Significant Increase of Sexual Dysfunction in Patients With Renal Failure Receiving Renal Replacement Therapy: A Systematic Review and Meta-Analysis

BackgroundIt has been shown that sexual dysfunction (SD) is highly prevalent among patients with chronic renal failure (CRF), and starting renal replacement therapy may even increase it. However, SD is an infrequently reported problem in these treated patients.AimTo investigate the prevalence of SD among patients with CRF undergoing renal replacement therapy, by a meta-analysis method.MethodsPubMed, Embase, and the Cochrane Library were systematically searched for all studies assessing sexual function in patients with CRF receiving renal replacement therapy from January 2000 to April 2020. Relative risk (RR) with 95% CIs was used for analysis to assess the risk of SD in patients with CRF receiving renal replacement therapy. The cross-sectional study quality methodology checklist was used for the cross-sectional study. The methodologic quality of the case-control and cohort studies was assessed with the Newcastle-Ottawa Scale. Data were pooled for the random-effect model. Sensitivity analyses were conducted to assess potential bias. The Begg and Egger tests were used for publication bias analysis.OutcomesThe prevalence of SD among patients with CRF receiving renal replacement therapy was summarized using pooled RR and 95% CI.ResultsThis meta-analysis included 3,725 participants from 10 studies. Of these, 737 were patients with CRF receiving renal replacement therapy. The mean age of participants ranged from 32.75 to 56.1 years. Based on the random-effect model, synthesis of results demonstrated that the prevalence of SD was significantly increased among patients with CRF receiving renal replacement therapy in women (RR = 2.07, 95% CI: 1.47–2.91, P = .000; heterogeneity: I² = 78.7%, P = .000) and in men (RR = 2.95, 95% CI: 2.16–4.02, P = .000; heterogeneity: I² = 86.1%, P = .000). Estimates of the total effects were generally consistent in the sensitivity analysis. No evidence of publication bias was observed.Clinical ImplicationsPatients with CRF receiving renal replacement therapy had a significantly increased risk of SD, which suggests that clinicians should evaluate sexual function, when managing patients with CRF receiving renal replacement therapy.Strengths and LimitationsThis is the first study to explore the prevalence of SD among patients with CRF undergoing renal replacement therapy based on all available epidemiologic studies. However, all included studies were an observational design, which may downgrade this evidence.ConclusionThe prevalence of SD is significantly increased among patients with CRF receiving renal replacement therapy. More research studies are warranted to clarify the relationship.Luo L, Xiao C, Xiang Q, et al. Significant Increase of Sexual Dysfunction in Patients With Renal Failure Receiving Renal Replacement Therapy: A Systematic Review and Meta-Analysis. J Sex Med 2020;17:2382–2393.     

Is There an Association Between Contraception and Sexual Dysfunction in Women? A Systematic Review and Meta-analysis Based on Female Sexual Function Index

BackgroundA growing body of research investigates the sexual functioning status in women with contraceptives use; however, the evidence is still inconclusive.AimTo examine whether contraceptives use is associated with a higher risk of female sexual dysfunction (FSD).MethodsThe electronic databases MEDLINE, Embase, Cochrane Library databases, and PsychINFO were systematically screened for eligible studies before December 2019. We only included those studies assessing women's sexual functioning by the Female Sexual Function Index (FSFI). This study was registered on the PROSPERO (ID: CRD42020167723, http://www.crd.york.ac.uk/PROSPERO).OutcomesThe strength of the association between contraceptives use and risk of FSD was presented by calculating the standard mean dierences (SMDs) and the relative risk (RR) with a 95% confidence interval (CI). The pooled results were calculated using a random-effects model.ResultsA total of 12 studies (7 cross-sectional studies, 3 cohorts, and 1 case-control study) involving 9,427 participants were included. The mean age in the contraceptive users ranged from 22.5 ± 2.4 years to 38.2 ± 4.6 years, while the mean age in the nonusers was 22.5 ± 2.4 years to 36.0 ± 1.0 years. Pooled results showed that no significant difference in the total FSFI scores was observed between contraceptives use and noncontraception (SMD = −1.03, 95% CI: −2.08 to 0.01, P = .053; heterogeneity: I² = 98.2%, P < .001). In line with this finding, the pooled RR also yielded no association between contraception use and the risk of FSD (RR = 1.29, 95% CI: 0.72–2.28, P = .392; heterogeneity: I² = 76.0%, P = .0015). However, the subscale sexual desire showed a significant reduction in women who received contraceptives than those did not use contraception (SMD = −1.17, 95% CI: −2.09 to −0.24, P = .014; heterogeneity: I² = 97.7%, P < .001), while no significant differences were found in sexual arousal, lubrication, orgasm, satisfaction, and pain domain.Clinical ImplicationsThough evidence from this meta-analysis did not support an association between contraceptives use and the risk of FSD, the sexual desire could be significantly impaired by contraceptives use.Strengths & LimitationsThis is the first meta-analysis quantifying the relationship between contraceptives use and the risks of FSD. However, substantial heterogeneities were presented across the included studies.ConclusionNo direct association between contraceptives use and the risk of FSD was found. Nevertheless, declining sexual desire was significantly associated with contraceptives use. Additional double-blind, randomized, placebo-controlled trials are still warranted.Huang M, Li G, Liu J, et al. Is There an Association Between Contraception and Sexual Dysfunction in Women? A Systematic Review and Meta-analysis Based on Female Sexual Function Index. J Sex Med 2020;17:1942–1955.     

Sexual Functions in Women With Stress Urinary Incontinence After Mid-Urethral Sling Surgery: A Systematic Review and Meta-Analysis of Prospective Randomized and Non-Randomized Studies

BackgroundStress urinary incontinence (SUI) is a common, distressing health issue which affects many women. Mid-urethral sling (MUS) surgeries are recommended as gold standard interventions, although evidence regarding their impact on female sexual function remains controversial.AimTo provide high-quality evidence of the impact of MUS surgeries on sexual functions in women with SUI.MethodsA systematic search of PubMed, Embase, and the Cochrane Library was conducted to identify studies assessing the effect of MUS treatments on sexual functions in women with SUI. The included studies were prospective randomized or non-randomized trials which assessed patients using 2 validated questionnaires, the Female Sexual Function Index (FSFI) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Pre- and postoperative data regarding sexual function were extracted. Meta-analysis of comparable data was performed using Review Manager (version 5.3) software.Main outcome measuresThe relationship between MUS interventions and sexual functions was analyzed by pooling weighted mean differences (WMD) with 95% CI from studies which used either the FSFI or PISQ-12 questionnaires, before and after receiving surgical interventions.ResultsOf the 22 eligible studies, 13 utilized FSFI and 9 adopted the PISQ-12. Pooled analysis indicates that 6-month postoperative PISQ-12 scores were significantly higher than preoperative scores (WMD −3.31 points; 95% CI −5.32 to −1.30; P = .001). Similar results were found at the 12-month juncture (WMD −3.30 points; 95% CI −6.01 to −0.58; P = .02) and at 24 months (WMD −4.44 points; 95% CI −5.45 to −3.44; P < .00001). Likewise, pooled postoperative FSFI total scores were significantly higher than preoperative scores at 6 months (WMD −2.22 points; 95% CI −3.36 to −1.08; P = .00001) and 12 months (WMD −3.49 points; 95% CI −5.96 to −1.02; P = .006). Postoperative FSFI sub-scores also suggest that desire, arousal, orgasm, lubrication, satisfaction, and pain during sexual intercourse significantly improved postoperatively (all P < .05). Moreover, combined evidence highlighted a significant reduction in coital incontinence postoperatively (risk ratio 5.78; 95% CI 3.16–10.58; P < .00001).Clinical ImplicationsThese assessment tools might be more appropriately used to create opportunities for counseling.Strengths & LimitationsWe encountered substantial heterogeneity and insufficient long term follow-up data. There is also a distinct lack of standards, in terms of data recording and reporting across this evidence base which adds to the problems with the PISQ-12 and FSFI which, even though validated, appear unsophisticated and not necessarily fit-for-purpose.ConclusionThis meta-analysis confirms that sexual functions do improve after MUS surgeries for women with SUI.Lai S, Diao T, Zhang W, et al. Sexual Functions in Women With Stress Urinary Incontinence After Mid-Urethral Sling Surgery: A Systematic Review and Meta-Analysis of Prospective Randomized and Non-Randomized Studies. J Sex Med 2020;17:1956–1970.     

Is There an Association Between Schizophrenia and Sexual Dysfunction in Both Sexes? A Systematic Review and Meta-Analysis

BackgroundMounting clinical studies have reported patients with schizophrenia are at high risk of developing sexual dysfunction (SD), but a directly calculated prevalence of SD is currently lacking.AimTo further quantify the association between schizophrenia and SD.MethodsMEDLINE (PubMed), Embase (OVID), the Cochrane Library databases, and the PsycINFO were systematically searched for eligible studies reporting the sexual functioning in patients with schizophrenia. This meta-analysis has been registered on PROSPERO (ID: CRD42019121720, http://www.crd.york.ac.uk/PROSPERO).OutcomesThe relationship between schizophrenia and SD was detected by calculating the relative risk (RR) with a 95% confidence interval (CI). The GRADE-profiler was employed to rank the quality of the evidence.Results10 observational studies (3 case-control studies and 7 cross-sectional studies) were finally included, enrolling a total of 3,570 participants (mean age 28.6–46.2 years), of whom 1,161 had schizophrenia and the remainders were the healthy control subjects. Synthetic results indicated that schizophrenia was significantly associated with an increased risk of SD regardless of gender (3 studies reporting both sexes: RR = 2.24, 95%CI: 1.66–3.03, P < .001, heterogeneity: I² = 0.0%, P = .431; 7 studies reporting men: RR = 2.63, 95%CI: 1.68–4.13, P < .001, heterogeneity: I² = 82.7%, P < .001; 5 studies reporting women: RR = 2.07, 95%CI: 1.46–2.94, P < .001; heterogeneity: I² = 79.7%, P = .001). In accordance with the GRADE-profiler, the quality of the evidence of primary outcomes was LOW, MODERATE, and LOW in studies including both sexes, men, and women, respectively.Clinical ImplicationsOur findings confirmed the potential link between schizophrenia and SD. Clinicians should routinely assess the sexual functioning for those patients with schizophrenia and further recommend the preferred antipsychotics for them.Strengths & LimitationsThis is the first meta-analysis investigating the association between schizophrenia and the risks of SD in both sexes. Nonetheless, substantial heterogeneities were identified across the selected studies.ConclusionRobust data from this meta-analysis showed increased rates of SD in patients with schizophrenia compared with the general populations. Therefore, more specific psychological and pharmaceutical interventions are needed to help patients with schizophrenia gain a better sexual life.Zhao S, Wang X, Qiang X, et al. Is There an Association Between Schizophrenia and Sexual Dysfunction in Both Sexes? A Systematic Review and Meta-Analysis. J Sex Med 2020;17:1476–1488.     

Sexual Dysfunction in Women With End-Stage Renal Disease: A Systematic Review and Meta-Analysis

BackgroundIn women with end-stage renal disease (ESRD), female sexual dysfunction (SD) remains underestimated.AimTo explore the prevalence, correlates, diagnostic approach and treatment modalities of sexual symptoms in females with ESRD.MethodsWe performed a systematic review and meta-analysis to estimate both the prevalence of SD and the pooled Female Sexual Function Index (FSFI) scores in ESRD females. Similarly, for studies reporting the FSFI score before and after renal transplantation (RT), we estimated the effect of RT on sexual function. Further assessment of heterogeneity was conducted via subgroup and sensitivity analyses, cumulative meta-analysis and univariate meta-regression of important correlates. Records were identified through searching PubMed, Cochrane Library and Scopus databases as well as sources of grey literature until November 2020 (PROSPERO ID: CRD42020215178).OutcomesWe included 47 studies with 61 patient group entries and 3490 ESRD female individuals (median age: 45.2 years, ΙQR: 40.4-50.6).ResultsThe SD prevalence in all females with ESRD was 74% (95%CI: 67%-80%, I² = 92%) and the FSFI total score 16.1 points (95%CI: 14.3-17.8, I² = 98%). The female SD prevalence was 63% (95%CI: 43%-81%, I² = 92%) in renal transplant recipients, 80% (95%CI: 72%-87%, I² = 91%) in hemodialysis patients and 67% (95%CI: 46%-84%, I² = 90%) in peritoneal dialysis patients. The total FSFI score improved by 7.5 points (95%CI: 3.9-11.1, I² = 92%) after RT. Older age and menopause were associated with higher SD prevalence.Clinical TranslationFemale SD is highly prevalent in all ESRD women, but renal transplant recipients reported improved sexual function.Strengths & LimitationsWe provide the first study about SD in females and assessed the role of RT on sexual function. Contrary, none of the included studies evaluated the concomitant presence of distress with SD. The levels of heterogeneity were substantially high for all outcomes and we could not adjust for further correlates, which might have affected our measures.ConclusionsSexual symptoms negatively affect the quality of life and warrants appropriate clinical attention, as they are an underdetermined and undertreated clinical entity in females with ESRD. Studies on treatment modalities of female SD in patients with ESRD are mandatory, as currently no relevant studies or clinical recommendations exist.Pyrgidis N, Mykoniatis I, Tishukov M, et al. Sexual Dysfunction in Women With End-Stage Renal Disease: A Systematic Review and Meta-Analysis. Sex Med Rev 2021;18:936–945.     

CO2-Laser therapy and Genitourinary Syndrome of Menopause: A Systematic Review and Meta-Analysis

BackgroundGenitourinary syndrome of menopause (GSM) is a widespread condition with a great impact on quality of life and self-image.AimWe aimed to systematically review the current literature on CO2-Laser therapy efficacy for the treatment of GSM.MethodsMEDLINE and Embase databases were systematically queried in December 2020 Studies included women with a diagnosis of Vulvo-Vaginal Atrophy (VVA) or GSM without an history of gynaecological and/or breast cancer, pelvic organ prolapse staged higher than 2, pelvic radiotherapy or Sjogren's Syndrome. The quality of the evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42021238121.OutcomesEffects of CO2-Laser therapy on GSM symptoms assessed through subjective or objective efficacy measurement methods.ResultsA total of 803 articles were identified. Of these, 25 studies were included in this review for a total of 1,152 patients. All studies showed a significant reduction in VVA and/or GSM symptoms (dryness, dyspareunia, itching, burning, dysuria). The pooled mean differences for the symptoms were: dryness -5.15 (95% CI:-5.72,-4.58; P < .001; I²:62%; n = 296), dyspareunia -5.27 (95% CI:-5.93,-4.62; P < .001; I²:68%; n = 296), itching -2.75 (95% CI:-4.0,-1.51; P < .001; I²:93%; n = 281), burning -2.66 (95% CI:-3.75, -1.57; P < .001; I²:86%; n = 296) and dysuria -2.14 (95% CI:-3.41,-0.87; P < .001; I²:95%; n = 281). FSFI, WHIS and VMV scores also improved significantly. The pooled mean differences for these scores were: FSFI 10.8 (95% CI:8.41,13.37; P < .001; I²:84%; n = 273), WHIS 8.29 (95% CI:6.16,10.42; P < .001; I²:95%; n = 262) and VMV 30.4 (95% CI:22.38,38.55; P < .001; I²:24%; n = 68). CO2-Laser application showed a beneficial safety profile and no major adverse events were reported.Clinical ImplicationsVaginal laser treatment resulted in both a statistically and clinically significant improvement in GSM symptoms. FSFI improved significantly in all 8 included studies but it reached a clinically relevant level only in 2 of them.Strengths & LimitationsThe strength of the current meta-analysis is the comprehensive literature search. We reported data from a high number of patients (1,152) and high number of laser applications (more than 3,800). The main limitations are related to the high heterogeneity of the included studies investigating laser effects. Moreover, most of them are single center and nonrandomized studies.ConclusionThe data suggest that CO2-Laser is a safe energy-based therapeutic option for the management of VVA and/or GSM symptoms in postmenopausal women; however, the quality of the body of evidence is “very low” or “low”.Filippini M, Porcari I, Ruffolo AF, et al., CO2-Laser therapy and Genitourinary Syndrome of Menopause: A Systematic Review and Meta-Analysis. J Sex Med 2022;19:452–470.     

Long-term Quality of Life and Sexual Function After Neoadjuvant Chemotherapy and Radical Surgery for Locally Advanced Cervical Cancer

BackgroundCervical cancer survivors report the worst quality of life (QoL) among all cancer survivors and this is mainly due to their younger age and the long-term treatment sequelae.AimThe purpose of this study is to assess the long-term QoL and sexual function of locally advanced cervical cancer (LACC) patients treated with neoadjuvant chemotherapy (NACT) and radical hysterectomy (RH) instead of the standard chemoradiotherapy.MethodsThis is a retrospective case-control study including LACC patients (FIGO stage IIB-IVA) treated with the NACT-RH strategy and a control group of healthy women undergoing hysterectomy for uterine fibromatosis in the same period.OutcomesMain outcome measures were the EORTC QLQ-C30 and EORTC QLQ-CX24 for quality of life and Female Sexual Function Index (FSFI) for sexual function.ResultsOverall, 96 patients were included: 48 LACC and 48 controls. The mean age at diagnosis was 45.5 ± 9.0 and 47.0 ± 7.8, respectively (P = .38). Compared to controls, LACC patients reported lower mean scores for the global health status (69.4 ± 22.6 vs 81.2 ± 24.3; Mean Difference (MD): -11.80 [95% CI: -21.19, -2.41]; P = .016), QLQ-C30 functional scale (80.1 ± 22.6 vs 92.4 ± 14.9; MD: -12.30 [95% CI: -19.96, -4.64]; P = .002), QLQ-Cx24 functional scale (55.5 ± 25.0 vs 80.4 ± 22.4; MD: -24.00 [95% CI: -34.40, -15.40]; P < .001), and the total FSFI (19.3 ± 9.6 vs 26.2 ± 9.9; MD: -6.90 [95% CI: -10.80, -3.00]; P < .001). On the other hand, LACC patients reported higher mean scores on the QLQ-C30 (16.9 ± 22.1 vs 8.4 ± 16.6; MD: 8.50 [95% CI: 0.68, 16.32]; P = .03) and QLQ-CX24 (26.0 ± 28.8 vs 15.0 ± 11.7; MD: 11.00 [95% CI: -2.21, 19.79]; P = .01) symptoms scales.Clinical implicationsThe confirmed poor quality of life even in surgically treated LACC survivors underlines the importance of tailoring parametrectomy based on lymph node status and developing personalized strategies.Strengths and limitationsThe study assessed the long-term QoL and sexual function in the specific subpopulation of LACC patients treated with NACT-RH. Main limitations include the small sample size and the retrospective design.ConclusionLACC long-term survivors treated with NACT-RH experience poor QoL and sexual dysfunction.Palaia I, Santangelo G, Caruso G, et al. Long-term Quality of Life and Sexual Function After Neoadjuvant Chemotherapy and Radical Surgery for Locally Advanced Cervical Cancer. J Sex Med 2022;19:613–619.     

Effects of Pelvic Floor Muscle Training on Sexual Dysfunction,Sexual Satisfaction of Partners,Urinary Symptoms,and Pelvic Floor Muscle Strength in Women With Overactive Bladder: A Randomized Controlled Study

BackgroundIn women with overactive bladder (OAB), sexual dysfunctions and sexual satisfaction of their partners have been problems that are as important as urinary symptoms.AimTo investigate the effects of pelvic floor muscle training (PFMT) on sexual dysfunction, sexual satisfaction of partners, urinary symptoms, and pelvic floor muscle strength (PFMS) in women with OAB.MethodsWomen with OAB were randomized into 2 groups: 6-week PFMT (n = 21) (home exercise program) and a control group (n = 22) (did not receive any treatment for OAB).OutcomesSexual dysfunction, sexual satisfaction of partner, urinary symptoms, and PFMS were assessed at baseline and after 6 weeks with the Female Sexual Function Index (FSFI), a Visual Analogue Scale (VAS), the OAB-Version8 (OAB-V8), and the Modified Oxford Scale (MOS), respectively.ResultsAfter 6 weeks, there was an increase in FSFI domains [desire (95% CI: 0.18 to 0.64; P:.001, d: 0.88); arousal (95% CI: 0.42 to 1.24, P:<.001, d: 1.17); orgasm (95% CI:0.85 to 1.47; P:<.001, d:1.89); satisfaction (95% CI: 0.85 to 1.44; P:<.001, d: 2.29); sexual pain (95% CI:0.80 to 1.52; P:<.001, d:1.47); total score (95% CI: 3.70 to 5.94; P:<.001, d: 2.55)], sexual satisfaction of partners (95% CI: 1.80 to 2.85; P:<.001, d:2.83) and PFMS scores (95% CI: 1.10 to 1.55; P:<.001, d:3.18), and a decrease in the OAB-V8 score (95% CI: -13.01 to -7.10; P:<.001, d:2.19) in the PFMT group compared to the control group. There was a significant decrease in sexual dysfunction in the PFMT group compared to the control group (P:.046).Clinical ImplicationsIn order to improve sexual function, sexual satisfaction of the partners, urinary symptoms, and PFMS in women with OAB, PFMT should be added to the rehabilitation program in clinics.Strengths & LimitationsThe strength of this study was that it is a randomized controlled trial investigating the effect of PFMT in improving sexual function in OAB. The limitations of our study were the lack of a long-term (6 months-1 year) follow-up and the inability to blind.ConclusionPFMT was effective in improving sexual dysfunction, sexual satisfaction of partners, urinary symptoms, and PFMS in women with OAB.Celenay ST, Karaaslan Y, Ozdemir E. Effects of Pelvic Floor Muscle Training on Sexual Dysfunction, Sexual Satisfaction of Partners, Urinary Symptoms, and Pelvic Floor Muscle Strength in Women With Overactive Bladder: A Randomized Controlled Study. J Sex Med 2022;19:1421–1430.     

Efficacy and Safety of Flibanserin in Women with Hypoactive Sexual Desire Disorder: A Systematic Review and Meta-Analysis

IntroductionFlibanserin, is a postsynaptic agonist of serotonin receptor 1A and an antagonist of serotonin receptor 2A, has been shown to increase sexual desire and reduce distress in women with hypoactive sexual desire disorder (HSDD).AimWe carried out a systematic review and meta-analysis to assess the efficacy and safety of the drug in women with HSDD.MethodsA literature review was performed to identify all published randomized double-blind, placebo-controlled trials of flibanserin for the treatment of HSDD. The search included the following databases: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. The reference lists of the retrieved studies were also investigated.Main Outcome MeasuresFour publications involving a total of 3,414 patients were used in the analysis, including four randomized controlled trials that compared flibanserin with placebo.ResultsFor the comparison of flibanserin with placebo, primary efficacy endpoints: satisfying sexual events (the standardized mean difference [SMD] = 0.59, 95% confidence interval [CI] = 0.37–0.80, P < 0.00001); sexual desire score (the SMD = 1.91, 95% CI = 0.21 to 3.60, P = 0.03) and Female Sexual Function Index (FSFI) desire domain score (the SMD = 0.32, 95% CI = 0.19–0.46, P < 0.00001) and key secondary efficacy endpoints: FSFI total score, Female Sexual Distress Scale-Revised (FSDS-R) total score, FSDS-R Item 13 score, Patient's Global Impression of Improvement score and Patient Benefit Evaluation indicated that flibanserin was more effective than the placebo. Safety assessments included the proportion of women who experienced an adverse event (odds ratio = 1.54, 95% CI = 1.34 to 1.76, P < 0.00001), nervous system disorders and fatigue indicated that flibanserin was well tolerated.ConclusionsThis meta-analysis indicates that flibanserin to be an effective and safe treatment for HSDD in women.     

Sexual Activity and Related Factors of Older Women in Hunan,China: A Cross-Sectional Study

BackgroundSexuality has an important impact on people's physical and mental health, but current research on the sexual activity of older Chinese women has many limitations and more detailed studies are needed.AimThe objective was to determine the prevalence of sexual activity and related factors in women aged 55 to 85 years in Hunan, China.MethodsBased on the data from the Hunan Provincial Women Health Needs Survey in 2018, we conducted a secondary analysis of 2,401 older women aged 55 and above. The dependent variable was sexual activity, and independent variables included sociodemographic characteristics, health behaviors, reproductive and chronic medical history, and psychological characteristics. All statistical analyses were performed using SPSS 26.0. Chi-square test was used to assess the association between categorical variables, and binary logistic regression was used to examine factors related to sexual activity.OutcomesSexual activity and related factors.ResultsThe prevalence of sexual activity among older women was 12.5% (301/2401) in the past month. Having a partner (OR = 1.484; 95% CI, 1.048-2.101; P = .026), jogging (OR = 2.061; 95% CI, 1.391-3.054; P < .001), dancing (OR = 1.477; 95% CI, 1.106-1.974; P = .008), vegetarian-based diet (OR = 2.197; 95% CI, 1.334-3.618; P = .002), meat-based diet (OR = 2.196; 95% CI, 1.144-4.216; P = .018) were positively associated with being sexually active. Whereas, aging (OR = 0.781; 95% CI, 0.647-0.942; P = .010), living in the urban (OR = 0.628; 95% CI, 0.488-0.808; P < .001), hypertension (OR = 0.702; 95% CI, 0.520-0.949; P = .021), and anxiety (OR = 0.680; 95% CI, 0.475-0.972; P = .034) were negatively associated with being sexually active.Clinical ImplicationsHealth care workers need to be aware that older women still have sexual activity and understand the needs of older women for sex education, take the initiative to discuss safe sex with them, and solve their sexual problems.Strengths and LimitationsThis is one of the largest studies to determine the prevalence of sexual activity among older women in China and its related factors. In addition, new factors such as exercise types and eating habits related to sexual activity were discovered. The limitation of this study is that it did not use a specific questionnaire to assess the sexual activity and did not consider physical tenderness other than sexual intercourse.ConclusionsSome older women still have had sexual activity in the past month and factors such as lifestyles that can be changed and chronic diseases that can be self-managed were found to predict sexual activity.Li T, LuoY, Meng Y, et al. Sexual Activity and Related Factors of Older Women in Hunan, China: A Cross-Sectional Study. J Sex Med 2022;19:302–310.     

Impaired Sexual Function in Young Women With PCOS: The Detrimental Effect of Anovulation

BackgroundEven though polycystic ovary syndrome (PCOS) is a common reproductive disorder affecting young women, its impact on their sexual health is not well known.AimTo examine the different aspects of female sexuality in young women with PCOS and attempt to associate hormonal changes and ovulatory status with their sexual function.MethodsAnthropometric characteristics, hormonal levels and sexual function based on the Female Sexual Function Index (FSFI) questionnaire were assessed in 76 young women with PCOS and 133 matched controls.OutcomesSexual function is significantly impaired in young women with PCOS.ResultsWomen with PCOS demonstrated lower scores than controls in arousal (5.04 ± 1.19 vs 4.48 ± 1.44, P < .001), lubrication (5.29 ± 1.17 vs 4.69 ± 1.54, P < .001), orgasm (4.78 ± 1.40 vs 4.11 ± 1.61, P = .001), satisfaction (5.22 ± 1.10 vs 4.78 ± 1.31, P = .016), and total score of the FSFI (29.51 ± 5.83 vs 26.76 ± 6.81, P < .001), even after correction for BMI. When corrected for total testosterone, the domains of lubrication, satisfaction, and total score of FSFI remained significantly impaired in women with PCOS (P values .037, .024, & .044 respectively). In multivariate logistic regression analysis, after adjusting for the effect of BMI and hormone levels, dysfunction in orgasm, satisfaction and the total FSFI score were still 3–4 times more common in PCOS (adjusted OR [95% CI]: 3.54, P = .020; 2.96, P = .050; 3.87, P = .027). Even though no statistically significant differences were observed between women with ovulatory PCOS and controls, we detected statistically significant differences in all domains of sexual function apart from pain between controls and PCOS women with anovulation (desire P value .04, arousal P value <.001, lubrication P value <.001, orgasm P value .001, satisfaction P value .001 and FSFI total score P value <.001).Clinical ImplicationsWomen with PCOS have compromised sexual function, which is independent of their BMI and highly dependent on their ovulatory status.Strengths and LimitationsThis is the first study in women with PCOS that implicates anovulation as a risk factor for sexual impairment in PCOS. Further studies are needed to elucidate the mechanisms implicated and to examine the effect of PCOS therapy on the patients’ sexual function.ConclusionThe adverse effect of PCOS status on the female sexual function is independent of BMI and only partially dependent on hormonal changes characterizing the syndrome. Anovulation appears to be the major determinant of sexual impairment among women with PCOS.Mantzou D, Stamou MI, Armeni AK, et al. Impaired Sexual Function in Young Women With PCOS: The Detrimental Effect of Anovulation. J Sex Med 2021;18:1872–1879.     

Educational Programs and Sexual Counselling for Postmenopausal Sexual Dysfunction: A Systematic Review and Meta-Analysis

BackgroundFemale sexual dysfunction has a high prevalence in women in the postmenopausal period. Not only factors like comorbidities and chronic illnesses are responsible for this high prevalence, but also psychological and interpersonal factors play a significant role. Sexual counselling educational programs have shown positive sexual behavioral changes and they should be considered the first line approach to female sexual dysfunction in this group of women.AimTo review the evidence of the efficacy of sexual counselling educational programs for sexual dysfunction in postmenopausal women.MethodsA systematic search was performed in February 2021 from electronic databases (MEDLINE, CENTRAL, and Scopus), unpublished studies, ongoing clinical trials, conference abstracts and journal archives, dissertations and theses, gray literature and free search on the Google Scholar search engine. Studies that evaluate the effectiveness of sexual educational programs in postmenopausal women were selected. Study selection and data extraction were performed by 2 independent researchers. Extracted data included author identification, publication date, geographic location, study population and sample size, type of intervention, sexual function evaluation tool and outcome. Studies that evaluate sexual function by using the Female Sexual Function Index (FSFI) were included in the meta-analysis, calculating the mean difference.OutcomesImprovement of sexual function in postmenopausal women.ResultsWe included 8 studies in the systematic review, 6 randomized and 2 nonrandomized controlled trials, with a total sample size of 619 women, aged between 39 and 75 years old, all in menopause for less than 5 years. The studies described sexual education programs, with 4–10 sessions, 45–60 minutes each, including themes like sexual anatomy, physiological sexual response, menopause, methods of stimulation, and common sexual myths. Five studies also included cognitive-behavior therapy and 3 studies assessed mindfulness techniques. Six studies evaluated the effectiveness of sexual educational programs using FSFI. The results showed that sexual counselling educational programs had statistically significant effects on enhancing the total FSFI score (mean difference = +7.14, 95% confidence interval = 3.70–10.6, P < .0001) in comparison to routine care. Results were also significant in all evaluated sex domains: pain, arousal, lubrication, desire, orgasm and satisfaction (P < .05).ConclusionOur meta-analysis shows that sexual counselling educational programs are effective in improving sexual dysfunction in postmenopausal women when compared to routine care. These are simple approaches, easily administered with minimal resources that help prevent the psychological and social consequences of sexual dysfunction at this age. IMS Silva, MP Pinto, D Gonçalves. Educational Programs and Sexual Counselling for Postmenopausal Sexual Dysfunction: A Systematic Review and Meta-Analysis. J Sex Med 2022;19:54–63.     

Intravaginal electrical stimulation as a monotherapy for female stress urinary incontinence: A systematic review and meta-analysis

Background and purposeSince patients, physiotherapists and gynaecologists continue to seek effective conservative treatments for stress urinary incontinence (SUI), the aim of this systematic review and meta-analysis was to determine the therapeutic efficacy of intravaginal electrical stimulation (ES) in women with SUI.MethodsWe searched PubMed, Embase, EBSCOHost and Ovid for randomized controlled trials. For dichotomous data, we calculated the risk ratio (RR) and 95% confidence interval (CI). For continuous data, we calculated the mean difference (MD) and 95% CI. Heterogeneity was assessed with I² statistics.ResultsOf the 686 records identified, a total of 10 articles met the inclusion criteria. A meta-analysis revealed significant differences between the ES and no active treatment groups in the pooled objective cure rates (RR: 4.20; 95% CI: 1.70 to 10.40; p = 0.001; I² = 0%) and subjective cure or improvement rates (RR: 4.96; 95%: 1.01 to 24.37; p = 0.04; I² = 0%). No significant differences were found in the pooled number of incontinence episodes per 24 h (MD: 0.16; 95% CI: 0.68 to 0.37; p = 0.56; I² = 0%), the pooled Incontinence Quality of Life Questionnaire scores (MD: 1.84; 95% CI: 2.11 to 5.80; p = 0.36; I² = 0%) or the pooled number of adverse effects (RR: 0.69; 95% CI: 0.38 to 1.27; p = 0.23; I² = 0%) between the ES and other conservative treatment groups.ConclusionThere was insufficient evidence for or against the use of intravaginal ES therapy for women with SUI, partly due to the variability in the interventions of the included trials and the small number of trials included.     

Genital Pain and Numbness and Female Sexual Dysfunction in Adult Bicyclists

IntroductionBicycle seat pressure on the perineum may impair arousal and clitoral erection, likely contributing to genital pain and numbness experienced by female cyclists.AimWe aimed to identify the association between genital pain and numbness experienced by female cyclists and female sexual dysfunction (FSD).MethodsFemale cyclists were recruited to complete an online survey using the Female Sexual Function Index (FSFI), a validated questionnaire to assess FSD. Cyclist demographics, experience, preferred riding style, use of ergonomic cycle modifications, and genital discomfort while riding were also queried. Multivariate logistic regression analysis was used to evaluate risk factors of FSD.Main Outcome MeasuresThe main outcome was FSFI score, which is used to diagnose FSD when the FSFI score is <26.55.ResultsOf the survey respondents, 178 (53.1%) completed the survey and FSFI questionnaire. Mean age was 48.1 years (±0.8 standard error [SE]), and the average riding experience was 17.1 years (±0.9 SE). Overall, 53.9% of female cyclists had FSD, 58.1% reported genital numbness, and 69.1% reported genital pain. After adjusting for age, body mass index, relationship status, smoking history, comorbidities, and average time spent cycling per week, females who reported experiencing genital numbness half the time or more were more likely to have FSD (adjusted odds ratio [aOR], 6.0; 95% CI, 1.5–23.6; P = .01), especially if localized to the clitoris (aOR, 2.5; 95% CI, 1.2–5.5; P = .02). Females that reported genital pain half the time or more while cycling also were more likely to have FSD (aOR, 3.6; 95% CI, 1.2–11.1; P = .02). Cyclists experiencing genital pain within the first hour of their ride were more likely to have FSD (aOR, 12.6; 95% CI, 2.5–63.1; P = .002). Frequency and duration of cycling were not associated with FSD. Analysis of FSFI domains found that the frequency of numbness was correlated with decreased arousal, orgasm, and satisfaction during intercourse, whereas the frequency of pain significantly reduced arousal, orgasm, and genital lubrication.Clinical ImplicationsFemale cyclists that experience numbness and/or pain have higher odds of reporting FSD.Strengths & LimitationsOur study includes a validated questionnaire to assess FSD and queries specific characteristics and symptoms of genital pain and genital numbness; however, the study is limited by its cross-sectional survey design.ConclusionThis study highlights the need for cyclists to address genital pain and numbness experienced while cycling, and future studies are required to determine if alleviating these symptoms can reduce the impact of cycling on female sexual function.Greenberg GR, Khandwala YS, Breyer BN, et al. Genital Pain and Numbness and Female Sexual Dysfunction in Adult Bicyclists. J Sex Med 2019; 16:1381–1389.     

Erectile Dysfunction and Risk of Clinical Cardiovascular Events: A Meta-Analysis of Seven Cohort Studies

IntroductionFor many years, erectile dysfunction (ED) has been considered as a complication of cardiovascular disease (CVD) or regarded as a late consequence of generalized arterial disease. However, a growing body of evidence suggests that ED is an early manifestation of atherosclerosis and a precursor to systemic vascular disease.AimWe conducted a meta-analysis to evaluate the association between ED and the risk of CVD events.MethodsRelevant studies published between January 1966 and September 2009 were identified by searching Medline, Embase, and The Cochrane Library. Studies were selected using a prior defined criteria. The strength of the relationship between ED and CVD events was assessed by adjusted relative risks (RRs).Main Outcome MeasuresThe adjusted RRs of CVD events.ResultsA total of 45,558 participants from seven cohort studies (eight full-text articles) were identified in this meta-analysis. The studies provided adjusted RRs estimates for ED subjects comparing with health subjects, leading to a pooled adjusted RR of 1.47 (95% confidence interval [CI], 1.29–1.66, P < 0.001; P for heterogeneity = 0.152; I² = 36.2%) for CVD events. The risks of CVD, all-cause mortality and myocardial infarction were 1.41 (95% CI, 1.22–1.64 P < 0.001), 1.23 (95% CI, 1.02–1.48; P = 0.034), and 1.43 (95% CI, 1.10–1.85 P = 0.007), respectively. The overall adjusted RR decreased significant from 1.63 (<7 years) to 1.37 (≥7 years) along with the elongation of follow-up.ConclusionsThere is evidence of an increased risk of CVD events for patients with ED. Patients who are discovered to have ED are supposed to be thoroughly assessed for cardiovascular risk and occult systemic vascular disease. Guo W, Liao C, Zou Y, Li F, Li T, Zhou Q, Cao Y, and Mao X. Erectile dysfunction and risk of clinical cardiovascular events: A meta-analysis of seven cohort studies.     

Genital Pain and Sexual Functioning: Effects on Sexual Experience,Psychological Health,and Quality of Life

BackgroundGenital pain (GP) is a common symptom in women of reproductive age. The prevalence of GP is difficult to gauge as it has been underreported by both patients and clinicians and neglected in clinical studies despite wide recognition of the adverse effects to women's health.AimThe purpose of the present study was 3-fold: (i) to explore the self-reported presence and perception of GP and its association with sexual functioning, sexual distress, emotions, psychopathology, and quality of life (QoL); (ii) to explore if, controlling for the pain effect, women with Female Sexual Function Index (FSFI) scores indicating sexual dysfunction also reported worse outcomes regarding sexual distress, emotions, psychological health, and QoL than GP women with higher FSFI scores; and (iii) to evaluate the effects of GP duration, comparing women with GP with shorter (<6 months) duration of symptoms with women with longer (≥6 months) duration of symptom of GP on sexual functioning, distress, emotions, psychopathology and QoL.MethodsA total of 1,034 women (age ranges between 18 and 40 years) from the Italian general population completed a web survey on sexual health.Outcomes6 self-report questionnaires exploring different biopsychosocial factors were assessed: the FSFI, the Female Sexual Distress Scale, the Positive and Negative Affect Schedule, the Short Form McGill Pain Questionnaire adapted for GP, the Short Form 36, and the Symptom Check List-90-Revised.ResultsWomen who reported GP (n = 319) indicated generally lower sexual function than women without GP (n = 648; P = .036). They reported a higher level of sexual distress (P < .001), more negative emotions related to sexual experiences (P = .001), lower scores in all QoL domains (P < .001), and higher levels of psychopathological symptoms (P < .001). Controlling for pain effects, women whose FSFI scores indicated sexual dysfunction (n = 150) reported higher rates of sexual distress than women whose FSFI scores indicated normal sexual function (n = 169; P < .001).The scores also indicated fewer positive (P < .001) and more negative emotions (P < .001) related to sexuality, lower QoL (P < .001) and significantly higher psychological burden (P < .001). Moreover, women experiencing GP for ≥6 months reported significantly lower means on the FSFI total score (P < .05; especially in the desire, satisfaction, and pain domains), distress (P < .001), and emotions (P < .05) than women experiencing GP duration <6 months. No significant differences were found on the QoL and the psychopathological symptoms.Clinical ImplicationsGP is significantly pervasive, but a high percentage of sexual problems and related emotional suffering is overlooked. Raising awareness about this issue is critical, both among clinicians and the general public.Strengths & LimitationsThe present study highlighted important characteristics of GP from a community sample; the results indicate problems related to pain experiences and their repercussions on sexual, psychological, affective health, and QoL. Major limitations are related to the use of self-report measures via a web-based study.ConclusionThe results provide evidence of a lack of awareness regarding pain experiences as they relate to sexual functioning in women; clinicians would be advised to more fully investigate sexual functioning and psychosocial variables associated with GP during routine consultation beginning with the first onset of the symptoms.Nimbi FM, Rossi V, Tripodi F, et al. Genital Pain and Sexual Functioning: Effects on Sexual Experience, Psychological Health, and Quality of Life. J Sex Med 2020; 17:771–783.     

Is There a Relationship Between Overactive Bladder and Sexual Dysfunction in Women With Multiple Sclerosis?

BackgroundLower urinary tract Symptoms (LUTS) and Sexual dysfunction (SD) are common in women with MS and affect quality of life.AimThe aim of this study was to determine the relationship between sexual dysfunction (SD) and overactive bladder in women with Multiple Sclerosis (MS).MethodsFrom January 2019 to January 2021, we evaluated 89 female MS patients admitted for LUTS in a Neuro-Urology Department. SD was investigated using the Female Sexual Function Index (FSFI). All subjects completed the Urinary Symptom Profile scale (USP) and Hospital Anxiety and Depression Scale (HAD A/HAD D). Neurological impairment was assessed using the Expanded Disability Status Scale (EDSS). All patients underwent neurological examination and urodynamic studies. Univariate analysis and Multivariate logistic regression analysis were performed to identify predictors of SD in women with MS (FSFI <26.55).OutcomesPrimary outcome was to determine the association between sexual dysfunction in women with MS and LUTS (overactive bladder, stress incontinence or voiding dysfunction).ResultsSexual dysfunction (FSFI<26,55) affected 74% of women with MS, even with low physical disabilities (EDSS<5). Univariate analysis showed that overactive bladder was more frequent in SD group, but no statistical difference was found (P < .12). No relationship was found between sexual dysfunction and stress incontinence (P = ,47), voiding dysfunction (P= 0.79) or urinary retention (P= .96). Multivariate logistic regression analysis identified overactive bladder to be an independent predictor of sexual dysfunction [aOR 0.03 (CI 0,0.98)]. Sexual dysfunction was not associated with detrusor overactivity on urodynamic studies or with impairment mobility but was strongly associated with the presence of depression (P < .01).Clinical implicationsSexual disorders in women with MS should be assessed as much as urinary disorder.Strengths and limitationsthis study included the largest cohort of women with MS. But the sample was obtained in an outpatient setting with low neurological impairment.ConclusionIn our study, SD was frequent affecting young women with no anticholinergic treatment and low physical impairment. Overactive bladder seemed to be independent predictor of sexual dysfunction. Conversely, SD was not associated with detrusor overactivity, neurological impairment, or duration of disease but was strongly associated with depression.Breton FL, Chesnel C, Lagnau P, et al. Is There a Relationship Between Overactive Bladder and Sexual Dysfunction in Women With Multiple Sclerosis?. J Sex Med 2022;19:729–737.     

Male and Female Sexual Dysfunction in Pediatric Cancer Survivors

BackgroundPediatric cancer survivors suffer indirect long-term effects of their disease; however, there is a paucity of data regarding the effect of pediatric cancer survivorship on sexual function.AimTo assess the prevalence and risk factors associated with sexual dysfunction among pediatric cancer survivors.MethodsPediatric cancer survivors were recruited to complete an online survey using the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF-5), both validated questionnaires to assess female sexual dysfunction (FSD) and erectile dysfunction (ED). Patient demographics, oncologic history, prior treatment, and sexual habits were also queried. Logistic regression was used to evaluate risk factors for sexual dysfunction, and Mann-Whitney U test was used to identify factors associated with individual domains of the FSFI.OutcomesThe main outcome measures were FSFI and IIEF-5 score, which are used to diagnose FSD (FSFI<26.55) and ED (IIEF-5<22).ResultsA total of 21 (72.4%) female respondents and 20 (71.4%) male respondents were sexually active and completed the survey and FSFI or IIEF-5 questionnaire, respectively. Mean (±SD) age was 23.7 (4.1) years, and average age at diagnosis was 9.1 (5.0), with no difference between genders. Overall, 25.0% (5/20) of male and 52.4% (11/21) of female pediatric cancer survivors reported sexual dysfunction (P = .11). Oncologic history and prior treatment were not associated with sexual function. Females who reported difficulty relaxing during intercourse in the last 6 months had higher odds of reporting sexual dysfunction (odds ratio: 13.6, 95% confidence interval: 1.2–151.2, P = .03). Subgroup analysis of FSFI domains found that previous radiation therapy was correlated with decreased lubrication and satisfaction during intercourse, whereas previous treatment to the pelvic region significantly reduced satisfaction and increased pain during intercourse.Clinical ImplicationsFemale pediatric cancer survivors have higher odds of reporting sexual dysfunction after treatment and should be screened appropriately to provide early intervention and to mitigate risk.Strength & LimitationsOur study includes validated questionnaires to assess FSD and ED and queries specific characteristics to assess their association with sexual dysfunction. However, the study is limited by sample size and its cross-sectional survey design.ConclusionsThe prevalence of female sexual dysfunction in this cohort is higher than that in the general population of equivalent-aged individuals, and clinicians should be aware of these potential long-term sequelae.Greenberg DR, Khandwala YS, Bhambhvani HP, et-al. Male and Female Sexual Dysfunction in Pediatric Cancer Survivors. J Sex Med 2020;17:1715–1722.     

Erectile Dysfunction in Multiple Sclerosis: A Prevalence Meta-Analysis and Systematic Review

BackgroundA connection between multiple sclerosis (MS) and erectile dysfunction (ED) has been debatable.AimTo assess the pooled prevalence of ED among men with MS and whether MS was a risk factor for ED.MethodsA systematic review of the literature was conducted in PubMed, Scopus, Web of Science, and the Cochrane Library to find relevant English-language studies published up to February 2022 that assessed the prevalence of ED in MS patients. Two authors independently evaluated the full text of the enrolled studies to determine eligibility, and if there was disagreement, the decision was made by a third author after discussion. Assessment tools adapted for prevalence studies were used to evaluate the quality of cross-sectional studies, and the quality of case-control studies was assessed by Newcastle-Ottawa scale. The relative risk (RR) and its 95% confidence interval (CI) were used to assess the strength of association between MS and the risk of ED. The sources of heterogeneity were investigated by subgroup analysis. Sensitivity analysis was conducted to evaluate the stability of the results.OutcomesThe pooled prevalence of ED in MS patients as well as 95% CIs were estimated, and the RR and its 95% CI were used to assess the strength of association between MS and the risk of ED.ResultsSixteen studies included collectively gave information about ED in 2,760 MS men, resulting in a pooled prevalence of 49% (95% CI = 42–56%) for ED with a large heterogeneity. Synthesis of results revealed that MS was significantly associated with an increased risk of ED (RR = 3.17, 95% CI = 2.31–4.36, P < .001; heterogeneity: I² = 0.0%, P = .716). The pooled prevalence estimates of ED were 55, 63, and 57% in the age >40, IIEF diagnostic tool, and mean disease duration >10 years subgroups, respectively.Clinical ImplicationsThe present meta-analysis indicates that MS patients had a significantly increased risk of ED, which should raise awareness of the potential association between MS and ED by clinicians.Strengths & LimitationsThis is the first meta-analysis to provide the global prevalence of ED in MS patients and to demonstrate that MS is a risk factor for ED. However, all enrolled studies were observational in design, which may reduce the robustness of this evidence.ConclusionResults of this meta-analysis showed that ED was highly prevalent in adult men with MS and MS was a potential risk factor for ED development.Wu X, Zhang Y, Zhang W, et al. Erectile Dysfunction in Multiple Sclerosis: A Prevalence Meta-Analysis and Systematic Review. J Sex Med 2022;19:1255–1268.