The Self‐Estimation Index of Erectile Function‐No Sexual Intercourse (SIEF‐NS): A Multidimensional Scale to Assess Erectile Dysfunction in the Absence of Sexual Intercourse

IntroductionA new concept of Erectile Dysfunction with No Sexual Intercourse (ED‐NS) is proposed to acknowledge the subpopulation of patients who are unable to achieve or sustain an erection in the absence of sexual intercourse. Since the commonly used ED diagnostic tool, International Index of Erectile Function Questionnaire is not able to adequately assess the erectile function (EF) in the absence of intercourse, the researchers developed a new 10‐item questionnaire to better evaluate the EF in this special patient subpopulation: Self‐Estimation Index of Erectile Function‐No Sexual Intercourse (SIEF‐NS).AimTo validate the reliability, sensitivity and specificity of SIEF‐NS.MethodsThe study was carried out in three phases. Phase one applied component analysis to 126 ED‐NS patients to search for the primary factors and Cronbach's alpha standardized statistic values for SIEF‐NS. Phase two applied discriminant analysis to participants' (212 ED‐NS patients and 193 normal controls) scores on each question item, each factor and the overall 10‐item questionnaire. Phase three investigated SIEF‐NS's capability of evaluating treatment effect on 41 ED‐NS patients.Main Outcome MeasuresReliability, sensitivity and specificity were defined and used to evaluate the performance of SIEF‐NS.ResultsEF by autonomic response (factor 1) and EF with potential sexual partners (factor 2) are the two primary factors with eigenvalues greater than 1.0. High degree of internal consistency was observed for the two factors and the 10‐item questionnaire (Cronbach's alpha values: 0.871 for 10 items, 0.84 for factor 1, and 0.823 for factor 2). SIEF‐NS demonstrated adequate construct validity, high sensitivity (0.925) and specificity (0.829) to diagnose ED‐NS. The EF scores of ED‐NS patients post treatment showed significant improvement (P < 0.05).ConclusionSIEF‐NS can be used to identify ED‐NS patients and detect treatment‐related EF changes in ED‐NS patients. Yuan Y, Zhang Z, Gao B, Peng J, Cui W, Song W, Xin Z, and Guo Y. The Self‐Estimation Index of Erectile Function‐No Sexual Intercourse (SIEF‐NS): A multidimensional scale to assess erectile dysfunction in the absence of sexual intercourse. J Sex Med 2014;11:1201–1207.     

More than Sexual Function: Predictors of Sexual Satisfaction in a Sample of Women Age 40–70

IntroductionThe literature provides a complex picture of sexual satisfaction and its predictors. To date, studies have provided a list of predictors of sexual satisfaction, including relational and psychological factors, but very little information is available on the direct effects of these predictors in midlife women, independently from the effects of sexual function on sexual satisfaction.AimThe main aim of this article is to provide empirical evidence on factors that predict sexual satisfaction in middle-aged women above and beyond the explanation provided by sexual function.Main Outcome MeasuresThe three items on sexual satisfaction from the Female Sexual Functioning Index were used to assess different aspects of sexual satisfaction.MethodsA sample of 86 women age 40–70 years recruited from a clinic completed a battery of questionnaires on sexual satisfaction and potential predictors, including, psychological well-being, body attitudes, menopausal symptoms, and relationship adjustment.ResultsRelationship adjustment, psychological well-being, and menopausal symptoms predicted sexual satisfaction above and beyond sexual functioning. Body attitudes did not predict sexual satisfaction in midlife women.ConclusionsData supported the hypothesis that sexual satisfaction is only partially explained by sexual function. Other factors involved in women's lives, such as psychological well-being, relationship adjustment, and, to a lesser extent, menopausal symptoms, affect sexual satisfaction independently from sexual function. Dundon CM, and Rellini AH. More than sexual function: Predictors of sexual satisfaction in a sample of women age 40–70.     

Self‐Assessment of Genital Anatomy and Sexual Function within a Belgian,Dutch‐Speaking Female Population: A Validation Study

IntroductionData on self‐perceived genital anatomy and sensitivity should be part of the long‐term follow‐up of genitoplasty procedures. However, no normative data, based on a large sample, exist to date.AimsValidation of the Self‐Assessment of Genital Anatomy and Sexual Function, Female version (SAGAS‐F) questionnaire within a Belgian, Dutch‐speaking female population.MethodsSeven hundred forty‐nine women with no history of genital surgery (aged 18–69 years, median 25 years) completed an Internet‐based survey of whom 21 women underwent a gynecological examination as to correlate self‐reported genital sensitivity assessed in an experimental setting.Main Outcome MeasuresThe SAGAS‐F enables women to rate the sexual pleasure, discomfort, intensity of orgasm, and effort required for achieving orgasm in specified areas around the clitoris and within the vagina, as well as genital appearance. The latter was similarly evaluated by an experienced gynecologist, and women were asked to functionally rate the anatomical areas pointed out with a vaginal swab.ResultsSexual pleasure and orgasm were strongest, and effort to attain orgasm and discomfort was lowest when stimulating the clitoris and sides of the clitoris (P < 0.05). Vaginal sensitivity increased with increasing vaginal depth, but overall orgasmic sensitivity was lower as compared with the clitoris. Functional scores on the SAGAS‐F and during gynecological examination corresponded highly on most anatomical areas (P < 0.05). Gynecologist's ratings corresponded highly with the women's ratings for vaginal size (90%) but not for clitoral size (48%).ConclusionsReplication of the original pilot study results support the validity of the questionnaire. The SAGAS‐F discriminates reasonably well between various genital areas in terms of erotic sensitivity. The clitoris itself appeared to be the most sensitive, consistent with maximum nerve density in this area. Surgery to the clitoris could disrupt neurological pathways and compromise erotic sensation and pleasure. Bronselaer G, Callens N, De Sutter P, De Cuypere G, T'Sjoen G, Cools M, and Hoebeke P. Self‐assessment of genital anatomy and sexual function in women (SAGAS‐F): Validation within a Belgian, Dutch‐speaking population. J Sex Med 2013;10:3006–3018.     

The Development and Validation of the Male Genital Self‐Image Scale: Results from a Nationally Representative Probability Sample of Men in the United States

IntroductionNumerous factors may affect men's sexual experiences, including their health status, past trauma or abuse, medication use, relationships, mood, anxiety, and body image. Little research has assessed the influence of men's genital self‐image on their sexual function or behaviors and none has done so in a nationally representative sample.AimsThe purpose of this study was to, in a nationally representative probability sample of men ages 18 to 60, assess the reliability and validity of the Male Genital Self‐Image Scale (MGSIS), and to examine the relationship between scores on the MGSIS and men's scores on the International Index of Erectile Function (IIEF).MethodsThe MGSIS was developed in two stages. Phase One involved a review of the literature and an analysis of cross‐sectional survey data. Phase Two involved an administration of the scale items to a nationally representative sample of men in the United States ages 18 to 60.Main Outcome MeasuresMeasures include demographic items, the IIEF, and the MGSIS.ResultsOverall, most men felt positively about their genitals. However, 24.6% of men expressed some discomfort letting a healthcare provider examine their genitals and about 20% reported dissatisfaction with their genital size. The MGSIS was found to be reliable and valid, with the MGSIS‐5 (consisting of five items) being the best fit to the data.ConclusionThe MGSIS was found to be a reliable and valid measure. In addition, men's scores on the MGSIS‐5 were found to be positively related to men's scores on the IIEF.     

Psychometric Testing of the Modified Breastfeeding Self‐Efficacy Scale (Short Form) Among Mothers of Ill or Preterm Infants

ObjectiveTo psychometrically assess the modified Breastfeeding Self‐Efficacy Scale–Short Form (BSES‐SF) among mothers of ill or preterm infants.DesignMethodological study.SettingThree neonatal intensive care units (NICUs) located in two hospitals in a central Canadian city.ParticipantsOne hundred forty‐four (144) breastfeeding mothers of ill or preterm infants.MethodsMothers completed the BSES‐SF modified for mothers of ill or preterm infants, the Hill and Humenick (H&H) Lactation Scale, and demographic questions.ResultsThe Cronbach's alpha coefficient for internal consistency for the BSES‐SF revised for mothers of ill or preterm infants was 0.88. Construct validity was assessed using comparison of contrasted groups (mothers who continued to breastfeed and those who discontinued) and correlation with the construct of maternal perceptions of insufficient milk supply. Support for predictive validity was demonstrated through significant mean differences between mothers who were breastfeeding (M = 83.44, SD = 8.23) and those who discontinued breastfeeding and breast pumping (M = 75.51, SD = 10.08) at 6‐weeks post–infant hospital discharge.ConclusionDemographic response patterns suggest that the modified BSES‐SF is a unique tool to identify breastfeeding mothers of ill or preterm infants at risk of prematurely discontinuing. This study provides evidence that the modified BSES‐SF may be a valid and reliable measure of breastfeeding self‐efficacy among a sample of mothers of ill or preterm infants.     

The Impact of Mid‐Urethral Slings for the Treatment of Urodynamic Stress Incontinence on Female Sexual Function: A Multicenter Prospective Study

IntroductionUrinary incontinence is a common condition that negatively impacts on female sexuality (FS).AimTo evaluate FS before and after a mid‐urethral sling (MUS) procedure using the Female Sexual Function Index (FSFI). We included women that were both sexually and nonsexually active at baseline.MethodsOne hundred fifty‐seven women complaining of urodynamic stress incontinence underwent a MUS procedure and were enrolled in the study. All patients answered the Italian translation of FSFI, before and 12 months after surgery. To understand the real impact of the MUS on female sexual function, for the first time in the literature, we also monitored and included in the final analysis all the women who are nonsexually active at baseline. We evaluated the prevalence of female sexual dysfunction according to the FSFI cutoff point (26.55).Main Outcome MeasuresFSFI total score, pads use, and stress test presurgery and postsurgery.ResultsOne hundred thirty‐three patients completed the study protocol: 105 out of 133 underwent to a trans‐obturator procedure, while 28 out of 133 had a retropubic procedure. After the 12‐month follow up, 115 out of 133 patients (86%) were dry, 10 improved their symptoms, and the remaining 8 were unchanged. Seventy‐nine out of 133 (59%) patients reported an active sexual life before surgery. Fifty‐four (41%) reported they were not sexually active before surgery. Twelve months after surgery, 22 out of 54 nonsexually active women (40%) reestablished sexual activity, whereas only 6 out of 79 (7.5%) patients, sexually active at baseline, were not sexually active 1 year after surgery (P < 0.05). After adjusting for multiple testing, only age, menopause, and storage symptoms remained significantly correlated with the FSFI total score postsurgery as independent variables.ConclusionsOur data showed that after a MUS procedure, female sexual function improves. We also found that a very relevant percentage of nonsexually active women reported renewed sexual activity after MUS. Filocamo MT, Serati M, Frumenzio E, Li Marzi V, Cattoni E, Champagne A, Salvatore S, Nicita G, and Costantini E. The impact of mid‐urethral slings for the treatment of urodynamic stress incontinence on female sexual function: A multicenter prospective study. J Sex Med 2011;8:2002–2008.     

ORIGINAL RESEARCH—OUTCOMES ASSESSMENT: Development and Validation of a 6-Item Version of the Female Sexual Function Index (FSFI) as a Diagnostic Tool for Female Sexual Dysfunction

IntroductionA limiting step in the evaluation of female sexual dysfunction (FSD) is the availability of a rapid screening procedure. Often, practitioners avoid investigating sexual symptoms due to concerns of insufficient time or lack of proper tools to address FSD.AimThe purpose of this study was to prepare and validate an abridged form of the most popular psychometric diagnostic test (Female Sexual Function Index, FSFI-19) to provide a fast screener of FSD for easy use in outpatient visits, epidemiological studies, and assessment of treatment response.MethodsWe interviewed and administered the FSFI-19 to 200 women attending outpatient clinics for sexual and reproductive medicine. Forty women were excluded because they had no sexual activity or failed to attend the retest visit. Patients were evaluated on two subsequent visits to validate the abridged form of the questionnaire. Overall, 105 were found to suffer from a FSD.Main Outcome MeasureWe assessed, individually, the sensibility and sensitivity of all questions of the full-length FSFI. We then estimated the performance of each item with respect to the specific sexual domain they address. By selecting the best combination of performing items in each domain, we built an abridged, 6-item form of the FSFI.ResultsThe Receiver Operating Characteristic curves of the FSFI-6 showed that women who scored ≤19 were classified as having FSD. Using the cut-off of 19, the sensitivity and specificity of the test were, 0.93 and 0.94, respectively. Reliability, internal consistency, and stability on retest were also good.ConclusionsThe abridged FSFI-6 is a valuable tool for screening women that are likely to suffer from FSD. In six simple questions, taking no more than 3 minutes, a score of less than 19 indicates the need for further investigations, including the full-length FSFI-19 and a dedicated interview. In conclusion, this is a novel tool that can help any doctor to disclose FSD rapidly and efficiently. Isidori AM, Pozza C, Esposito K, Giugliano D, Morano S, Vignozzi L, Corona G, Lenzi A, and Jannini EA. Development and validation of a 6-item version of the Female Sexual Function Index (FSFI) as a diagnostic tool for female sexual dysfunction.     

Sexual Dysfunction Management and Expectations Assessment in Multiple Sclerosis—Female (SEA‐MS‐F): Creation and Validation of a Specific Questionnaire

IntroductionUntil now, no questionnaire has been developed to study specific expectations concerning sexual dysfunction management and the availability of information on sexuality in the female population affected by multiple sclerosis (MS). Understanding and meeting the patient's expectations is an issue of considerable importance in the evaluation of medical care.Aim and Main Outcome MeasureWe present the development and validation of a specific questionnaire designed for women with MS in order to assess their expectations in terms of sexual dysfunction management: the SEA‐MS‐F (Sexual Dysfunction Management and Expectations Assessment in Multiple Sclerosis—Female).MethodsThis questionnaire was created and validated by an expert panel, using the Delphi method. The psychometric evaluation was obtained with a sample of 40 female MS patients. Cronbach's alpha index and principal component analysis were used to measure the questionnaire's internal consistency.ResultsA consensus on the questionnaire was reached with the Delphi method. The SEA‐MS‐F is fully compliant with the criteria for psychometric validation among female MS patients, and its internal consistency is excellent (Cronbach's alpha 0.948).ConclusionThe SEA‐MS‐F appears to be a useful tool that could be used either in routine medical situations or in prospective studies of MS in order to ascertain women's expectations concerning the management of their sexual dysfunction. Bisseriex H, Guinet‐Lacoste A, Chevret‐Méasson M, Costa P, Sheikh Ismael S, Rousseau A, Amarenco G, and SEA‐MS‐F Group. Sexual Dysfunction Management and Expectations Assessment in Multiple Sclerosis—Female (SEA‐MS‐F): Creation and validation of a specific questionnaire. J Sex Med 2014;11:2955–2965.     

Sexual Function in the Late Postmenopause: A Decade of Follow‐Up in a Population‐Based Cohort of Australian Women

IntroductionThere is a paucity of longitudinal studies assessing sexual function of women in the late postmenopause.AimThis study aims to describe sexual function of women in the late postmenopause and to investigate change from early postmenopause.MethodsCross‐sectional analysis of 2012/13 and longitudinal analysis from 2002/04 of the population based, Australian cohort of the Women's Healthy Ageing Project, applying validated instruments: Short Personal Experience Questionnaire (SPEQ), Female Sexual Distress Scale (FSDS), Hospital Anxiety and Depression Scale, Geriatric Depression Scale, and California Verbal Learning Test.Main Outcome MeasuresSexual activity, SPEQ, and FSDS.ResultsTwo hundred thirty women responded (follow‐up rate 53%), mean age was 70 years (range 64–77), 49.8% were sexually active. FSDS scores showed more distress for sexually active women (8.3 vs. 3.2, P < 0.001). For 23 (23%) sexually active and for five (7%) inactive women, the diagnosis of female sexual dysfunction could be made. After adjustment, available partner (odds ratio [OR] 4.31, P < 0.001), no history of depression (OR 0.49, P = 0.036), moderate compared with no alcohol consumption (OR 2.43, P = 0.019), and better cognitive function score (OR1.09, P = 0.050) were significantly predictive for sexual activity. Compared with early postmenopause, 18% more women had ceased sexual activity. For women maintaining their sexual activity through to late postmenopause (n = 82), SPEQ and FSDS scores had not changed significantly, but frequency of sexual activity had decreased (P = 0.003) and partner difficulties had increased (P = 0.043). [Correction added on 10 July 2014, after first online publication: Mean age of respondents was added.]ConclusionsIn late postmenopause, half of the women were sexually active. Most important predictors were partner availability and no history of depression. However, being sexually active or having a partner were associated with higher levels of sexual distress. Compared with early postmenopause, sexual function scores had declined overall but were stable for women maintaining sexual activity. Further research into causes of sexual distress and reasons for sexual inactivity at this reproductive stage is warranted. Lonnèe‐Hoffmann RAM, Dennerstein L, Lehert P, and Szoeke C. Sexual function in the late postmenopause: A decade of follow‐up in a population‐based cohort of Australian women. J Sex Med 2014;11:2029–2038.     

Impact of a First Treatment with Phosphodiesterase Inhibitors on Men and Partners’ Quality of Sexual Life: Results of a Prospective Study in Primary Care

IntroductionPhosphodiesterase type 5 inhibitors (PDE5is) as oral treatment for erectile dysfunction (ED) facilitate the management of ED in primary care. Still, compliance is low and general practitioners (GPs) do not always feel confident with this pathology.AimThe aim of this paper is to evaluate the impact of a first treatment with PDE5i on the patient and his partner and the management of ED by GPs.MethodsThe Evaluation après traitement de la dyfonction erectile, du bien‐êtré émotionnel d'un patient en fonction de la rigidité de son érection survey was a longitudinal, observational French study with prospective collection of data from the GP, the patient, and his partner at baseline and after 3 months of treatment. GPs benefited from a short educational session before starting the survey.Main Outcome MeasuresThe main outcome measures are the Erection Hardness Score (EHS), Self‐Esteem and Relationship (SEAR) questionnaire, Index of Sexual Life (ISL), and Erectile Dysfunction Inventory of Treatment Satisfaction.ResultsA total of 478 men aged 19–80 years (mean 57 years) were included in the survey by 229 GPs. Before treatment, EHS was mostly grade 1 (28%) or 2 (44%). At the end of the survey, an improvement was reported for 88% of the patients and 58% achieved maximum score EHS 4 (penis completely hard and fully rigid). Mean SEAR scores significantly increased after 3 months for self‐esteem, overall and sexual relationship, and more notably with greater improvement in EHS (P < 0.001). Improvement in partners’ ISL scores was significantly higher with greater improvement in EHS (P < 0.001) and in SEAR score for self‐esteem. The safety profile of PDE5i was good with few adverse events, mostly headaches. More than 80% of the participating GPs considered that the survey had changed their management of ED.ConclusionAfter 3 months of treatment with PDE5i, a significant improvement in self‐esteem was observed in patients with ED, associated with improvement in erection. Costa P, Grandmottet G, Mai HD, and Droupy S. Impact of a first treatment with phosphodiesterase inhibitors on men and partners’ quality of sexual life: Results of a prospective study in primary care. J Sex Med **;**:**–**.     

Effect of Drug Use and Influence of Abstinence on Sexual Functioning in a Spanish Male Drug‐Dependent Sample: A Multisite Study

IntroductionTo date, it has been difficult to address the issue of sexual functioning and drug use, and many approaches to it have basic problems and methodological errors.AimThe present cross‐sectional study compared the sexual functioning scores of a group of drug users with those of a group of nondrug users. It explored the relationship between drug abstinence and sexual functioning.Main Outcome MeasuresA sample of 905 males participated in this study (549 met the substance dependence criteria and 356 were controls). All of them were assessed with the Changes in Sexual Functioning Questionnaire‐Drugs version.MethodThe assessment was conducted from September 2009 to January 2011. The clinical sample was evaluated in nine different substance abuse treatment facilities.ResultsResults show that, overall, all dimensions (pleasure, desire, arousal, and orgasm) were moderately impaired. Yet, differences regarding preferred substance were observed. Pleasure and orgasm were the two areas most significantly impaired. In these areas, all drugs seemed to negatively affect sexual functioning. However, desire and arousal were not affected by all the substances. In addition, at least after 2 weeks of drug abstinence, no relationship was found between drug abstinence and improvement in sexual functioning. The sample studied had an average of 1 year of drug abstinence and was found to have poorer sexual functioning than the control group.ConclusionsTherefore, these results seem to contradict those that argue that drug use only impairs sexual functioning temporarily. Moreover, they suggest that sexual functioning does not improve just by stopping drug use. Vallejo‐Medina P and Sierra JC. Effect of drug use and influence of abstinence on sexual functioning in a Spanish male drug‐dependent sample: A multisite study. J Sex Med **;**:**–**.     

Measuring Women's Satisfaction with Treatment for Sexual Dysfunction: Development and Initial Validation of the Women's Inventory of Treatment Satisfaction (WITS‐9)

AimTo develop a brief, psychometrically sound, measure of satisfaction with treatment for female sexual arousal disorder.MethodIn Phase 1, women in focus groups generated items measuring satisfaction with treatment for arousal disorder. In Phase 2, expert clinicians/researchers and women with self‐reported female sexual arousal disorder (FSAD) assessed the content validity of the items. In Phase 3, women enrolled in a double‐blind treatment trial for female sexual dysfunction completed the Women's Inventory of Treatment Satisfaction (WITS) and the Female Sexual Function Inventory (FSFI) to provide reliability and validity information.Main Outcome MeasuresWITS and FSFI.ResultsIn Phase 2, 36 items demonstrated adequate content validity. In Phase 3, 20 items correlated with symptom improvement on the FSFI arousal subscale. Factor analysis sorted these items into three dimensions: initiation/receptivity satisfaction, treatment satisfaction, and perceived partner satisfaction. The three items with the highest loadings on each factor formed the WITS‐9. Internal consistency (α) reliability coefficients for the total WITS‐9 score and the three subscale scores were 0.92, 0.93, 0.92, and 0.79, respectively. Correlations of WITS‐9 scores with the FSFI change scores for subgroups with different sexual dysfunctions offer construct validity support that the WITS‐9 measures treatment satisfaction for women with a variety of sexual dysfunctions.ConclusionsThe WITS‐9 is a brief, psychometrically sound scale that is useful for assessing treatment satisfaction in women with sexual dysfunctions. While the WITS‐9 is promising, further work needs to be done to obtain reliability and validity information in additional samples. Corty EW, Althof SE, and Wieder M. Measuring women's satisfaction with treatment for sexual dysfunction: Development and initial validation of the Women's Inventory of Treatment Satisfaction (WITS‐9)     

Development and validation of a new screening tool for hypoactive sexual desire disorder: The Brief Profile of Female Sexual Function© (B-PFSF©)

Aim. To develop a screening tool to allow a postmenopausal woman to determine whether to seek evaluation for hypoactive sexual desire disorder (HSDD).

Methods. The Brief Profile of Female Sexual Function^© (B-PFSF^©) was developed using items from the Profile of Female Sexual Function^© (PFSF^©) and the Personal Distress Scale^© (PDS^©). Logistic regression analysis was used to select items best able to discriminate between women with HSDD (n = 743) and controls (n = 226) and a screening cut-off score was identified. Cross-validation analyses were conducted using PFSF and PDS responses from an independent group of 147 HSDD women and 104 controls. Forty cognitive interviews were additionally conducted to assess validity of the final tool.

Results. A seven-item instrument was found to provide good discrimination between postmenopausal women with HSDD and controls and to be a reliable and valid tool. Ninety-six percent of women with HSDD and 97% of control women in the independent validation were classified correctly using the identified cut-off score. In the cognitive interviews, all women stated that the questionnaire was easy to complete and covered relevant aspects of sexual function.

Conclusion. The Brief Profile of Female Sexual Function (B-PFSF) is psychometrically valid and appropriate for use as a self-administered screening tool.     

The Role of Regulatory Proteins and S‐nitrosylation of Endothelial Nitric Oxide Synthase in the Human Clitoris: Implications for Female Sexual Function

IntroductionDuring female sexual arousal, clitoral blood flow is controlled by endothelial nitric oxide synthase (eNOS) and its product, nitric oxide (NO). The mechanisms regulating eNOS activity and NO bioavailability in the clitoris are largely unknown.AimTo identify proteins involved in regulation of eNOS activity within the clitoris and to evaluate the effects of S‐nitrosoglutathione reductase (GSNO‐R) and eNOS nitrosylation/denitrosylation on clitoral blood flow.MethodsImmunohistochemistry for eNOS, caveolin‐1 (Cav1), heat shock protein‐90 (Hsp90), phosphodiesterase type 5 (PDE5), GSNO‐R, and soluble guanylate cyclase (sGC) was performed on human and murine clitoral tissue. Western blot analysis was performed for eNOS, phosphorylated eNOS (phospho‐eNOS, Ser1177), Cav1, Hsp90, sGC, PDE5, phosphoinositide 3‐kinase (PI3K), Akt (protein kinase B), and GSNO‐R on protein from human clitoral tissue. A biotin switch assay was used to analyze the S‐nitrosylation of eNOS, nNOS, and GSNO‐R. Clitoral blood flow was measured in wild‐type and GSNO‐R^‐/‐ mice at baseline and during cavernous nerve electrical stimulation (CNES).Main Outcome MeasuresLocalization of eNOS regulatory proteins and clitoral blood flow.ResultseNOS and GSNO‐R co‐localized to the vascular endothelium and sinusoids of human clitoral tissue. Immunohistochemistry also localized Cav1 and Hsp90 to the endothelium and PDE5 and sGC to the trabecular smooth muscle. Expression of S‐nitrosylated (SNO)‐eNOS and SNO‐GSNO‐R was detected by biotin switch assays. Wild‐type control mice exhibited increased clitoral blood flow with CNES whereas GSNO‐R^‐/‐ animals failed to show an increase in blood flow.ConclusionsSeveral key eNOS regulatory proteins are present in the clitoral tissue in a cellular specific pattern. S‐nitrosylation of eNOS may also represent a key regulatory mechanism governing eNOS activation/deactivation since mice deficient in GSNO‐R failed to increase clitoral blood flow. Additional studies are necessary to define the role of S‐nitrosylation in the genital vascular response and its subsequent impact on female sexual function. Oliver JL, Kavoussi PK, Smith RP, Woodson RI, Corbett ST, Costabile RA, Palmer LA, and Lysiak JJ. The role of regulatory proteins and s‐nitrosylation of endothelial nitric oxide synthase in the human clitoris: Implications for female sexual function. J Sex Med 2014;11:1927–1935.     

The Global Online Sexuality Survey (GOSS): The United States of America in 2011. Chapter I: Erectile Dysfunction Among English‐Speakers

IntroductionThe Global Online Sexuality Survey (GOSS) is a worldwide epidemiologic study of sexuality and sexual disorders, based on validated questionnaires and applying age adjustment to the World Standard Population (WSP) by the World Health Organization. In 2010, the first report of GOSS came from the Middle East, describing an erectile dysfunction (ED) prevalence rate of 47%.AimThis report studies the prevalence rate of ED in the United States as of 2011–2012 and evaluates risk factors for ED.Main Outcome MeasuresPrevalence of ED.MethodsGOSS was randomly deployed to English‐speaking male web surfers in the United States via paid advertising on Facebook, comprising 146 questions including the abbreviated 5‐item International Index of Erectile Function.ResultsTwo thousand twenty‐two males participated; with a mean age was 52.38 years ± 14.5. Prevalence of ED was 37.7%, adjusted to 33.7% according to WSP, comparable across ethnic groups. The following risk factors were associated with higher risk for ED: diabetes mellitus, hypertension with and without antihypertensive treatment, coronary heart disease, obesity (defined by body mass index), difficult micturition, subjectively reported depression, interpersonal distress, subjectively reported impotence, in addition to novel factors such as subjectively reported premature ejaculation (PE) and concerns over genital size (not a smaller penis per se), low libido, and irregular coitus. Frequency of smoking and alcohol were not associated with higher prevalence of ED, although duration of smoking was.ConclusionAdjusted to WSP, prevalence rate of ED in the United States of America is 33.7% in the year 2011, in contrast to the adjusted prevalence in the Middle East (47%). Most of the classical risk factors for ED play the same role in the United States and the World, including diabetes, hypertension, and aging. Concerns over genital size and PE are emerging risk factors for ED. Shaeer O and Shaeer K. The Global Online Sexuality Survey (GOSS): The United States of America in 2011. Chapter I: Erectile dysfunction among English‐speakers. J Sex Med 2012;9:3018–3027.     

Impact of Medical Treatments for Male Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia on Ejaculatory Function: A Systematic Review and Meta‐Analysis

IntroductionSeveral drugs, currently used to treat lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), can be associated with bothersome sexual side effects, including ejaculatory dysfunction (EjD).AimTo provide a systematic review and meta‐analysis of the available randomized clinical trials (RCTs) reporting the impact of medical treatments for LUTS due to BPH on ejaculatory function.Main Outcome MeasureEjD related to medical treatments for LUTS.MethodsA systematic literature search was performed using PubMed, Scopus and Cochrane databases. EjD was identified using both free text (“ejaculat*,” “retrograde ejaculation,” “anejaculation,” “ejaculatory dysfunction”) and Mesh (“Ejaculation”) searches.ResultsOf 101 retrieved articles, 23 were included in the present meta‐analysis. EjD was significantly more common with alpha‐blockers (ABs) than with placebo (OR:5.88; P < 0.0001), in particular, considering Tamsulosin (OR:8.58; P = 0.006) or Silodosin (OR:32.5; P < 0.0001), with Tamsulosin associated with significantly lower risk of EjD than Silodosin (OR:0.09; P < 0.00001). Conversely, Doxazosin and Terazosin were associated with a risk similar to placebo. Meta‐regression showed that EjD was associated with IPSS and with Qmax both before and after treatment with ABs, while multivariate analysis demonstrated that EjD was independently associated with the improvement of IPSS (adj.r:0.2012; P < 0.0001) and Qmax (adj.r:0.522; P < 0.0001).EjD was significantly more common with 5ARIs as compared with placebo (OR:2.73; P < 0.0001). Both Finasteride (OR 2.70; P < 0.0001) and Dutasteride (OR 2.81; P = 0.0002) were associated with significantly higher risk of EjD than placebo. EjD was significantly more common with combination therapy as compared with ABs alone (OR:3.75; P < 0.0001),or with 5ARIs alone (OR:2.76; P = 0.02).ConclusionsABs and 5ARI were both associated with significantly higher risk of EjD than placebo. More the AB is effective over time, greater is the incidence of EjD. Finasteride has the same risk of Dutasteride to cause EjD. Combination therapy with ABs and 5ARIs resulted in a 3‐fold increased risk of EjD as compared with ABs or 5ARIs alone. These data can be relevant both for drug selection and patients counseling. Gacci M, Ficarra V, Sebastianelli A, Corona G, Serni S, Shariat SF, Maggi M, Zattoni F, Carini M, and Novara G. Impact of medical treatments for male lower urinary tract symptoms due to benign prostatic hyperplasia on ejaculatory function: A systematic review and meta‐analysis. J Sex Med 2014;11:1554–1566.     

More than Foreskin: Circumcision Status,History of HIV/STI,and Sexual Risk in a Clinic‐Based Sample of Men in Puerto Rico

IntroductionCircumcision among adult men has been widely promoted as a strategy to reduce human immunodeficiency virus (HIV) transmission risk. However, much of the available data derive from studies conducted in Africa, and there is as yet little research in the Caribbean region where sexual transmission is also a primary contributor to rapidly escalating HIV incidence.AimIn an effort to fill the void of data from the Caribbean, the objective of this article is to compare history of sexually transmitted infections (STI) and HIV diagnosis in relation to circumcision status in a clinic‐based sample of men in Puerto Rico.MethodsData derive from an ongoing epidemiological study being conducted in a large STI/HIV prevention and treatment center in San Juan in which 660 men were randomly selected from the clinic's waiting room.Main Outcome MeasuresWe assessed the association between circumcision status and self‐reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit.ResultsAlmost a third (32.4%) of the men were circumcised (CM). Compared with uncircumcised (UC) men, CM have accumulated larger numbers of STI in their lifetime (CM = 73.4% vs. UC = 65.7%; P = 0.048), have higher rates of previous diagnosis of warts (CM = 18.8% vs. UC = 12.2%; P = 0.024), and were more likely to have HIV infection (CM = 43.0% vs. UC = 33.9%; P = 0.023). Results indicate that being CM predicted the likelihood of HIV infection (P value = 0.027).ConclusionsThese analyses represent the first assessment of the association between circumcision and STI/HIV among men in the Caribbean. While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection. Findings suggest the need to apply caution in the use of circumcision as an HIV prevention strategy, particularly in settings where more effective combinations of interventions have yet to be fully implemented. Rodriguez‐Diaz CE, Clatts MC, Jovet‐Toledo GG, Vargas‐Molina RL, Goldsamt LA, and García H. More than foreskin: Circumcision status, history of HIV/STI, and sexual risk in a clinic‐based sample of men in Puerto Rico. J Sex Med 2012;9:2933–2937.     

The Impact of Intravaginal Ejaculatory Latency Time and Erectile Function on Anxiety and Depression in the Four Types of Premature Ejaculation: A Large Cross‐Sectional Study in a Chinese Population

IntroductionA new classification of premature ejaculation (PE) has been proposed, including the categories of lifelong PE (LPE), acquired PE (APE), natural variable PE (NVPE), and premature‐like ejaculatory dysfunction (PLED).AimThe aim of this study was to evaluate the impact of intravaginal ejaculation latency time (IELT) and erectile function on anxiety and depression among patients with PE in general and according to the four types of PE.MethodsBetween September 2011 and September 2012, we conducted a cross‐sectional study in the Anhui province of China. We enrolled 4,000 men aged over 18 years, each of whom had been in a stable, monogamous, heterosexual relationship with the same partner for at least 6 months.Main Outcome MeasurementsSelf‐estimated IELT, the International Index of Erectile Function‐5 (IIEF‐5) and the Zung Self‐Rating Anxiety and Depression Scales (SAS/SDS) were used to measure PE, erectile dysfunction (ED), anxiety, and depression, respectively, among the entire study population.ResultsOf the 3,016 men evaluated, 25.80% complained of PE. Distribution of the four types of PE among men with PE was as follows: LPE, 12.34%; APE, 18.77%; NVPE, 44.09%; PLED, 24.81%. Men with PE presented lower IIEF‐5 scores and higher SAS and SDS scores vs. men without PE (P < 0.001 for all). Similar findings were observed in men with APE when compared with other PE syndromes. After adjustment for age in men with PE, IELT was negatively associated with SAS and SDS scores (SAS, adjusted r = −0.42, P < 0.001; SDS, adjusted r = −0.45, P < 0.001). IIEF‐5 score was negatively associated with SAS and SDS scores (SAS, adjusted r = −0.54, P < 0.001; SDS, adjusted r = −0.50, P < 0.001). These negative relationships were strongest in men with PLED (IELT vs. SAS: adjusted r = −0.63, P < 0.001; IELT vs. SDS, adjusted r = −0.60, P < 0.001; IIEF‐5 vs. SAS: adjusted r = −0.57, P < 0.001; IELT vs. SDS, adjusted r = −0.55, P < 0.001).ConclusionsAPE patients reported higher rates of ED, anxiety, and depression than men with other types of PE. The negative relationships between IELT/IIEF‐5 and SAS/SDS were strongest in men with PLED. Gao J, Zhang X, Su P, Peng Z, Liu J, Xia L, Lu Z, Yang J, Tang D, Gao P, Zhou J, Hao Z, and Liang C. The impact of intravaginal ejaculatory latency time and erectile function on anxiety and depression in the four types of premature ejaculation: A large cross‐sectional study in a Chinese population. J Sex Med 2014;11:521–528.