Comparison of Hiraoka's Transurethral Detachment Prostatectomy and Transurethral Resection of the Prostate Effects on Postoperative Erectile Function in Patients With Benign Prostatic Hyperplasia: A Prospective Randomized Controlled Study

BackgroundCurrently, no study has focused on the postoperative erectile function in patients with benign prostatic hyperplasia (BPH) by comparing Hiraoka's transurethral detachment of prostate (TUDP) and transurethral resection of prostate (TURP).AimTo compare the effects of Hiraoka's TUDP and TURP on postoperative erectile function in patients with BPH after long-term follow-up.MethodsA total of 104 consecutive patients with BPH treated in our hospital between September 2018 and February 2019 were included in the study. All patients who met the inclusion criteria were randomly divided into the Hiraoka's TUDP (n = 52) and TURP (n = 52) groups. Patient baseline data were collected. The international index of erectile function (IIEF-5), minimal clinically important difference (MCID), and quality of life scale (QOLS) were used to evaluate erectile function and quality of life 3, 6, and 12 months after surgery. Primary study endpoints were IIEF-5 and MCID. Secondary study endpoints were QOLS and independent prognostic factors for MCID.OutcomesHiraoka's TUDP experienced greater improvement in postoperative IIEF5 scores than patients who underwent TURP.ResultsPatients in the Hiraoka's TUDP group had significantly higher mean IIEF-5 scores than those in the TURP group 6 and 12 months after surgery (6 months: 18.9 vs 14.8, P < .001; 12 months: 18.1 vs 15.7, P < .001). The percentages of patients in the TUDP group who achieved an MCID were 88.5% and 80.8%, compared to 30.8% and 46.2% in the TURP group (P < .001 for both), 6 and 12 months after the operation, respectively. Patients in the TUDP group had lower QOLS scores than those in the TURP group after the surgery. The surgical method was an independent prognostic factor for MCID (odds ratio = 0.218).Clinical ImplicationsUntil now, no study has focused on the postoperative erectile function in patients with BPH by comparing Hiraoka's TUDP and TURP. Our study addressed this issue, which can add a new paradigm in the management to BPH.Strength & LimitationsThe comparison between Hiraoka's TUDP and TURP using a statistically appropriate, adequately powered methodology is the strength of the study. The single center and less participants are the limitations of the study. We believe that multicenter and large-sample studies are needed to further verify these study conclusions.ConclusionsAmong similar cohorts of patients with BPH who underwent TUDP and TURP, patients who underwent Hiraoka's TUDP experienced greater improvement in postoperative IIEF5 scores than patients who underwent TURP, while improvement in IPSS was similar among both groups.Pan C, Zhan Y, Zhao Y, et al. Comparison of Hiraoka's Transurethral Detachment Prostatectomy and Transurethral Resection of the Prostate Effects on Postoperative Erectile Function in Patients With Benign Prostatic Hyperplasia: A Prospective Randomized Controlled Study. J Sex Med 2020;17:2181–2190.     

Changing Aspects of Male Sexual Functions Accompanying Treatment of Benign Prostatic Hyperplasia With Silodosin 8 mg Per Day

BackgroundAlpha-adrenergic antagonist treatment for benign prostatic hyperplasia (BPH) and drug-related sexual side effects are frequent in aging men.AimTo investigate functional changes in erectile and ejaculatory aspects of male sexuality under Silodosin 8 mg per day treatment for BPH.MethodsSexually active patients diagnosed with BPH and who initiated Silodosin treatment were the subjects of the study. The International Prostate Symptom Score, premature ejaculation patient profile (PEP-male) questionnaire, Sexual Health Inventory for Men (SHIM) questionnaire, and estimated intravaginal ejaculation latency time (IELT) values of the participants were used to evaluate sexual functions. Data evaluation was performed in 8 urology clinics retrospectively.OutcomesParticipant ratings for SHIM, PEP, and estimated IELT were the primary outcome measures in the study.ResultsAmong 187 recruited patients, data of 98 patients, who completed the trial period in the study, were eligible. The median age of the eligible participants who completed the trial period for 3 months was 59.5 years (range 45–82). 16 patients of 187 (8%) reported a desire for drug withdrawal for anejaculation during the recruitment period. 46 (46.9%) and 49 (50%) patients reported anejaculation in the first and third month of the treatment, respectively. De novo erectile dysfunction was noticed in 15 patients (15.3%). There was a significant increase in the estimated IELT of subjects in both the first (P = .01) and third (P = .002) month. SHIM-1 (P = .008), SHIM-total (P = .009), and PEP scores (P = .008) were also improved in the third month of the treatment. Neither baseline patient characteristics nor changes in the International Prostate Symptom Score after treatment predicted final outcomes with multivariable analysis. The subgroup analysis of participants who reported “anejaculation” also revealed better outcomes compared with participants ejaculating naturally in the third month as per SHIM ratings.Clinical ImplicationsDespite several male patients having dry orgasms due to Silodosin-induced anejaculation, the majority experienced improved erectile function.Strengths & LimitationsThe present study demonstrated pioneering results while investigating both erectile and ejaculatory dimensions of the male sexual function during Silodosin treatment for BPH. However, lack of partner evaluation, low follow-up rates, and lack of knowledge about reasons why subjects are lost to follow-up after drug initiation have limited our interpretation.ConclusionMost patients using Silodosin 8 mg per day for BPH treatment experienced improvement in their erectile function, estimated IELT, and premature ejaculation profile in the third month of the treatment. Underlying mechanisms and reasons for individual differences necessitate further investigation.Cihan A, Kazaz İO, Yıldırım Ö, et al. Changing Aspects of Male Sexual Functions Accompanying Treatment of Benign Prostatic Hyperplasia With Silodosin 8 mg Per Day. J Sex Med 2020;17:1094–1100.     

Impact of Kidney Transplantation on Male Sexual Function: Results from a Ten-Year Retrospective Study

BackgroundThe effects of kidney transplantation on male sexual function are controversial.AimTo evaluate the impact of kidney transplantation on erectile and ejaculatory function and to assess a possible correlation between some selected characteristics of patients and their erectile and ejaculatory function after renal transplantation.MethodsAn observational retrospective analysis was conducted on male patients who had undergone kidney transplantation from January 2009 to April 2019. A prospectively maintained database was used to collect all data. Patients were evaluated before kidney transplant and 6 and 12 months after kidney transplant. Male patients undergoing renal transplantation for any cause who were sexually active with a stable partner were included in the study.OutcomesThe main outcome measures included the International Index of Erectile Function (IIEF-15) and the 4-item version of Male Sexual Health Quality–Ejaculation Disorders (MSHQ-EjD Short Form) questionnaires. The first 3 questions of the MSHQ-EjD Short Form were used to assess the ejaculatory function, whereas the fourth question was used to evaluate the ejaculation bother.ResultsA total of 95 patients were eligible in the study. The evaluation of sexual function was available in 56 patients (58.9%). Mean IIEF-15 significantly decreased at 6 months (P < .001) remaining unchanged at 12 months (P = .228). Mean MSHQ-EjD Short Form (1–3) significantly decreased at 6-month follow-up (P < .001) and at 12-month follow-up (P = .024). Mean MSHQ-EjD Short Form (4) was significantly increased compared with the baseline at both 6 and 12 months (P < .05). IIEF-15 was significantly related to the MSHQ-EjD Short Form at 6-month and 12-month follow-up (P < .001). Age, diabetes, hypertension, smoking, pretransplantation testosterone, time for transplantation, baseline IIEF-15, and baseline MSHQ-EjD Short Form (1–3) were significantly associated (P < .05) with both IIEF-15 and the MSHQ-EjD Short Form (1–3) at 6-month and 12-month follow-up after kidney transplantation.Clinical ImplicationsImprovement of knowledge regarding the effects of kidney transplantation on sexual function and about the patient characteristics related to sexual health after transplantation.Strength & LimitationsThis is the first article that analyzes in depth the ejaculatory function in patients who had undergone kidney transplantation assessing ejaculation with a validated questionnaire. The main limitation is the retrospective design of the study.ConclusionKidney transplantation appears to have a negative impact on sexual health, significantly worsening both erectile and ejaculatory functions. Age, diabetes, hypertension, smoking, pretransplantation testosterone levels, time for transplantation, as well as erectile and ejaculatory function before transplant were significantly related to erectile and ejaculatory functions after renal transplantation.Spirito L, Manfredi C, Carrano R, et al. Impact of Kidney Transplantation on Male Sexual Function: Results from a Ten-Year Retrospective Study. J Sex Med 2020;17:2191–2197.     

Effect of Prostate Artery Embolization on Erectile Function – A Single Center Experience of 167 Patients

BackgroundProstate artery embolization (PAE) is an emerging therapy for lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).AimThis retrospective study was conducted to assess the effect of prostate artery embolization (PAE) on erectile function in a cohort of patients with LUTS attributable to BPH at 3-months after the procedure.MethodsA retrospective review was performed on 167 patients who underwent PAE. Data collected included Sexual Health Inventory in Men (SHIM) scores at 3, 6, and 12 months post-PAE, in conjunction with the International Prostate Symptom Scores (IPSS), Quality of Life (QoL) scores, and prostate volumes. Primary outcome was erectile function as assessed by SHIM scores at 3 months after PAE. An analysis was performed to identify patients with a ±5-point SHIM change to group them according to this minimum clinically significant difference in erectile function. Adverse events were recorded using the Clavien-Dindo (CD) classification.OutcomesAt 3 months following PAE, median IPSS decreased by 16.0 [IQR, 9.0–22.0] points, median QOL decreased by 4.0 [IQR, 2.0–5.0] points, and median prostate volume decreased by 33 g [IQR, 14–55].ResultsMedian SHIM score was 17.0 [IQR, 12.0–22.0] at baseline, 18.0 [IQR, 14.0–23.0] at 3 months [P = .031], 19.0 [IQR, 14.5–21.5] at 6 months [P = .106] and 20 [IQR, 16.0–24.0] at 12 months [P = .010] following PAE. In patients with no erectile dysfunction (ED) at baseline, 21% (n = 9) reported some degree of decline in erectile function post-PAE. However, 38% (n = 40) of patients who presented with mild-to-moderate ED reported improvement in their erectile function 3 months following PAE. Overall, the changes in baseline SHIM score were relatively small; 82% (n = 137) of patients did not have more than 5 points of change in their SHIM scores at 3 months following PAE.Clinical ImplicationsOur findings suggest PAE has no adverse impact on erectile function for most patients.Strengths & LimitationsThe study was performed at a single center with 1 operator's experience, and is retrospective with no control group.ConclusionFindings suggest that prostate artery embolization has no adverse effect on erectile function in the majority of patients with LUTS attributable to BPH at 3 months after the procedure.Bhatia S, Acharya V, Jalaeian H, et al., Effect of Prostate Artery Embolization on Erectile Function – A Single Center Experience of 167 Patients. J Sex Med 2022;19:594–602.     

Tadalafil Once Daily Improves Ejaculatory Function,Erectile Function,and Sexual Satisfaction in Men with Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia and Erectile Dysfunction: Results from a Randomized,Placebo‐ and Tamsulosin-Controlled, 12-Week Double-Blind Study

IntroductionTadalafil, a long‐acting phosphodiesterase type 5 inhibitor, is approved for treating signs and symptoms of benign prostatic hyperplasia (BPH) and erectile dysfunction (ED); tamsulosin, an alpha‐blocker, is approved for treating signs and symptoms of BPH.AimTo determine the effects of tadalafil or tamsulosin on sexual function, including ejaculation and orgasm, satisfaction, and erectile function, in sexually active men with ED and lower urinary tract symptoms suggestive of BPH (LUTS/BPH).MethodsA randomized, double‐blind, placebo‐controlled study of tadalafil 5 mg once daily for 12 weeks in men with LUTS/BPH; tamsulosin 0.4 mg once daily was an active control.Main Outcome MeasuresThe International Index of Erectile Function (IIEF) questionnaire was administered at baseline and 4, 8, and 12 weeks. Analysis of orgasm and ejaculation was post hoc based on the IIEF‐Orgasmic Function (OF) domain (IIEF‐Q9 [ejaculatory frequency] and Q10 [orgasmic frequency]). Other measures included IIEF‐Intercourse Satisfaction (IS), Overall Satisfaction (OS), and Erectile Function (EF) domains. Changes from baseline to 12 weeks (or last observation) vs. placebo were analyzed using analysis of covariance. Higher IIEF scores indicate better functioning.ResultsOf 511 study participants, 310 (60.7%) had ED and were sexually active. The IIEF‐OF increased significantly through 12 weeks with tadalafil vs. placebo (P = 0.048), as did IIEF‐Q9 (P = 0.045) but not IIEF‐Q10 (P = 0.100). Compared with placebo, IIEF‐OF, Q9, and Q10 decreased significantly with tamsulosin (all P < 0.05). The IIEF‐IS and OS increased significantly at end point with tadalafil (both P < 0.001); for tamsulosin, change was not significant for IS, while OS decreased significantly (P = 0.009). The IIEF‐EF domain increased significantly vs. placebo with tadalafil (P < 0.001) but not tamsulosin (P = 0.699).ConclusionsTadalafil 5 mg once daily significantly improved ejaculation and orgasm, intercourse and overall satisfaction, and erectile function. Men receiving tamsulosin 0.4 mg once daily experienced a decrease in both ejaculatory/orgasmic frequency and overall satisfaction vs. placebo, with no significant effect on erectile function.     

Why Are Men Satisfied or Dissatisfied with Penile Implants? A Mixed Method Study on Satisfaction with Penile Prosthesis Implantation

IntroductionStudies have demonstrated high levels of satisfaction with penile prosthesis implantation (PPI). However, qualitative research exploring the experience of PPI through men's narratives is scarce.AimThe main goals were to analyze (i) the level of sexual satisfaction (quantitatively), and (ii) the reasons for satisfaction and/or dissatisfaction with PPI (qualitatively).MethodParticipants were 47 men with erectile dysfunction who underwent surgery between 2003 and 2012, placed by a single surgeon. Structured telephone interviews were carried out.Main Outcome MeasuresSatisfaction with PPI was a qualitative and quantitative measure assessed through the following four items: (i) “Would you repeat the PPI surgery?”; (ii) “Would you recommend the PPI surgery?”; (iii) “How satisfied are you with the PP?”; and (iv) “Could you explain the motives of your satisfaction/dissatisfaction?”.ResultsThe majority of men (79%) reported to be satisfied with PPI. Content analysis revealed four main themes for men's satisfaction with the PPI: (i) psychological factors were reported 54 times (n = 54) and included positive emotions, self-esteem, confidence, enhancement of male identity, major live change, and self-image; (ii) improvement of sexual function was reported 54 times (n = 54) and referred to achievement of vaginal penetration, increase of sexual desire, sexual satisfaction, penis size, and improvement of erectile function; (iii) relationship factors were reported 11 times (n = 11) and referred to relationship improvement and the possibility of giving pleasure to the partner; and (iv) improvement in urinary function (n = 3).ConclusionsThe level of satisfaction with the implementation of penile prostheses is very high, therefore constituting a treatment for erectile dysfunction with a positive impact on the experience of men at sexual, psychological and relational level.     

Erectile and Ejaculatory Dysfunction Associated with Use of Psychotropic Drugs: A Systematic Review

BackgroundSexual dysfunction may be a side effect of treatment with antipsychotics, antidepressants, and other psychotropic drugs.AimTo review the evidence concerning male sexual dysfunctions in patients taking psychotropic drugs to provide specific information to nonpsychiatric physicians for the management of these dysfunctions.MethodsA systematic search of Medline and Embase databases was performed up to October 15^th, 2020. We included randomized controlled trials comparing the effects of psychotropic drugs versus placebo or versus another drug of the same class, for at least 5 weeks.OutcomesWe considered studies whose male population could be evaluated separately from the female population and with a separate analysis of the different phases of the male sex cycle.ResultsWe included 41 studies in the final review. There was a significant association between sexual dysfunction and antidepressant drug therapy, compared to placebo (decreased libido OR 1.89, 95% CI:1.40 to 2.56, 22 series, 11 trials, 7706 participants; erectile dysfunction OR = 2.28, 95% CI: 1.31 to 3.97; 11 trials, 3008 participants; ejaculatory dysfunction OR = 7.31, 95% CI: 4.38 to 12.20,19 trials, 3973 participants). When the effects of selective serotonin reuptake inhibitors (SSRIs) were evaluated separately from those of serotonin/norepinephrine reuptake inhibitors (SNRIs), the use of SNRIs but not that of SSRIs was characterized by significantly higher odds of erectile dysfunction compared to placebo. Only limited data were found regarding the effects of antipsychotics on the phases of the male sexual cycle, as it was shown that aripiprazole and risperidone showed lower and higher odds for erectile or ejaculatory dysfunction, respectively, compared to other atypical antipsychotics.Clinical ImplicationsTreatment of male sexual dysfunction in patients taking psychotropics requires a basic knowledge of the different drugs that affect sexual function with different mechanisms.Strengths & LimitationsThe effects of psychotropic drugs on erectile function and ejaculation were evaluated separately. The great variability of the mechanisms of action makes it difficult to make comparisons between the effects of the different classes of psychotropic drugs.ConclusionsAdministration of antipsychotics affects male sexual function with different mechanisms, although the increase in prolactin values associated with the administration of first-generation antipsychotics and some atypical, such as risperidone, seems to play a primary role in determining male sexual dysfunction. Most antidepressants cause decreased libido, ejaculatory and erectile dysfunction, however the administration of SNRIs appears to be possibly associated with a specific risk of erectile dysfunction.Trinchieri M, Trinchieri M, Perletti G, et al. Erectile and Ejaculatory Dysfunction Associated with Use of Psychotropic Drugs: A Systematic Review. J Sex Med 2021;18:1354–1363.     

Sexual Satisfaction in Men Suffering From Erectile Dysfunction After Robot-Assisted Radical Prostatectomy for Prostate Cancer: An Observational Study

BackgroundPreservation of erectile function is an important postoperative quality of life concern for patients after robot-assisted radical prostatectomy (RARP) for prostate cancer. Although erectile function may recover, many men continue to suffer from erectile dysfunction (ED).AimThis study aims to determine whether satisfaction with sexual life improves in patients with ED after RARP and which factors are associated with satisfaction during follow-up.MethodsA review was carried out of a prospectively maintained database of patients with prostate cancer who underwent a RARP between 2006 and 2019. The “International Index of Erectile Function” questionnaire was used to describe ED (range 5-25), overall satisfaction with sexual life and sexual desire (range for both: 2-10). Patients with ED due to RARP were compared with those without ED after RARP. Mixed effect model was used to test differences in satisfaction over time. Mann-Whitney U tests and multiple logistic regression were used to assess factors associated with being satisfied at 24 and 36 months.OutcomesThe main outcomes of this study are the overall satisfaction with sexual life score over time and factors which influence sexual satisfaction.ResultsData of 2808 patients were reviewed. Patients whose erectile function was not known (n = 643) or who had ED at the baseline (n = 1281) were excluded. About 884 patients were included for analysis. They had an overall satisfaction score of 8.4. Patients with ED due to RARP had mean overall satisfaction scores of 4.8, 4.8, 4.9, and 4.6 at 6 mo, 12 mo, 24 mo, and 36 mo. These scores were significantly lower than those of patients without ED at every time point. In multiple regression analysis, higher overall satisfaction score at the baseline and higher sexual desire at 24 and 36 months' follow-up were associated with satisfaction with sexual life at 24 and 36 months’ follow-up. No association was found for erectile function.Clinical implicationsInterventions focusing on adjustment to the changes in sexual functioning might improve sexual satisfaction; especially for those men who continue to suffer from ED.Strengths & LimitationsStrengths of this study are the large number of patients, time of follow-up, and use of multiple validated questionnaires. Our results must be interpreted within the limits of retrospectively collected, observational data.ConclusionSatisfaction with sexual life in men with ED due to RARP may take a long time to improve. One could counsel patients that sexual satisfaction is based on individual baseline sexual satisfaction and the return of sexual desire after RARP.Albers LF, Tillier CN, van Muilekom HAM, et al. Sexual Satisfaction in Men Suffering From Erectile Dysfunction After Robot-Assisted Radical Prostatectomy for Prostate Cancer: An Observational Study. J Sex Med 2021;18:339–346.     

Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence,Motivation Analysis,and Surgical Outcomes

BackgroundPenile inversion vaginoplasty is the surgical gold standard for genital gender-affirmative surgery in transgender women. However, there is an increase of attention for gender-confirming vulvoplasty (GCV), in which no neovaginal cavity is created.AimTo describe underlying motives and surgical outcomes of GCV in transgender women.MethodsAll transgender women who underwent GCV were retrospectively identified from a departmental database. A retrospective chart study was conducted, recording underlying motives, demographics, perioperative complications, and reoperations.OutcomesUnderlying motives and perioperative complication rate.ResultsIn the period January 1990 to January 2020, 17 transgender women underwent GCV at our center. Most women reported that their motivation to undergo GCV was because they had no wish for postoperative neovaginal penetration (n = 10, 59%). This was due to a sexual preference toward women without the wish for neovaginal penetrative intercourse (n = 6, 35%) or due to a negative sexual experience in the past (n = 4, 24%). Some women desired vaginoplasty with neovaginal cavity creation but were ineligible for this because of their medical history (n = 4, 24%), for example, due to locoregional radiotherapy. The median clinical follow-up was 34 months (range 3-190). The postoperative course was uncomplicated in 11 (65%) women. Postoperative complications comprised the following: meatal stenosis (n = 2, for which surgical correction), remnant corpus spongiosum tissue (n = 1, for which surgical correction), minor wound dehiscence (n = 3, for which conservative management), and postoperative urinary tract infection (n = 1, successfully treated with oral antibiotics). One woman, who developed meatal stenosis, had a history of radiotherapy because of rectal carcinoma and needed 2 surgical procedures under general anesthesia to correct this. Information on self-reported satisfaction was available for 12 women. All were satisfied with the postoperative result and they graded their neovagina an 8.2 ± 0.9 out of 10.Clinical ImplicationsGCV may be added to the surgical repertoire of the gender surgeon. Transgender women with a desire for genital gender-affirmative surgery should be counseled on surgical options and its (dis)advantages.Strengths & LimitationsStrengths of this study comprise that it is from a high-volume center. A weakness of this study is the retrospective design. The absence of a self-reported outcome measure validated for the transgender persons is a well-known problem.ConclusionAn increase is observed in transgender women who opt for GCV; however, the absolute number undergoing this surgery remains small in our center. Postoperative complications do occur but are generally minor and treatable.van der Sluis WB, Steensma TD, Timmermans FW, et al. Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence, Motivation Analysis, and Surgical Outcomes. J Sex Med 2020;17:1566–1573.     

Sexual Motivators and Endorsement of Models Describing Sexual Response of Men Undergoing Androgen Deprivation Therapy for Advanced Prostate Cancer

BackgroundAndrogen deprivation therapy (ADT) administered against metastatic prostate cancer has significant side effects including sexual dysfunction.AimTo assess sexual interest and motivators for sex during ADT and to find out what model of sexuality best describes the sexual experience for men during this treatment.MethodsA questionnaire was mailed to patients who had received ADT for ≥6 months. Patients were asked to choose all relevant entities from a list of sexual motivators and between models of sexuality described by Masters and Johnson (excitement and physical experiences), Kaplan (sexual desire), and Basson (intimacy and closeness to partner). Erectile function was assessed by the Erection Hardness Scale, and sexual satisfaction was measured on a scale from 0 to 10.OutcomesSexual activity, erectile function, sexual satisfaction, and motivators for sexual interest in the study subjects as well as the proportion of participants who endorsed either of the 3 models of sexuality.ResultsA total of 173 men were invited, and 76 returned the questionnaires (44%). The median age was 76 (range 69–80) years, and the median duration of ADT was 30 months. A total of 62 men had been sexually active before ADT, and of these, 2 were still active. Another 29 were interested in sexual activity. 3 men endorsed the Masters and Johnson model, whereas the remaining participants did not endorse any of the models. The motivators for sexual interest were feeling an emotional connection to the partner (n = 16), sexual desire (n = 10), satisfaction of the partner (n = 8), fear that the partner would leave (n = 4), achieving orgasm (n = 3), and a desire to feel masculine (n = 1). No one was interested in sexual activity to reduce stress or to maintain confidence. Only 1 patient had erections sufficient for penetrative intercourse, and the median sexual satisfaction for the entire group was 0 (interquartile range: 0–5).Clinical ImplicationsSexuality and sexual function should be addressed in men undergoing ADT.Strengths & LimitationsThe main strength of our study is that we are the first to explore both motivators for sexual activity and endorsement of sexual models in men undergoing ADT. The study is limited by the relatively low number of participants and the response rate of 44%.ConclusionADT is detrimental to sexual function. However, many patients maintain an interest in sexual activity, which does not fit our established models. Rather, factors such as keeping an emotional connection with a partner play a role.Fode M, Mosholt KS, Nielsen TK, et al. Sexual Motivators and Endorsement of Models Describing Sexual Response of Men Undergoing Androgen Deprivation Therapy for Advanced Prostate Cancer. J Sex Med 2020;17:1538–1543.     

Sexual Rehabilitation After Treatment for Prostate Cancer—Part 1: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015)

IntroductionSexual dysfunction is common in patients after radical prostatectomy (RP) for prostate cancer.AimTo provide the International Consultation for Sexual Medicine (ICSM) 2015 recommendations concerning prevention and management strategies for post-RP erectile function impairment in terms of preoperative patient characteristics and intraoperative factors that could influence erectile function recovery.MethodsA literature search was performed using Google and PubMed databases for English-language original and review articles published up to August 2016.Main Outcome MeasuresLevels of evidence (LEs) and grades of recommendations (GRs) based on a thorough analysis of the literature and committee consensus.ResultsNine recommendations are provided by the ICSM 2015 committee on sexual rehabilitation after RP. Recommendation 1 states that clinicians should discuss the occurrence of postsurgical erectile dysfunction (temporary or permanent) with every candidate for RP (expert opinion, clinical principle). Recommendation 2 states that validated instruments for assessing erectile function recovery such as the International Index of Erectile Function and Expanded Prostate Cancer Index Composite questionnaires are available to monitor EF recovery after RP (LE = 1, GR = A). Recommendation 3 states there is insufficient evidence that a specific surgical technique (open vs laparoscopic vs robot-assisted radical prostatectomy) promotes better results in postoperative EF recovery (LE = 2, GR = C). Recommendation 4 states that recognized predictors of EF recovery include but are not limited to younger age, preoperative EF, and bilateral nerve-sparing surgery (LE = 2, GR = B). Recommendation 5 states that patients should be informed about key elements of the pathophysiology of postoperative erectile dysfunction, such as nerve injury and cavernous venous leak (expert opinion, clinical principle).ConclusionsThis article discusses Recommendations 1 to 5 of the ICSM 2015 committee on sexual rehabilitation after RP.Salonia A, Adaikan G, Buvat J, et al. Sexual Rehabilitation After Treatment for Prostate Cancer—Part 1: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017;14:285–296.     

Sexual Dysfunction and Satisfaction in Kidney Transplant Patients

Introduction10% of the world’s population suffers from chronic kidney disease. Kidney transplants provide an improvement in the quality of life of those patients. Sexual dysfunction is common after kidney transplantation, and its etiology is presumed to be multifactorial. It has a negative impact on sexual satisfaction and health-related quality-of-life. The integration of a new organ into the body can imply an adjustment of body image, which may eventually have a negative influence on intimacy and sexual behaviors.AimTo evaluate male sexual function, sexual satisfaction, and body image satisfaction among a convenience sample of patients who have had a kidney transplant.MethodsThis is a cross-sectional study that included 460 patients, from a single healthcare center, who had undergone a kidney transplant procedure >4 weeks ago. A total of 112 respondents (mean = 55.5 years, SD = 11.4) answered the questionnaires properly.Main Outcome MeasuresAll recruited patients answered a self-reported sociodemographic questionnaire, in addition to the International Index of Erectile function, the New Scale of Sexual Satisfaction, the Brief Symptom Inventory, and the Body Image Scale.ResultsA correlation was found between sexual function and sexual satisfaction (r = 0.598, P < .001, n = 112), as well as between body image satisfaction and sexual function (r = −0.193, P = .042, n = 112). The length of time after a kidney transplant (≤ or >36 months) was not associated with a difference in sexual functioning or sexual satisfaction.Clinical ImplicationsThis study showed the obvious implications of sexual function on sexual satisfaction, which should alert healthcare professionals to the importance of identifying and managing sexual dysfunction in patients with chronic kidney disease, to optimize their global and sexual health satisfaction.Strength & LimitationsThis study identified a high prevalence of sexual dysfunction among kidney transplant recipients. This should reinforce the need for the medical community to evaluate the quality-of-life domains of patients with chronic disease. There is still a lack of information concerning any longitudinal evaluation of kidney transplant patients’ sexual function and the effects that this surgery has on sexuality.ConclusionsThis study corroborated the severe effects that kidney transplant patients often report regarding their sexuality. Among the patients who participated in the study, sexual function proved to be relevant in relation to sexual satisfaction.Mota RL, Fonseca R, Santos JC, et al. Sexual Dysfunction and Satisfaction in Kidney Transplant Patients. J Sex Med 2019;16:1018–1028.     

High Grade Gynecomastia: Surgical Correction and Potential Impact on Erectile Function

IntroductionGynecomastia denotes benign enlargement of the male breast. It is a common belief that gynecomastia is stigmatizing and may frequently cause social embarrassment and psychological stress. It is possible that this may reflect on erectile function of the afflicted. High grade gynecomastia requires radical breast tissue excision and skin reduction ending up in aesthetically unappealing scars.AimThe purpose of this study is to evaluate the reduction mammaplasty using no vertical scar technique in males with high grade gynecomastia; as regards technical refinements and outcome in the hope of providing a cosmetically appealing solution to this condition. This study also reports on the effect of high grade gynecomastia on erectile function, as well as the effect of surgery.MethodsFifteen male patients with gynecomastia underwent breast reduction using the “no vertical scar reduction mammaplasty.” Erectile function was evaluated before and after surgery.Main Outcome MeasuresSurgical outcome and erectile function.ResultsAll patients but one were satisfied with the outcome. Complications were minimal and manageable. Eleven out of 15 patients had a preoperative International Index of Erectile Function (IIEF) score less than 20 denoting erectile dysfunction. All but one (n = 10) showed improvement in their IIEF score following surgery. The difference between pre-operative IIEF (average 17.8) and postoperative (average 23.5) was statistically significant.ConclusionsThe “no vertical scar reduction mammaplasty” is a reliable technique in cases with gynecomastia and significant ptosis. It has the added benefits of avoiding the vertical scar, hiding the transverse scar in the shadow of the inferior aspect of the breast, with minimal complications. Gynecomastia as a condition causing a feminized outlook may have a negative impact on self confidence and body image. We suggest that this may have a potential negative effect on erectile function, that can be improved by adequate surgical correction. El Noamani S, Thabet AM, Enab AA, Shaeer O, and El-Sadat A. High grade gynecomastia: Surgical correction and potential impact on erectile function.     

Preservation of sexual function with the prostatic urethral lift: a novel treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia

IntroductionWe investigated the prostatic urethral lift, a novel, minimally invasive treatment for symptomatic lower urinary tract complaints presumed to be from benign prostatic hyperplasia (BPH), which aims to mechanically open the prostatic urethra without ablation or resection. We hypothesized that this novel approach would not degrade erectile or ejaculatory function.AimsWe sought to determine the effect of the prostatic urethral lift procedure on erectile and ejaculatory function.MethodsThe procedure was performed on 64 men in Australia with an average age of 66.9 years and an average duration of lower urinary tract symptom (LUTS) of 4.7 years. Primary inclusion criteria included International Prostate Symptom Score (IPSS) > 13, Qmax of 5–12 mL/second, and prostate specific antigen (PSA) < 10 ng/mL. Baseline IPSS was 22.9 ± 5.4 (N = 64). There were no inclusion criteria for sexual function. Baseline Sexual Health Inventory for Men (SHIM) was 11.7 ± 8.6 (N = 58); baseline Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ‐EjD) function score was 9.0 ± 3.7 (N = 46); and lack of sexual activity or unwillingness to answer sexual function questionnaires accounted for the reduced sample size in the sexual function instruments. Implants were placed to separate encroaching lateral prostatic lobes.Main Outcome MeasuresPatients were evaluated at 6 weeks and 3, 6, and 12 months postprocedure via the SHIM and MSHQ‐EjD instruments.ResultsThere was no evidence of degradation in sexual function after treatment for LUTS with the prostatic urethral lift procedure. Erectile function, as measured by SHIM, was slightly increased at all time points as compared with baseline. No patient reported retrograde ejaculation at any follow‐up visit.Conclusions.We demonstrated significant improvement in LUTS with no evidence of degradation in erectile or ejaculatory function after treatment with the prostatic urethral lift procedure. This procedure warrants further study as a new option for patients underserved by current treatments for LUTS/BPH. Woo HH, Bolton DM, Laborde E, Jack G, Chin PT, Rashid P, Thavaseelan J, and McVary KT. Preservation of sexual function with the prostatic urethral lift: A novel treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia. J Sex Med 2012;9:568–575.     

Is Mode of Delivery Associated With Sexual Response? A Pilot Study of Genital and Subjective Sexual Arousal in Primiparous Women With Vaginal or Cesarean Section Births

IntroductionAlthough postpartum sexual concerns are common, limited data exist on postpartum sexual response. Furthermore, the physiological process of vaginal birth may negatively impact genital response compared with unlabored cesarean section (C-section), but this hypothesis has yet to be tested.AimTo (i) compare genital and subjective sexual response and sexual concordance by mode of delivery with inclusion of a control group, (ii) compare groups on self-reported sexual function over the past month, (iii) examine the relationship between laboratory measurement of sexual response and self-reported sexual function, and (iv) investigate association between obstetrical factors and breastfeeding and between sexual response and self-reported sexual function.Methods3 groups of cisgender women were recruited from the community: primiparous women who delivered via vaginal birth within the past 2 years (VB group; n = 16), primiparous women who delivered via unlabored C-section within the past 2 years (CS group, n = 15), and age-matched nulliparous women (NP group, n = 18). Laser Doppler imaging was used to assess genital response while participants watched a neutral and erotic film.Main Outcome MeasuresThe main outcome measures were change in flux units from neural to erotic video as a measure of genital response, subjective sexual arousal rated continuously throughout films, perceived genital response rated after films, and Female Sexual Function Index (FSFI).ResultsWomen in the VB group had significantly lower change in flux units than women in the CS (P = .005, d = 1.39) and NP (P < .001, d = 1.80) groups. Groups did not differ on their subjective indices of sexual response or in sexual concordance. Women in both postpartum groups reported lower FSFI scores than women in the NP group. No relationship was determined between FSFI scores and sexual response in the laboratory. Results suggested that genital trauma and breastfeeding may negatively impact FSFI scores, but they were not related to genital response or subjective sexual arousal as measured in the laboratory.Clinical ImplicationsResults underscore the importance of balancing objective and subjective indices of sexual response and function, especially considering the biopsychosocial nature of postpartum sexuality.Strengths & LimitationsThe present study is the first to apply modern sexual psychophysiological methodology to the study of postpartum sexuality. Cross-sectional methodology limits the ability to make causal inferences, and the strict inclusion criteria limits generalizability.ConclusionPhysiological changes as a result of labor and delivery may have a detrimental impact on genital response; however, these physiological differences may not impact women's subjective experience of postpartum sexuality.Cappell J, Bouchard KN, Chamberlain SM, et al. Is Mode of Delivery Associated With Sexual Response? A Pilot Study of Genital and Subjective Sexual Arousal in Primiparous Women With Vaginal or Cesarean Section Births. J Sex Med 2020; 17:257–272.     

The Female Factor: Predicting Compliance with a Post-Prostatectomy Erectile Preservation Program

IntroductionEarly post-radical prostatectomy (RP) erectile preservation (EP) therapy may be critical to preserve erections after surgery.AimTo assess if pre-RP female sexual function predicts of partner compliance with an EP protocol.Main Outcome MeasuresCompliance, defined as use of localized penile EP therapy (intracavernosal injections [ICIs], vacuum erection device [VED], or alprostadil) at 3 and 6 months after RP.MethodsRecords of patients enrolled in our EP program from April 2007 to June 2008 were reviewed. Before surgery, patients completed the Sexual Health Inventory for Men (SHIM) and their female partners completed the Female Sexual Function Index (FSFI) questionnaire. Prior to surgery, patients were advised to take sildenafil 25 mg every nightly and use a 250-µg alprostadil suppository three times/week. At 1 month, additional daily use of a VED was encouraged. All patients unable to achieve erections sufficient for penetration were encouraged to initiate ICI of Trimix (phentolamine, papaverine, and PGE1) twice weekly after 3 months following surgery. Data were analyzed using binary logistic regression analysis holding all input variables constant.ResultsTwenty-nine patients had preoperative SHIM > 7 and pre-RP partner FSFI data available. After a 4-week follow-up, compliance with alprostadil suppository declined and both ICI and VED usage increased. At 6 months, six (25.0%) patients had return of natural erectile function and 22 (91.7%) were achieving assisted erections. Higher preoperative partner FSFI scores were associated with greater compliance to the localized penile therapy component of our EP protocol (risk ratio 3.8, P = 0.05).ConclusionsPreoperative female sexual function correlated with greater partner compliance with the localized component of our EP protocol. Consideration of a female partner's preoperative sexual function in predicting patient erectile function recovery after RP is warranted. Future studies are necessary to determine the clinical significance of this factor. Moskovic DJ, Mohamed O, Sathyamoorthy K, Miles BJ, Link RE, Lipshultz LI, and Khera M. The female factor: Predicting compliance with a post-prostatectomy erectile preservation program.     

Sexual Sensation Seeking,Sexual Compulsivity,and Gender Identity and Its Relationship With Sexual Functioning in a Population Sample of Men and Women

IntroductionDespite awareness of the importance of psycho-affective factors in the development of sexual problems, there is a lack of studies exploring the relation of sexual sensation seeking (SSS) and sexual compulsivity (SC) to sexual functioning. Because sex differences in SSS and SC have been reported, gender identity (GI; an individual’s own experience of his or her gender that is unrelated to the actual biological sex) might act as a moderator in this relation.AimTo understand the role of SSS and SC for men and women's sexual functioning and to explore whether these potential associations are moderated by GI.MethodsA population-based cross-sectional online survey targeted 279 individuals (69.2% women, 30.8% men; mean age = 32 years). Validated questionnaires, including the Sexual Sensation Seeking Scale, the Sexual Compulsivity Scale, the Female Sexual Function Index, the Premature Ejaculation Diagnostic Tool, and the International Index of Erectile Function, were applied.Main Outcome MeasuresVariations in SSS and SC and their association with sexual functioning were investigated using Spearman rank correlation. Moderation analyses were conducted using regression models in which the interaction terms between SSS and GI and between SCS and GI as predictors of sexual functioning were included.ResultsA statistically significant correlation between SSS and SC could be detected in men and women (r = 0.41 and 0.33, respectively; P < .001 for the two comparisons). In women, higher levels of SSS were associated with higher levels of desire, arousal, lubrication, and orgasm and less sexual pain (P < .05 for all comparisons). No moderating effect of GI could be detected. In men, GI was a significant moderator in the relation between SC and erectile function (β = 0.47; P < .001) and between SSS and erectile and ejaculatory function (β = −0.41 and 0.30; P < .001 for the two comparisons).ConclusionThe present study is the first to show a link between SSS and SC and sexual functioning. The results might have important clinical implications and can provide useful information for programs aimed at sexual health enhancement.     

Opioid Use After Laparoscopic Surgery for Endometriosis and Pelvic Pain

Study ObjectiveThe primary objective was to quantify postoperative opioid use after laparoscopic surgery for endometriosis or pelvic pain. The secondary objective was to identify patient characteristics associated with greater postoperative opioid requirements.DesignProspective, survey-based study in which subjects completed 1 preoperative and 7 postoperative surveys within 28 days of surgery regarding medication usage and pain control.SettingTertiary care, academic center.PatientsA total of 100 women with endometriosis or pelvic pain.InterventionsLaparoscopic same-day discharge surgery by fellowship-trained minimally invasive gynecologists.Measurements and Main ResultsA total of 100 patients were recruited and 8 excluded, for a final sample size of 92 patients. All patients completed the preoperative survey. Postoperative response rates ranged from 70.7% to 80%. The mean number of pills (5 mg oxycodone tablets) taken by day 28 was 6.8. The average number of pills prescribed was 10.2, with a minimum of 4 (n = 1) and maximum of 20 (n = 3). Previous laparoscopy for pelvic pain was associated with a significant increase in postoperative narcotic use (8.2 vs 5.6; p = .044). Hysterectomy was the only surgical procedure associated with a significant increase in postoperative narcotic use (9.7 vs 5.4; p = .013). There were no difference in number of pills taken by presence of deep endometriosis or pathology-confirmed endometriosis (all p >.36). There was a trend of greater opioid use in patients with diagnoses of self-reported chronic pelvic pain, anxiety, and depression (7.9 vs 5.7, p = .051; 7.7 vs 5.2, p = .155; 8.1 vs 5.6, p = .118).ConclusionMost patients undergoing laparoscopic surgery for endometriosis and pelvic pain had a lower postoperative opioid requirement than prescribed, suggesting surgeons can prescribe fewer postoperative narcotics in this population. Patients with a previous surgery for pelvic pain, self-reported chronic pelvic pain syndrome, anxiety, and depression may represent a subset of patients with increased postoperative opioid requirements.     

Creation and Psychometric Validation of the Sexual Minorities and Prostate Cancer Scale (SMACS) in Sexual Minority Patients-The Restore-2 Study

BackgroundExisting measures of sexual functioning in prostate cancer survivors focus primarily on erectile function and do not adequately measure the experiences of sexual minority men.AimTo develop and psychometrically evaluate a new scale to measure sexual functioning among sexual minority men with prostate cancer.MethodsSexual minority prostate cancer patients (n = 401) completed an online battery of urinary and sexual functioning tests in 2019, including a new 37-item instrument about their sexual functioning post-treatment for prostate cancer.OutcomesWe used confirmatory factor analysis to determine the construct validity of a new scale including five subscales: a four-factor model for all participants (n = 401) evaluated Sexual Satisfaction, Sexual Confidence, Frequency of Sexual Problems, and Urinary Incontinence in Sex. A single-factor model completed only by participants who had attempted or desired receptive anal sex (n = 255) was evaluated in the fifth subscale: Problematic Receptive Anal Sex. To evaluate criterion validity, we calculated the intercorrelations between each Sexual Minorities and Prostate Cancer Scale (SMACS) subscale and four related scales: the Expanded Prostate Cancer Index Composite-50 (EPIC), the Functional Assessment of Cancer Therapy-Prostate, the Brief Symptom Inventory-18, and the International Consultation on incontinence questionnaire. Cronbach's alphas were calculated to measure internal consistency (ie, reliability).ResultsCronbach's alpha values ranged from 0.64 to 0.89. Loadings (0.479–0.926) and model fit indices were strong (Root Mean Square Error of Approximation: 0.085, Standardized root mean squared residual: 0.063, comparative fit index: 0.927, Tucker-Lewis Index: 0.907). For criterion validity, Sexual Satisfaction, Sexual Confidence, and Frequency of Sexual Problems were moderately correlated with EPIC function and bother scores (r = 0.50–0.72) and Urinary incontinence in sex correlated moderately with EPIC Urinary Function and International Consultation on incontinence questionnaire scores (0.45–0.56).Clinical ImplicationsThe SMACS can be used by clinicians and researchers to comprehensively measure sexual functioning in sexual minority men, in conjunction with existing scales.Strengths and limitationsThis new scale is validated in a large, geographically diverse cohort of sexual minority cancer survivors and fills an important gap in existing measures of sexual functioning. Limitations include a lack of a validation sample.ConclusionThe SMACS is a valid and reliable new scale that measures sexual minority men's experience of urinary incontinence in sex, problematic receptive anal sex, and sexual distress.Polter EJ, Kohli N, Rosser BRS, et al. Creation and Psychometric Validation of the Sexual Minorities and Prostate Cancer Scale (SMACS) in Sexual Minority Patients-The Restore-2 Study. J Sex Med 2022;19:529–540.     

Sexual Rehabilitation After Treatment For Prostate Cancer—Part 2: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015)

IntroductionSexual dysfunction is common in patients after radical prostatectomy (RP) for prostate cancer.AimTo provide the International Consultation for Sexual Medicine (ICSM) 2015 recommendations concerning management strategies for post-RP erectile function impairment and to analyze post-RP sexual dysfunction other than erectile dysfunction.MethodsA literature search was performed using Google and PubMed database for English-language original and review articles published up to August 2016.Main Outcome MeasuresLevels of evidence (LEs) and grades of recommendations (GRs) are provided based on a thorough analysis of the literature and committee consensus.ResultsNine recommendations are provided by the ICSM 2015 committee on sexual rehabilitation after RP. Recommendation 6 states that the recovery of postoperative erectile function can take several years (LE = 2, GR = C). Recommendation 7 states there are conflicting data as to whether penile rehabilitation with phosphodiesterase type 5 inhibitors improves recovery of spontaneous erections (LE = 1, GR = A). Recommendation 8 states that the data are inadequate to support any specific regimen as optimal for penile rehabilitation (LE = 3, GR = C). Recommendation 9 states that men undergoing RP (any technique) are at risk of sexual changes other than erectile dysfunction, including decreased libido, changes in orgasm, anejaculation, Peyronie-like disease, and changes in penile size (LE = 2, GR = B).ConclusionThis article discusses Recommendations 6 to 9 of the ICSM 2015 committee on sexual rehabilitation after RP.Salonia A, Adaikan G, Buvat J, et al. Sexual Rehabilitation After Treatment For Prostate Cancer–Part 2: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017;14:297–315.