidence-based medical literature and consensus discussions between members of this International Society for Sexual Medicine (ISSM) standards committee. Results. For men with ED, a general examination including blood pressure and pulse measurements and a focused genital exam are advised. Fasting blood sugar, serum total testosterone, prolactin levels, and a lipid profile may reveal significant comorbid conditions. Conclusions. Though physical examination and laboratory evaluation of most men with ED may not reveal the exact diagnosis, these opportunities to identify critical comorbid conditions should not be missed. Ghanem HM, Salonia A, and Martin-Morales A. SOP: Physical examination and laboratory testing for men with erectile dysfunction. J Sex Med **;**:**-**.

Breast cancer and its treatment negatively affect the important aspects of a woman's life such as sexual health, cognitive functions, body image, and weight. Abrupt estrogen deficiency following chemotherapy and/or hormonal therapy plays an important role in worsening of sexuality. Aim. To evaluate the impact of breast cancer treatment on sexual functioning, cognitive function, and body weight in premenopausal women. Methods. Thirty-five women with a premenopausal diagnosis of breast cancer who are candidate to adjuvant treatment completed validated questionnaires on menopausal symptoms, sexuality, partner relationship, depression, body image, and cognitive functions after surgery (T0), then after chemotherapy or at least 6 months of endocrine therapy (T1), and after 1 year (T2). In addition, gynecological and dietological examinations were performed. Main Outcome Measure. The following validated questionnaires were used: Greene Climacteric Scale, Beck Depression Inventory, Body Attitude Test, McCoy revised Italian version McCoy Female Sexuality Questionnaire, Cues for Sexual Desire Scale, Dyadic Adjustment Scale, Numeric Matrix Test and Rey uditory-verbal learning test, to measure cognitive functions, a recall 24 H questionnaire to evaluate food intake, Minnesota Leisure Time Physical Activity questionnaire and Eating Attitude Test-40, while anthropometric and plicometry data were assessed by a dietitian. Results. Low levels of sexual functioning were registered at baseline; a further decrease in sexual activity, quality of the partnered relationship, desire, and arousability was demonstrated at T1 and T2. We found a significant increase in hot flushes and anxiety. Nonsignificant deterioration of body image was demonstrated. Although women reported losing memory and concentration, "chemobrain" effect was not demonstrated as cognitive tests improved after 6 months, probably because of "learning effect." Women who had undergone chemotherapy gained weight and fat disposition was typically android. Conclusions. Young women undergoing adjuvant breast cancer therapy experience a heavy impairment in important quality of life domains as sexuality and targeted support interventions are needed.

Chronic pelvic pain (CPP) in women is a long lasting and often disabling condition. It seems reasonable to expect that as a result of the pain, extreme fatigue and/or emotional problems, women with CPP may report a variety of sexual problems. Aim. The present study investigated differences in the report of sexual problems in women with CPP compared with healthy controls, and whether the association of CPP with sexual problems was moderated or mediated by somatic and psychological factors as manifested in women suffering from CPP. Method. One hundred fifty-four women with CPP and 58 age-matched controls completed self-report measures for sexual functioning, pain, physical impairment, anxiety, depression, and sexual and physical abuse. Main Outcome Measure. Golombok Rust Inventory of Sexual Satisfaction. Results. Women with CPP reported higher levels of vaginistic complaints, sexual avoidance, nonsensuality and sexual dissatisfaction than healthy controls. Sexual problems were associated with anxiety, depression, and sexual abuse history but not with somatic factors as pain and physical impairment. Anxiety as well as depression, irrespective of the report of sexual abuse experiences, mediated the effect of CPP on sexual problems. Sexual abuse was a general predictor of sexual problems in both women with CPP and controls. Conclusions. Anxiety and depression constitute important factors in the evaluation of sexual problems in women with CPP. ter Kuile MM, Weijenborg PTM, and Spinhoven P. Sexual functioning in women with chronic pelvic pain: The role of anxiety and depression. J Sex Med 2010;7:1901-1910.

It has been suggested that transforming growth factor-beta1 (TGF-beta1) plays an important role in the pathogenesis of diabetes-induced erectile dysfunction. To investigate the expression and activity of Smad transcriptional factors, the key molecules for the initiation of TGF-beta-mediated fibrosis, in the penis of streptozotocin (STZ)-induced diabetic rats. Fifty-two 8-week-old Sprague-Dawley rats were used and divided into control and diabetic groups. Diabetes was induced by an intravenous injection of STZ. Eight weeks later, erectile function was measured by electrical stimulation of the cavernous nerve (N = 12 per group). The penis was harvested and stained with Masson trichrome or antibody to TGF-beta1, phospho-Smad2 (P-Smad2), smooth muscle alpha-actin, and factor VIII (N = 12 per group). Penis specimens from a separate group of animals were used for TGF-beta1 enzyme-linked immunosorbent assay (ELISA), P-Smad2/Smad2, phospho-Smad3 (P-Smad3)/Smad3, fibronectin, collagen I, and collagen IV western blot, or hydroxyproline determination. Erectile function was significantly reduced in diabetic rats compared with that in controls. The expression of TGF-beta1, P-Smad2, and P-Smad3 protein evaluated by ELISA or western blot was higher in diabetic rats than in controls. Compared with that in control rats, P-Smad2 expression was higher mainly in smooth muscle cells and fibroblasts of diabetic rats, whereas no significant differences were noted in endothelial cells or in the dorsal nerve bundle. Cavernous smooth muscle and endothelial cell contents were lower in diabetic rats than in controls. Cavernous fibronectin, collagen IV, and hydroxyproline content was significantly higher in diabetic rats than in controls. Upregulation of TGF-beta1 and activation of the Smad signaling pathway in the penis of diabetic rats might play important roles in diabetes-induced structural changes and deterioration of erectile function.

Introduction. Several theories, including psychodynamic theories, sexual imprinting and early conditioning have been formulated to explain sexual development. Empirical data, however, remain insufficient for a thorough evaluation of these theories. Aim. In this study, we test the hypothesis that a critical period exists for the acquisition of sexual preferences, as suggested by empirical findings in birds and mammals (sexual imprinting). Methods. An Internet questionnaire was used. Main Outcome Measures. We gather data from individuals with a sexual preference for pregnant and/or lactating women, under the hypothesis that pregnancy or lactation may become sexually attractive in adulthood following an exposure to pregnant or lactating women in infancy. Results. We find that these preferences are more common in older siblings, i.e., in individuals who have been exposed to more maternal pregnancy and lactation. This result is independent of respondent and sibling sex. In addition, only maternal pregnancies and lactations experienced between 1.5 and 5 years of age are associated with the preferences. Conclusions. We discuss our findings in relation to theories of sexual development and to earlier reports of birth order effects on sexual behavior. We suggest that this age range may constitute a sensitive period for the acquisition of sexual preferences. Enquist M, Aronsson H, Ghirlanda S, Jansson L, and Jannini EA. Exposure to mother's pregnancy and lactation in infancy is associated with sexual attraction to pregnancy and lactation in adulthood.

The relationship between extramarital affairs and male sexual dysfunctions (SDs) has not been completely clarified. Aim. The aim of the present study is to describe how the reported presence of extramarital affairs vs. no report differentiates men attending medical care for SDs. Methods. A nonselected series of 2,592 heterosexual (mean age 55 Ϯ 12.5 years) male patients with SD was studied with Structured Interview on Erectile Dysfunction (SIEDY). Furthermore, a complete physical examination and a series of biochemical, hormonal, and penile vascular evaluations were performed. Main Outcome Measures. Several hormonal, biochemical, and instrumental parameters were investigated along with items derived from SIEDY. Results. Infidelity is associated with relational problems within the primary couple, particularly in those with a stable secondary relationship. Furthermore, a higher androgenization is present in men with infidelity. Patients with SD reporting extramarital affairs had higher stress at work, a longer primary relationship span, and higher risk of conflicts within the primal couple and within the family. In addition, infidel men showed a higher risk of partner's illness and partner's hypoactive sexual desire. Among organic factors, a lower prevalence of hypogonadism was observed in infidel men. These subjects showed a better sexual function than the rest of the sample. In addition, they reported a higher intercourse frequency in the previous 3 months (considering both the primary and secondary relationship), a lower prevalence of hypoactive sexual desire (HSD), and a lower feeling of discomfort or guilt about autoerotism. Finally, when SIEDY scales were considered, SIEDY Scale 2 (relational domain) and Scale 3 (intrapsychic domain) scores were significantly higher in infidel subjects when compared with the rest of the sample. Conclusions. Infidelity is associated with relational problems within the primary couple, particularly in those with a stable secondary relationship. Furthermore, a higher androgenization is present in men who commit infidelity. correlates of extramarital affairs and differences between stable and occasional infidelity among men with sexual dysfunctions. J Sex Med 2009;6:866-875.

Erectile dysfunction (ED) is a frequent complaint of elderly subjects and is closely associated with endothelial dysfunction and cardiovascular disease (CVD). Uric acid is also associated with endothelial dysfunction, oxidative stress, and CVD, raising the hypothesis that an increased serum uric acid might predict ED in patients who are at risk for coronary artery disease (CAD). Aim. This study aims to evaluate the association of serum uric acid levels with presence and severity of ED in patients presenting with chest pain of presumed cardiac origin. Methods. This is a cross-sectional study of 312 adult male patients with suspected CAD who underwent exercise stress test (EST) for workup of chest pain and completed a sexual health inventory for men survey form to determine the presence and severity of ED. Routine serum biochemistry (and uric acid levels) were measured. Logistic regression analysis was used to assess risk factors for ED. Main Outcome Measures. The short version of the International Index of Erectile Function questionnaire diagnosed ED (cutoff score ≤ 21). Serum uric acid levels were determined. Patients with chest pain of suspected cardiac origin underwent an EST. Results. One hundred forty-nine of 312 (47.7%) male subjects had ED by survey criteria. Patients with ED were older and had more frequent CAD, hypertension, diabetes and impaired renal function, and also had significantly higher levels of uric acid, fibrinogen, glucose, C-reactive protein, triglycerides compared with patients without ED. Uric acid levels were associated with ED by univariate analysis (odds ratio = 1.36, P = 0.002); however, this association was not observed in multivariate analysis adjusted for estimated glomerular filtration rate. Conclusion. Subjects presenting with chest pain of presumed cardiac origin are more likely to have ED if they have elevated uric acid levels.

Common complications of intracavernous injection therapy include pain, hematoma formation, syncope, prolonged erections, and penile fibrosis. Rare reported complications include postinjection cavernositis, intracorporeal needle breakage. We report a case of postinjection intracavernous needle breakage with successful ultrasound-guided retrieval. A 32-year-old patient complaining of a 6-month penile pain following intracavernous papaverine injection presented to our department. Clinical examination and penile ultrasound revealed a broken intracavernous needle at the left mid-dorsum aspect of the penis with surrounding fibrosis. A decision was made to remove the broken needle. The needle was dislodged effortlessly under local anesthesia. A deeply seated intracavernous broken needle should be immediately retrieved. Patients must be carefully instructed on the proper injection technique with emphasis on the delicacy of the needle and the possibility of needle breakage during injection.

Phosphodiesterase type 5 (PDE5) inhibitors are very effective agents for erectile dysfunction; however, specific patient populations are hard to treat. The efficacy of PDE5 inhibitors is limited because a minimum amount of nitric oxide (NO) is necessary. Resveratrol, a plant polyphenol, is reported to activate endothelial NO synthase (eNOS) through activation of sirtuin 1. We previously reported that human corpus cavernosal smooth muscle cells (CCSMCs) express eNOS and synthesize cyclic guanosine monophosphate (cGMP) via the NO/cGMP pathway. Aim. To investigate the ability of resveratrol and/or vardenafil to increase cGMP in an in vitro model using CCSMCs and to improve erectile function in an in vivo rat model of streptozotocin (STZ)-induced diabetes. Methods. CCSMCs were treated with resveratrol and/or vardenafil. Twenty male Sprague-Dawley rats were randomly divided into five groups (N = 4 in each group): age-matched controls, diabetic controls, and diabetic rats treated with resveratrol, vardenafil, or both in combination for the last 4 weeks of an 8-week period of diabetes induction. Main Outcome Measures. Intracellular cGMP measurement, intracovernous pressure (ICP)/mean arterial pressure (MAP) ratio, and smooth muscle/collagen ratio. Results. Intracellular cGMP level was elevated by resveratrol treatment in CCSMCs. The combination treatment of resveratrol and vardenafil had a synergistic effect. Diabetic rats showed impairment of erectile function. Treatment with either resveratrol or vardenafil improved ICP/MAP ratio, and combination therapy with resveratrol and vardenafil had a synergistic effect in improvement of ICP/MAP. Conclusions. Treatment with either resveratrol or vardenafil elevated cGMP level in CCSMCs and improved erectile function in STZ-induced diabetic rats. Furthermore, a synergistic effect was observed in vitro and in vivo. Resveratrol or combination therapy of resveratrol and vardenafil can improve erectile function in which NO release is impaired, although further study is needed to confirm the results. Fukuhara S, Tsujimura A, Okuda H, Yamamoto K, Takao T, Miyagawa Y, Nonomura N, and Okuyama A. Vardenafil and resveratrol synergistically enhance the nitric oxide/cyclic guanosine monophosphate pathway in corpus cavernosal smooth muscle cells and its therapeutic potential for erectile dysfunction in the streptozotocin-induced diabetic rat: Preliminary findings. J Sex Med 2011;8:1061-1071.

Prior research suggests that overactive bladder (OAB) is common and adversely affects sexuality in both men and women. However, more data are needed from population-based studies to evaluate the impact OAB on sexual health. Aim. To describe sexual health outcomes in men and women with continent and incontinent OAB (C-OAB, I-OAB) compared to those with no/minimal urinary symptoms (NMS) and to evaluate correlates of decreased sexual activity and enjoyment in men and women, and correlates of erectile dysfunction (ED), ejaculatory dysfunction (EjD), and premature ejaculation (PE) in men.

Ultrasonography of the penis is readily available to the urologist and gives good anatomic detail of soft tissue structures. It has not been widely utilized in the assessment of Peyronie's disease (PD). Aims. To describe the sonographic characteristics of the penis in PD and the relationship between clinical and sonographic features. Methods. This cross-sectional study enrolled patients from a single clinical practice. A PD-specific questionnaire was administered and sonographic evaluations were performed.

Cannabis is the most commonly used illicit substance worldwide. Despite this, its impact on sexual health is largely unknown. Aim. The aim of this article is to examine the association between cannabis use and a range of sexual health outcomes. Main Outcome Measures. The main outcome measures include the number of sexual partners in the past year, condom use at most recent vaginal or anal intercourse, diagnosis with a sexually transmissible infection in the previous year, and the occurrence of sexual problems. Methods. Method used in this article includes a computer-assisted telephone survey of 8,656 Australians aged 16-64 years resident in Australian households with a fixed telephone line. Results. Of the 8,650 who answered the questions about cannabis use, 754 (8.7%) reported cannabis use in the previous year with 126 (1.5%) reporting daily use, 126 reported (1.5%) weekly use, and 502 (5.8%) reported use less often than weekly. After adjusting for demographic factors, daily cannabis use compared with no use was associated with an increased likelihood of reporting two or more sexual partners in the previous year in both men (adjusted odds ratio 2.08, 95% confidence interval 1.11-3.89; P = 0.02) and women (2.58, 1.08-6.18; P = 0.03). Daily cannabis use was associated with reporting a diagnosis of a sexually transmissible infection in women but not men (7.19, 1.28-40.31; P = 0.02 and 1.45, 0.17-12.42; P = 0.74, respectively). Frequency of cannabis use was unrelated to sexual problems in women but daily use vs. no use was associated with increased reporting among men of an inability to reach orgasm (3.94, 1.71-9.07; P < 0.01), reaching orgasm too quickly (2.68, 1.41-5.08; P < 0.01), and too slowly (2.05, 1.02-4.12; P = 0.04). Conclusions. Frequent cannabis use is associated with higher numbers of sexual partners for both men and women, and difficulties in men's ability to orgasm as desired. Smith AMA, Ferris JA, Simpson JM, Shelley J, Pitts M, and Richters J. Cannabis use and sexual health. J Sex Med 2010;7:787-793.

Treatment with pelvic external beam radiotherapy with brachytherapy (EBRT/BT) for gynecological cancers may cause sexual dysfunction because of vaginal shortening and tightening. Regular vaginal dilator use is thought to reduce vaginal shortening and/or tightening, but compliance is poor. Aims. This study identified determinants of patients' adherence with dilator use after EBRT/BT. Methods. Semi-structured interviews were conducted with 30 women, aged 32-67 years, treated with EBRT/BT for gynecological cancers at two university medical centers in the past 36 months. Transcriptions were coded and analyzed with N-Vivo software. Main Outcome Measures. Determinants of dilator use were clustered based on the Health Action Process Approach, which describes (i) motivation processes that lead to a behavioral intention and (ii) volition processes that lead to the initiation or maintenance of actual behavior. Results. Almost all women attempted to perform long-term regular vaginal dilator use. Intended dilator use was determined by the expectation that it would prevent the development of vaginal adhesions and stenosis. Planning dilator use and making it part of a routine, using it under the shower, using lubricants, a smaller dilator size, or vibrators helped women. Others reported a lack of time or privacy, forgetting, or feeling tired. Women self-regulated dilator use by rotating the dilator and timing dilator use. Influencing factors were negative emotions regarding dilator use or its hard plastic design, (being anxious for) pain or blood loss, and an association with EBRT/BT. Some women mentioned a lack of instrumental support, for example, lubricants. Others received reassurance through informational support or were supported socially. Conclusion. Motivation and volition processes that determined dilator use were identified and used in the development of a sexual rehabilitation intervention. It is important to provide sufficient patient information and support, and enlarge patients' perceived self-efficacy. Bakker RM, Vermeer WM, Creutzberg CL, Mens JWM, Nout RA, and ter Kuile MM. Qualitative accounts of patients' determinants of vaginal dilator use after pelvic radiotherapy. J Sex Med 2015;12:764-773.

The literature lacks studies of the male sex drive. Most existing studies have focused on hypoactive sexual desire disorder in coupled heterosexual men, highlighting some of the main related biological, psychological, and social factors. To evaluate the role of selected psychological and social variables affecting male sexual desire such as quality of life, sexual function, distress, satisfaction, psychological symptoms, emotions, alexithymia, couple adjustment, sexism, cognitive schemas activated in a sexual context, sexual dysfunctional beliefs, and different classes of cognitions triggered during sexual activity about failure anticipation, erection concerns, age- and body-related thoughts, erotic fantasies, and negative attitudes toward sexuality. A wide self-administered survey used snowball sampling to reach 298 heterosexual Italian men (age = 32.66 ± 11.52 years) from the general population. 13 questionnaires exploring psychological and social elements involved in sexual respo...

Introduction.  A significant number of postmenopausal women suffer from distressing problems because of urogenital atrophy secondary to the decline in circulating estrogen levels. Treatment with topical hormones may provide relief in such women when used judiciously.Aim.  To study the effects of local estrogen with or without local testosterone on urogenital and sexual health in postmenopausal women.Methods.  Seventy-five postmenopausal women symptomatic for urogenital atrophy and sexual dysfunction were randomly divided into two study groups and one control group. The women in study group 1 received local estrogen cream; study group 2 received local estrogen and testosterone cream; the control group received nonhormonal lubricant KY gel for 12 weeks. The urogenital and sexuality score, along with the vaginal health index and the vaginal maturation index (VMI), was calculated at the beginning of therapy and 12 weeks later.Main Outcome Measures.  Changes in the urogenital and sexuality score along with vaginal health index and VMI.Results.  After 12 weeks of therapy, there was a significant improvement in all the four study parameters, which correlated well with the improvement in symptoms of urogenital atrophy and sexual dysfunction in both the study groups as compared with the control group. Improvement in sexuality score was greatest with combined estrogen–androgen therapy. There were no adverse effects and the therapies were well accepted without any compliance issue.Conclusion.  Local estrogen either alone or with androgen is highly effective in relieving symptoms of urogenital atrophy and in improving sexual function in symptomatic postmenopausal women. Raghunandan C, Agrawal S, Dubey P, Choudhury M, and Jain A. A comparative study of the effects of local estrogen with or without local testosterone on vulvovaginal and sexual dysfunction in postmenopausal women. J Sex Med 2010;7:1284–1290.

background: Investigators have postulated that family size may be influenced by biologic fertility potential in addition to sociodemographic factors. The aim of the current study is to determine if a diagnosis of infertility is associated with family size in the USA. methods: We analyzed data from the male and female samples of the 2002 National Survey of Family Growth using multivariable logistic regression models to determine the relationship between infertility and family size while adjusting for sociodemographic and reproductive characteristics.

Introduction. Despite a demonstrated relationship between sexual behaviors and health, including clinical risks, little is known about contemporary sexual behavior. Aims. To assess the rates of sexual behavior among adolescents and adults in the United States. Methods. We report the recent (past month, past year) and lifetime prevalence of sexual behaviors in a nationally representative probability sample of 5,865 men and women ages 14 to 94 in the United States (2,936 men, 2,929 women). Main Outcome Measures. Behaviors assessed included solo masturbation, partnered masturbation, giving and receiving oral sex, vaginal intercourse, and anal intercourse. Results. Masturbation was common throughout the lifespan and more common than partnered sexual activities during adolescence and older age (70+). Although uncommon among 14-to 15-year olds, in the past year 18.3% of 16-to 17-year-old males and 22.4% of 16-to 17-year-old females performed oral sex with an other-sex partner. Also in the past year, more than half of women and men ages 18 to 49 engaged in oral sex. The proportion of adults who reported vaginal sex in the past year was highest among men ages 25-39 and for women ages 20-29, then progressively declined among older age groups. More than 20% of men ages 25-49 and women ages 20-39 reported anal sex in the past year. Same-sex sexual behaviors occurring in the past year were uncommonly reported. Conclusions. Men and women engage in a diverse range of solo and partnered sexual behaviors throughout the life course. The rates of contemporary sexual behavior provided in this report will be valuable to those who develop, implement, and evaluate programs that seek to improve societal knowledge related to the prevalence of sexual behaviors and to sexual health clinicians whose work to improve sexual health among the population often requires such rates of behavior. Herbenick D, Reece M, Schick V, Sanders SA, Dodge B, and Fortenberry JD. Sexual behavior in the United States: Results from a national probability sample of men and women ages 14-94.

Introduction. Debate continues on whether or not male homosexuality (MH) is a result of biological or cultural factors. The debate persists despite the fact that these two sides have different abilities to create a scientific environment to support their cause. Biological theorists produced evidence, however, that these are not always robust. On the other hand, social theorists, without direct evidence confirming their positions, criticize, with good argument, methods and results of the other side. The aim of this Controversy is to understand the reasons of both perspectives. Methods. Two scientists (R.B. and A.C.C.) with expertise in the area of biology of MH were asked to contribute their opinions. The nurture position is discussed by a third expert in sexology (J.B.). Main Outcome Measure. Expert opinion supported by the critical review of the currently available literature. Result. The role of the Controversy's editor (E.A.J.) is to highlight the strengths and weaknesses of both sides. The two experts of the biological issue answer with their data to the questions: "Is male homosexuality partly explainable by immunology?" and "How is male homosexuality a Darwinian paradox?", respectively. Genetic and immunological factors, birth order, and fertility of relatives are largely discussed. Finally, the expert sustaining the idea that culture and experiences are important determining factors in sexual orientation used a psychosocial and holistic perspective to explain his position. Conclusions. The JSM's readers should recognize that there are several biological factors in MH. However, these findings do not seem to be able to explain all cases of homosexuality. Some others may be due to particular environmental factors. The issue is complicated and multifactorial, suggesting that further research should be undertaken to produce the final answer to the question raised in this Controversy section. Jannini EA, Blanchard R, Camperio-Ciani A, and Bancroft J. Male homosexuality: Nature or culture? J Sex Med 2010;7:3245-3253.

The challenge in the field of sexual medicine is to develop evidence-based principles for clinical evaluation and create a uniform, widely accepted diagnostic and treatment approach for all sexual problems and dysfunctions, for both genders. Aim. To provide recommendations for the broad approach for assessing sexual problems in a medical practice setting; to develop an evidence-based diagnostic and treatment algorithm for men and women with sexual dysfunctions. Methods. The PubMed literature was reviewed. Expert opinion was based on the grading of evidence-based medical literature and the Delphi consensus process. Results. The Committee determined three principles for clinical evaluation and management: (i) adoption of a patient-centered framework, with emphasis on cultural competence in clinical practice; (ii) application of evidencebased medicine in diagnostic and treatment planning; (iii) use of a unified management approach in evaluating and treating sexual problems in both men and women. The International Consultation in Sexual Medicine-5 stepwise diagnostic and treatment algorithm was developed for that purpose. According to this algorithm, sexual, medical, and psychosocial history is mandatory, whereas physical examination and laboratory tests are highly recommended in most cases. Furthermore, the Brief Sexual Symptom Checklist (BSSC) for Men and BSSC for Women, and more recently the Sexual Complaints Screener (SCS) for Men and SCS for Women, were all endorsed for screening purposes. A classification system was also defined; clinically, sexual dysfunctions are categorized in three types according to their etiology (Type I: psychogenic; Type II: organic; Type III: mixed). Final recommendations on specialized diagnostic tests were based on level of evidence.

We are still left with the issue of characterising what counts as successful outcome in sex therapy. The aim of this paper is to report the progress of the outcome measurement project initiated by the College of Sexual and Relationship Therapists. In this report, I have reviewed the existing literature to answer the following question: “Does there currently exist a validated evaluation tool (or a package of tools) by which the effectiveness and success of sex therapy in dealing with sexual problems can be measured and demonstrated?”. I start with discussing some of the key dilemmas in relation to measuring outcomes in sex therapy and arrive at a conceptual framework to address this. I finish with suggesting a few measurement tools that can be utilised in this regard.

Several preference studies comparing a short-acting with a longer-acting phosphodiesterase type 5 inhibitor have been conducted in men. Most men in those studies preferred tadalafil rather than sildenafil, and recent post hoc analysis of one study described several factors associated with men's treatment preference. No prospective studies have investigated the woman partners' preferences. Aim. To investigate the treatment preference of women who were partners of men using oral medications for erectile dysfunction (ED) in a single-center open-label crossover study. Methods. One hundred heterosexual couples in stable relationships, with male partners having ED based on the erectile function subscale of the International Index of Erectile Function, were randomly assigned to receive sildenafil or tadalafil for a 12-week phase, followed by another 12-week period using the alternate drug. Male and female participants completed sexual event diaries during both study phases, and the female participants were interviewed at baseline, midpoint, and end of study. Main Outcome Measures. Primary outcome data were the women's final interviews during which they were asked which drug they preferred and their reasons for that preference. Results. A total of 79.2% of the women preferred their partners' use of tadalafil, while 15.6% preferred sildenafil. Preference was not affected by age or treatment order randomization. Women preferring tadalafil reported feeling more relaxed, experiencing less pressure, and enjoying a more natural or spontaneous sexual experience as reasons for their choice. Mean number of tablets used, events recorded, events per week, and days between events were not significantly different during each study phase. Conclusion. Women's preferences were similar to men when using these two drugs. While the women's reasons for preferring tadalafil emphasized relaxed, satisfying, longer-lasting sexual experiences, those preferring sildenafil focused on satisfaction and drug effectiveness for their partner. Conaglen HM, and Conaglen JV. Investigating women's preference for sildenafil or tadalafil use by their partners with erectile dysfunction: The partners' preference study.

Introduction. The number of women with gestational diabetes mellitus (GDM) is growing worldwide in parallel with the obesity epidemic. The diagnosis of GDM leads to substantial modifications in the daily routine of these women, and these adjustments could potentially affect their sexual function. There are no previous studies on the sexual function of patients with GDM. Aim. The aim of this study was to investigate the sexual function of patients with GDM in comparison with healthy pregnant women at the same gestational age. Methods. Brazilian women in the third trimester of pregnancy with and without GDM were invited to participate in this cross-sectional study while waiting for their antenatal care visits at a single public tertiary teaching institution between March and December 2010. The Brazilian version of the Female Sexual Function Index (FSFI) questionnaire was used to assess sexual function. Main Outcome Measures. Desire, arousal, lubrication, orgasm, sexual satisfaction, and pain during and after coitus in the last 4 weeks, measured according to a standardized and validated questionnaire. Results. A total of 87 participants were enrolled (43 healthy women and 44 with GDM). There were no significant differences in the sociodemographic characteristics of both groups. The total FSFI scores of GDM patients was 21.0 Ϯ 9.59 compared with 22.3 Ϯ 9.17 for healthy women (P = 0.523). Difficulty in desire was the most common sexual dysfunction symptom in both groups, being reported by 42% and 50% of GDM and healthy women, respectively (P = 0.585). Conclusion. The sexual function of Brazilian patients with GDM does not differ significantly from that of healthy pregnant women at the same gestational age. Ribeiro MC, Nakamura MU, Scanavino Mde T, Torloni MR, and Mattar R. Female sexual function and gestational diabetes. J Sex Med 2012;9:786-792.

Testosterone deficiency syndrome (TDS) causes a wide range of symptoms that can lead to significant morbidity. Preliminary evidence has also linked TDS with premature mortality and with a number of comorbid diseases including diabetes and metabolic syndrome. Such associations can lead to substantial economic and qualityof-life implications, the magnitude of which remains largely unknown. Aim. To review the economic and quality-of-life consequences of a largely untreated condition and to consider the likely health economic benefits of testosterone treatment. Methods. A systematic review of four main areas: epidemiological evidence of the magnitude of TDS, estimates of cost of illness, impact on quality-of-life, and cost-effectiveness of testosterone treatment. Main Outcome Measure. Review of peer-reviewed literature. Results. The lack of clear universally accepted diagnostic criteria and the uncertainty surrounding the link between TDS and some of its consequences complicate the estimation of the burden of illness of TDS. Consequences of TDS that potentially lead to increased economic burden include depression, sexual dysfunction, mild cognitive impairment, osteoporosis, cardiovascular disease, and mortality. However, although good evidence exists demonstrating an association between TDS and sexual dysfunction and cognitive impairment, evidence is less strong for depression, the incidence of fractures and mortality, and highly controversial for cardiovascular disease. The consequences that are likely to impact on patients' quality of life include sexual function, energy levels, body composition, mood, and cognitive function. Conclusion. Understanding the burden is only the first step decision makers need to take to decide whether to allocate scarce resources to treat the condition. To make informed decisions on when and who to treat information is also needed on the cost-effectiveness of available treatments. Such data would highlight the benefits of treatment of TDS to physicians, patients, and to society as a whole. Maggi M, Schulman C, Quinton R, Langham S, and Uhl-Hochgraeber K. The burden of testosterone deficiency syndrome in adult men: Economic and qualityof-life impact. J Sex Med 2007;4:1056-1069.

Penile entrapment is a rare clinical entity requiring urgent and efficient management. If left untreated, it may result in vascular compromise to penile soft tissue structures. Management poses unique challenges to the treating physician through variable presentation as well as the lack of specifically designed treatment options. Aim. This article describes the use of the Gigli saw for management of penile entrapment. Main Outcome Measures and Methods. We employed the Gigli saw to remove an entrapped metallic peno-scrotal constriction ring. Results. We successfully removed the entrapped ring with no noted immediate complications. Conclusions. The Gigli saw can be safely used, and represents an easily available and potentially effective option in the management of penile entrapment. Eaton SH, Dickstein RJ, and Wiygul JB. Novel use of the Gigli saw for management of penile entrapment. J Sex Med 2009;6:595-597.

Introduction: D-Aspartate is an endogenous amino acid involved in LH and testosterone release in humans. In this study we investigate the impact of nutritional supplementation of sodium D-aspartate on the improvement of sperm quality in sub-fertile patients and the rate of pregnancies that occurred with their partners. Materials and Methods: A group of 30 patients affected by oligo-asthenozoospermia and a group of 30 patients affected by asthenozoospermia were treated with a daily dose of sodium D-aspartate for 90 days. After which, the change in spermatozoa concentration and their motility and the pregnancies that occurred with their partners were recorded. Results: We found that the supplementation of D-aspartate significantly increased the concentration and the motility of spermatozoa. In oligoasthenozoospermic patients the increase of sperm concentration was found to be 2.0-fold, P < 0.001 (from a mean of 8.2 ± 4.5 million spermatozoa/ml of seminal plasma before treatment to a mean of 16.5 ± 5.5 million after treatment). In asthenozoospermic patients, the increase of spermatozoa was 1.6-fold, P < 0.001 (from a mean of 29.9 ± 5.7 million spermatozoa/ml before treatment to a mean of 48.7 ± 12.8 after treatment). The same positive effects also occurred for sperm motility. Oligo-asthenozoospermic patients showed an increase of rapid progressive spermatozoa motility from a mean of 15.5% ± 4.4% before treatment to a mean of 23.1% ± 4.7% after D-aspartate treatment (1.49-fold increased, P < 0.001). The same effects occurred in oligo-asthenozoospermic patients. In these subjects the increase of rapid progressive spermatozoa motility was 1.86-fold (from 11.6% ± 3.9% before treatment to 21.6 ± 7.5 after treatment, P < 0.001). In addition, the treatment of D-aspartate in these patients consequently led to a significantly increased number of pregnancies occurring in the partners of the treated patients. Conclusions: Treatment of sub-fertile patients with sodium D-aspartate improved the number and the motility of the spermatozoa and consequently improved the rate of pregnancies of their partners.

Aim. Symptomatic late-onset hypogonadism is associated not only with a decline in serum testosterone, but also with a rise in serum estradiol. These endocrine changes negatively affect libido, sexual function, mood, behavior, lean body mass, and bone density. Currently, the most common treatment is exogenous testostosterone therapy. This treatment can be associated with skin irritation, gynecomastia, nipple tenderness, testicular atrophy, and decline in sperm counts. In this study we investigated the efficacy of clomiphene citrate in the treatment of hypogonadism with the objectives of raising endogenous serum testosterone (T) and improving the testosterone/estrogen (T/E) ratio. Methods. Our cohort consisted of 36 Caucasian men with hypogonadism defined as serum testosterone level less than 300 ng/dL. Each patient was treated with a daily dose of 25 mg clomiphene citrate and followed prospectively. Analysis of baseline and follow-up serum levels of testosterone and estradiol levels were performed. Results. The mean age was 39 years, and the mean pretreatment testosterone and estrogen levels were 247.6 ± 39.8 ng/dL and 32.3 ± 10.9, respectively. By the first follow-up visit (4-6 weeks), the mean testosterone level rose to 610.0 ± 178.6 ng/dL ( P < 0.00001). Moreover, the T/E ratio improved from 8.7 to 14.2 ( P < 0.001). There were no side effects reported by the patients. Conclusions. Low dose clomiphene citrate is effective in elevating serum testosterone levels and improving the testosterone/estadiol ratio in men with hypogonadism. This therapy represents an alternative to testosterone therapy by stimulating the endogenous androgen production pathway. Shabsigh A, Kang Y, Shabsign R, Gonzalez M, Liberson G, Fisch H, and Goluboff E. Clomiphene citrate effects on testosterone/estrogen ratio in male hypogonadism. J Sex Med 2005;2:716-721.

Until now, there are only few studies that focus on the specific treatment experiences of people with intersexuality and evaluate their outcome in terms of psychological, physical, and social well-being. Further, the presentation of the patients' perspective is often neglected in research. Aim. Overview of preliminary results of the Hamburg-Intersex-Study on gender assignment and medical history of adult subjects with intersexuality (disorders of sex development), as well as the patients retrospectively stated thoughts and feelings regarding these interventions. Main Outcome Measures. Medical records from participants of the study were analyzed. The subjective attitudes and evaluation of the treatment measures were assessed with a self-constructed questionnaire. Data on psychological well-being were measured with the Brief Symptom Inventory. Methods. In total, 37 adult participants (mean age 30.6 years) with following diagnosis were included: congenital adrenal hyperplasia, complete and partial androgen insensitivity syndrome, gonadal dysgenesis and disturbances of the androgen biosynthesis, such as 5 alpha reductase deficiency and 17 beta hydroxysteroid deficiency. Results. The majority of participants had (often multiple) genital surgery to correct the appearance of their genitalia and/or to enable sexual functioning. The diagnostic groups differ not only in amount and invasiveness of experienced surgical and medical treatment but also in the subjective and retrospective evaluation of the treatment measures and in the amount of reported psychological distress. Conclusion. Many subjects stated to have experienced the medical procedures and care very negatively, whereby the aspects of secrecy, untruthfulness, and concealment were stated as most difficult and burdening. Brinkmann L, Schuetzmann K, and Richter-Appelt H. Gender assignment and medical history of individuals with different forms of intersexuality: Evaluation of medical records and the patients' perspective. J Sex Med 2007;4:964-980.

Introduction. Pregnancy and childbirth is a special period in a woman's life, which involves significant physical, hormonal, psychological, social, and cultural changes that may influence her own sexuality as well as the health of a couple's sexual relationship. Aim. To comprehensively review the literature on the effects of pregnancy and the postpartum period on a couple's sexual health and well-being. Main Outcome Measures. Evidence from the published literature of the impact of pregnancy, childbirth, and the postpartum period on sexual function. Methods. Medline and PubMed search for relevant publications on the effects of pregnancy and childbirth on sexual health and function, with particular focus on the physical, hormonal, psychological, social, and cultural changes that may occur during the antepartum, intrapartum, and postpartum period. Results. Despite fears and myths about sexual activity during pregnancy, maintaining a couple's sexual interactions throughout pregnancy and the postpartum period can promote sexual health and well-being and a greater depth of intimacy. Conclusions. Clinicians must seek to engage in an open discussion and provide anticipatory guidance for the couple on expected changes in sexual health as well as promote the design of rigorous, evidence-based studies to further elucidate our understanding of sexual function during pregnancy and the postpartum. Johnson CE. Sexual health during pregnancy and the postpartum. J Sex Med 2011;8:1267-1284.

Little is known about the etiology or medical/psychological correlates of persistent genital arousal disorder (PGAD). Aim. The aims of this article were (i) to replicate the findings of earlier research identifying two subtypes of women with persistent arousal-those who meet all features of the condition and are at least moderately distressed, and those who meet only some features and are less distressed; and (ii) to identify the medical, psychological and/or pharmacological correlates of the condition. Method. A comprehensive web-based survey of persistent genital arousal (PGA) was posted on several Internet websites. Of the 156 women who completed the survey, 76 met all five features qualifying for a persistent genital arousal disorder (PGAD) group, and 48 met only some features (non-PGAD group). Main Outcome Measures. The main outcome measures were endorsement of diagnostic signs of depression, anxiety, obsessive-compulsive disorder, and panic attack as well as medical illnesses and pharmacological preparations. Results. Compared to non-PGA subjects, women with PGA were significantly more likely to be depressed (55% vs. 38%) and to report panic attacks (31.6% vs. 14.6%). They were more anxious and more likely to monitor their physical sensations. Both groups reported high rates of childhood and adult sexual abuse, although the PGA women reported a higher prevalence of sexual victimization. They were significantly more likely to endorse negative feelings about their genital sensations and also more likely to complain of chronic fatigue syndrome than women without the condition (10% vs. 0%). There were no significant relationships with pharmacologic agents and symptoms. Conclusions. Women who met all the criteria of PGAD were more likely than women who only met some of the criteria to report depression, anxiety, panic attacks, and certain obsessive-compulsive symptoms such as monitoring their physical sensations. It is hypothesized that for a subset of women, psychological factors, namely anxiety, reinforce exacerbate and maintain PGAD. Leiblum S, Seehuus M, Goldmeier D, and Brown C. Psychological, medical, and pharmacological correlates of persistent genital arousal disorder. J Sex Med 2007;4:1358-1366.

Introduction. Noncopulating (NC) male rats are apparently normal and healthy animals that will not mate despite repeated exposure to sexually receptive females. Several lines of evidence suggest the involvement of endogenous opioids in this sexual inhibitory state. Endogenous opioids and endocannabinoids are neuromodulators of neurotransmitter release, although through different mechanisms. Aim. To establish if the endocannabinoid anandamide was able to induce sexual behavior expression in male rats classified as noncopulators. Methods. NC male rats were intraperitoneally (i.p.) injected with anandamide or vehicle and tested for copulatory behavior with a receptive female during 120 minutes. Fourteen days after anandamide or vehicle injection, the animals were subjected to a second sexual behavior test during 60 minutes. Main Outcome Measures. The percentage of rats showing male sexual behavior responses: mount, intromission, ejaculation, and copulation resumption after ejaculation and the specific sexual behavior parameters were quantified. Results. Anandamide injection induced sexual behavior expression in 50% of previously NC rats, while the NC animals injected with vehicle did not show sexual behavior. The responding animals executed several successive ejaculatory series and were still capable of showing sexual behavior 14 days after anandamide injection. Copulation in these rats (the first copulatory series) was characterized by a large number of mounts and intromissions preceding ejaculation, as well as by statistically significant increases in the latencies to mount, intromit, and ejaculate when compared with the sexual performance of sexually naïve animals copulating for the first time. Conclusion. The endocannabinoid anandamide transforms previously NC rats into sexually active animals, capable of showing sexual behavior in a long-lasting manner. Only half of the NC population responds to anandamide injection, suggesting that different mechanisms underlie the sexual inhibition of NC rats. The endocannabinoid system seems to play a role in the regulation of male rat sexual behavior expression. Canseco-Alba A and Rodríguez-Manzo G. Anandamide transforms noncopulating rats into sexually active animals. J Sex Med

Little is known about the sexual functioning and behavior of men anxious about the size of their penis and the means that they might use to try to alter the size of their penis. Aim. To compare sexual functioning and behavior in men with body dysmorphic disorder (BDD) concerning penis size and in men with small penis anxiety (SPA without BDD) and in a control group of men who do not have any concerns.

Yoga is practiced both in developing and developed countries. Many patients and yoga protagonists claim that it is useful in improving sexual functions and treating sexual disorders. Aim. We wanted to study the effect of yoga on male sexual functioning. Methods. We studied 65 males (age range = 24-60 years, average age = 40 Ϯ 8.26 years) who were enrolled in a yoga camp and administered a known questionnaire, i.e., Male Sexual Quotient (MSQ) before and after 12 weeks session of yoga. Main Outcome Measures. MSQ scores before and after yoga sessions. Results. It was found that after the completion of yoga sessions, the sexual functions scores were significantly improved (P < 0.0001). The improvement occurred in scores of all the domains of sexual functions as studied by MSQ (desire, intercourse satisfaction, performance, confidence, partner synchronization, erection, ejaculatory control, orgasm).