Use of pelvic floor ultrasound to assess pelvic floor muscle function in Urological Chronic Pelvic Pain Syndrome in men

IntroductionAn important cause or maintaining factor for pain in Urological Chronic Pelvic Pain Syndrome (UCPPS) may be pelvic floor muscle (PFM) dysfunction, which may also be implicated in sexual dysfunction and influenced by psychosocial factors. Pelvic floor ultrasound is a noninvasive, reliable, and relatively simple method to assess PFM morphology and function and can be assessed by the anorectal angle (ARA) and levator plate angle (LPA).AimsThe aim of the present study was to examine PFM morphology in men with UCPPS as compared with controls and to examine the correlation with pain and psychosocial measures.MethodsOur participants were 24 men with UCPPS and 26 controls. A GE Voluson E8 ultrasound probe was placed on the perineum, and three‐dimensional images were taken at rest and during PFM contraction.Main Outcome MeasuresThe main outcomes were ARA and LPA at rest and contraction. Participants also completed the National Institute of Health (NIH) Chronic Prostatitis Symptom Index, Male Sexual Health Questionnaire, State Anxiety Inventory, and Pain Catastrophizing Scale.ResultsMen with UCPPS had more acute ARAs than controls both at rest and during contraction. The two groups did not differ in LPA at rest; however, men with UCPPS had significantly more acute angles during contraction and LP excursion. Acute ARAs were positively correlated with greater pain report and sexual dysfunction. Anxiety was correlated with more acute ARAs and more obtuse LPAs.ConclusionThree implications can be drawn from the findings. First, ARA at rest and during contraction as well as LP angle during contraction and LPA excursion separates men with UCPPS from controls. Second, ARA at rest and during contraction was correlated with pain and sexual dysfunction, while LPA at rest was related to anxiety. Third, pelvic floor ultrasound has the potential to be a useful and objective method of assessing PFM morphology in UCPPS. Davis SN, Morin M, Binik YM, Khalife S, and Carrier S. Use of pelvic floor ultrasound to assess pelvic floor muscle function in urological chronic pelvic pain syndrome in men. J Sex Med 2011;8:3173–3180.     

Predictors of sexual and relationship functioning in couples with Chronic Prostatitis/Chronic Pelvic Pain Syndrome

IntroductionBoth partners in a relationship are typically affected when one experiences sexual dysfunction and/or pain. However, couple functioning has rarely been investigated in Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS), a common condition in men involving pelvic pain and sexual dysfunction.AimTo identify potential predictors of sexual and relationship function among couples with CP/CPPS, and to examine associations among pain, sexual, and relationship variables in patients and their women partners.MethodsThirty-eight patients with CP/CPPS and their women partners completed questionnaires assessing sexual and relationship function via mail.Main Outcome MeasuresPatients completed a subscale from the Multidimensional Pain Inventory and the International Index of Erectile Function. Partners completed the Female Sexual Function Index. All participants completed the Golombok–Rust Inventory of Sexual Satisfaction and the Dyadic Adjustment Scale.ResultsCouples' sexual function, sexual satisfaction, and relationship adjustment were all significantly associated. Pain severity significantly predicted sexual and relationship functioning among couples. However, multiple regression models revealed that sexual and relationship variables were the strongest predictors of patient and partner functioning, over and above pain severity. Patient sexual function was predicted by patient sexual satisfaction and female sexual function, whereas female sexual function was predicted by female sexual satisfaction and patient relationship adjustment. With regard to sexual satisfaction, patient sexual function and relationship adjustment and female relationship adjustment predicted patient sexual satisfaction. Female sexual function predicted female sexual satisfaction. Among both patients and partners, relationship adjustment was significantly predicted by that of one's partner. The only partner variable that was significantly predicted by patient pain severity was female sexual function.ConclusionsSignificant links exist among the sexual and relationship functioning of patients with CP/CPPS and their partners. These results emphasize the importance of the interpersonal context on couples' functioning, and highlight the need to adopt a biopsychosocial approach when investigating CP/CPPS. Smith KB, Tripp D, Pukall C, and Nickel JC. Predictors of sexual and relationship functioning in couples with Chronic Prostatitis/Chronic Pelvic Pain Syndrome.     

A Prospective Study on Association of Prostatic Calcifications with Sexual Dysfunction in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

IntroductionChronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common debilitating condition of unclear etiology. Sexual dysfunction is an important component of the clinical phenotype of CP/CPPS. Patients often have prostatic calcifications, but a link to sexual dysfunction is unknown.AimThe aim of this study was to evaluate the association of prostatic calcifications with sexual dysfunction in this condition.MethodsA total of 358 males with CP/CPPS were consecutively enrolled, and a prospectively maintained database of these patients was analyzed. Calcifications were diagnosed using ultrasound imaging of the prostate. Symptom severity was measured using the National Institutes of Health Chronic Prostatitis Symptom Index (CPSI). Sexual dysfunction was evaluated using the validated 15‐item International Index of Erectile Function (IIEF‐15) questionnaire and 5‐item Premature Ejaculation Diagnostic Tool scales. The variables were compared between patients with prostatic calcifications and those without using the Student's t‐test, Wilcoxon unpaired test, or chi‐square test.Main Outcome MeasureLogistic regression models were developed to explore a possible association between prostatic calcifications and sexual dysfunction.ResultsMeasurable calcifications in the prostate were found in 175 (48.9%) of the 358 patients. Patients with calcifications were more likely to have higher white blood cell counts or positive bacteria cultures in their prostatic fluid, longer symptoms duration, and lower scores for the total IIEF‐15, IIEF‐erectile function, and IIEF‐intercourse satisfaction domains (P < 0.001 for each). However, the scores for CPSI, premature ejaculation, and IIEF‐orgasmic function, IIEF‐sexual desire, and IIEF‐overall satisfaction domains were identical between men with and without calcifications (P > 0.05 for each). Furthermore, logistic regression analyses revealed that intraprostatic calcification is significantly associated with self‐assessed erectile dysfunction (ED) (odds ratio:3.632, 95% confidence interval: 2.405–5.822, P < 0.001).ConclusionOur results showed that prostatic calcifications are significantly associated with the presence of ED in CP/CPPS males. Zhao Z, Xuan X, Zhang J, He J, and Zeng G. A prospective study on association of prostatic calcifications with sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). J Sex Med 2014;11:2528–2536.     

Tenderness as measured by pressure pain thresholds extends beyond the pelvis in chronic pelvic pain syndrome in men

IntroductionUrological Chronic Pelvic Pain Syndrome (UCPPS) in men is a common complaint, and causes significant impairment in quality of life. Until recently, the focus of research has primarily been on pain symptoms or underlying prostate pathology. However, new clinical phenotyping demonstrates pelvic tenderness to be an important component of UCPPS. Unfortunately, mechanisms underlying tenderness remain to be understood, and tenderness itself has not been well quantified.AimTo validate the use of pressure pain thresholds as a method of measuring tenderness in UCPPS and to demonstrate that tenderness extends beyond the pelvis.MethodsFifty‐five men diagnosed with UCPPS and 46 healthy controls were recruited through referrals and advertisements. Each participant filled out questionnaires and was assessed by a structured interview. In addition, all UCPPS men underwent urological assessment.Main Outcome MeasuresDemographic information was collected as well as the National Institutes of Health‐Chronic Prostatitis Symptom Index. Using a digital algometer, pressure pain thresholds on 10 genito‐pelvic and one control site (deltoid) were measured. The four‐glass test was used for all UCPPS men.ResultsUCPPS men had reliably lower pain thresholds compared to controls in all locations, including the deltoid. UCPPS men also demonstrated consistently lower overall pain thresholds regardless of location. Furthermore, pressure pain thresholds were able to correctly distinguish patients from controls 77% of the time. Prostate infection did not influence pain thresholds.ConclusionsLower pelvic and nonpelvic thresholds suggest the involvement of a central mechanism in UCPPS. Overall, the data confirm the move away from a prostate‐based view of UCPPS. This is supported by the failure to find threshold differences related to prostate infection. Pressure pain thresholds appear to be a promising method of assessing tenderness in UCPPS. Davis SNP, Maykut CA, Binik YM, Amsel R, and Carrier S. Tenderness as measured by pressure pain thresholds extends beyond the pelvis in chronic pelvic pain syndrome in men. J Sex Med 2011;8:232–239.     

Evaluation of Quality of Life and Sexual Satisfaction in Women Suffering from Chronic Pelvic Pain With or Without Endometriosis

IntroductionChronic pelvic pain (CPP) is one of the most frequent symptoms in women of reproductive age. This is an enigmatic clinical condition that results from the complex interactions of physiological and psychological factors with direct impact on the social, marital, and professional lives of women.AimTo evaluate the quality of life and sexual satisfaction of women who suffer from CPP with or without endometriosis.MethodForty‐nine patients who had been diagnosed with endometriosis and 35 patients with CPP diagnosed with another gynecological condition, all 84 of whom were treated at the Chronic Pelvic Pain and Endometriosis Clinic at Universidade Federal de São Paulo (UNIFESP) from January to July of 2008. The controls were 50 healthy women from the Family Planning Clinic at UNIFESP.Main Outcome MeasuresWorld Health Organization Quality of Life Assessment‐Bref (WHOQOL‐BREF) quality of life questionnaire and the Golombok‐Rust Inventory of Sexual Satisfaction (GRISS).ResultsNo statistically significant differences were observed between the groups with CPP symptoms, in either the results from the WHOQOL‐BREF or in the GRISS questionnaire. In both questionnaires, differences were observed when the two groups of symptomatic women were compared with the group of healthy women.ConclusionCPP caused by endometriosis or other gynecological conditions leads to a significant reduction of quality of life and sexual satisfaction. Tripoli TM, Sato H, Sartori MG, de Araujo FF, Girão MJBC, and Schor E. Evaluation of quality of life and sexual satisfaction in women suffering from chronic pelvic pain with or without endometriosis. J Sex Med 2011;8:497–503.     

Pelvic Examination Experiences in Women With and Without Chronic Pain During Intercourse

IntroductionAlthough pelvic examinations (PEs) are an important component of women's health, some women experience difficulty during PEs due to anxiety and pain. These difficulties may be heightened in women with chronic pain during sexual intercourse. Some evidence suggests that this population experiences pain and distress during PEs, but their experiences in this context have not been empirically investigated from a multidimensional perspective.AimsThe aims of this study were to compare the PE experiences of women with and without pain during intercourse and to examine predictors of negative experiences in each group.MethodWomen with vulvovaginal pain (n = 90), pelvic pain (n = 89), and women without current intercourse pain (n = 207) completed an online survey including sections assessing demographics, gynecological and medical history, and PE experiences. Respondents completed questionnaires assessing vaginal penetration cognitions and body image.Main Outcome MeasuresParticipants rated their most recent PE on numerical scales for pain, embarrassment, anxiety, and the overall quality of the experience.ResultsWomen with pelvic and vulvovaginal pain during intercourse reported significantly more pain and anxiety during their most recent PE compared with the no pain group, and women with a higher number of lifetime gynecological diagnoses reported significantly more pain. Multiple regression analyses indicated that various predisposing, examination‐related, and psychological factors predicted specific PE ratings in each group.ConclusionsThe results provide empirical support that PEs are more physically and emotionally difficult for women who experience chronic pain during intercourse. These findings have important clinical implications, as PEs are a critical part of complete reproductive care and play an essential role in the assessment/management of sexual pain, including Genito‐Pelvic Pain/Penetration Disorder. Boyer SC and Pukall CF. Pelvic examination experiences in women with and without chronic pain during intercourse. J Sex Med 2014;11:3035–3050.     

Sexual Satisfaction and Frequency of Orgasm in Women With Chronic Pelvic Pain due to Endometriosis

BackgroundDyspareunia, one of the main symptoms of the chronic gynecological pelvic pain disorder endometriosis, may interfere with the likelihood of reaching an orgasm, yet for women with dyspareunia, no data on orgasm rates in different sexual activities are available.AimThe aim of this study was to evaluate the ability to reach an orgasm and its association with sexual satisfaction during different sexual activities in women with a chronic pelvic pain disorder and in healthy control women.MethodsA set of questionnaires including the brief index of sexual functioning and global sexual functioning was used to evaluate sexuality in women affected with endometriosis (n = 434) and a nonaffected control group (n = 434) recruited in German-speaking countries.OutcomesThe primary outcome measure of this study was the orgasm rate during different types of sexual activities.ResultsOnly the ability to have an orgasm during sexual intercourse (P = .002) but not during masturbation (P = .509) or partnered noncoital sexual activities (P = .229) is affected by endometriosis. Dyspareunia was associated with a reduced ability to experience an orgasm during intercourse for endometriosis patients (P = .020) and control women (P = .006). The ability to orgasm during noncoital sexual activities (P = .006) and sexual intercourse (P = .038) was associated with a higher sexual satisfaction in women with endometriosis. For controls, only the ability to achieve an orgasm with sexual intercourse was associated with sexual satisfaction (P = .038).Clinical implicationsSexual counselling as part of medical support could help couples living with chronic pelvic pain of the female partner integrate noncoital sexual activities in their sex lives, leading to fewer sex-related problems and higher sexual desire and satisfaction.Strengths and limitationsThis study is the first to examine different ways of achieving an orgasm and sexual satisfaction in a large group of women with endometriosis and a matched control group. The breadth of the questionnaire allowed a differentiated analysis of factors influencing the likelihood of achieving an orgasm and overall sexual satisfaction. The one limitation is that the length and the intimate nature of the questionnaire possibly resulted in reluctance to answer this part of the questionnaire.ConclusionPartnered noncoital sexual activities may represent an alternative to reach orgasm for women with endometriosis-related chronic pelvic pain or anorgasmia during sexual intercourse.Hämmerli S, Kohl-Schwartz A, Imesch P, et al. Sexual Satisfaction and Frequency of Orgasm in Women With Chronic Pelvic Pain due to Endometriosis. J Sex Med 2020;17:2417–2426.     

Prevalence of Chronic Pelvic Pain by Sexual Orientation in a Large Cohort of Young Women in the United States

BackgroundSexual minority (lesbian, bisexual, mostly heterosexual) young women face many sexual and reproductive health disparities, but there is scant information on their experiences of chronic pelvic pain, including an absence of information on prevalence, treatment, and outcomes.AimThe purpose of this study was to describe the characteristics of chronic pelvic pain experiences of young women by sexual orientation identity and gender of sexual partners.MethodsThe analytical sample consisted of a nationwide sample of 6,150 U.S. young women (mean age = 23 years) from the Growing Up Today Study who completed cross-sectional questionnaires from 1996 to 2007.OutcomesAge-adjusted regression analyses were used to examine groups categorized by sexual orientation identity (completely heterosexual [ref.], mostly heterosexual, bisexual, lesbian) and gender of sexual partner (only men [ref.], no partners, both men, and women). We examined differences in lifetime and past-year chronic pelvic pain symptoms, diagnosis, treatment, and quality of life outcomes. Sensitivity analyses also examined the role of pelvic/gynecologic exam history and hormonal contraceptive use as potential effect modifiers.ResultsAround half of all women reported ever experiencing chronic pelvic pain, among whom nearly 90% had past-year chronic pelvic pain. Compared to completely heterosexual women, there was greater risk of lifetime chronic pelvic pain among mostly heterosexual (risk ratio [RR] = 1.30, 95% confidence interval [CI]: 1.22–1.38), bisexual (RR = 1.30, 95% CI: 1.10–1.52), and lesbian (RR = 1.23, 95% CI: 1.00–1.52) young women. Additionally, compared to young women with only past male sexual partners, young women who had both men and women as past sexual partners were more likely to report chronic pelvic pain interfered with their social activities (b = 0.63, 95% CI: 0.25–1.02), work/school (b = 0.55, 95% CI: 0.17–0.93), and sex (b = 0.53, 95% CI: 0.05–1.00).Clinical ImplicationsHealthcare providers, medical education, and field-wide standards of care should be attentive to the way sexual orientation-based healthcare disparities can manifest into differential prognosis and quality of life outcomes for women with chronic pelvic pain (particularly bisexual women).Strengths & LimitationsOur study is the first to examine a variety of chronic pelvic pain outcomes in a nationwide U.S. sample across different outcomes (ie, past-year and lifetime). Though limited by sample homogeneity in terms of age, race, ethnicity, and gender, findings from this article provide foundational insights about chronic pelvic pain experiences of sexual minority young women.ConclusionOur key finding is that sexual minority women were commonly affected by chronic pelvic pain, and bisexual women face pain-related quality of life disparities.Tabaac AR, Chwa C, Sutter ME, et al. Prevalence of Chronic Pelvic Pain by Sexual Orientation in a Large Cohort of Young Women in the United States. J Sex Med 2022;19:1012–1023.     

Temporal Summation in Chronic Pelvic Pain

ObjectiveThis study sought to characterize central sensitization further among women with chronic pelvic pain by identifying temporal summation using a cotton-tipped applicator test that can be used at the bedside.MethodA total of 36 women (18 with chronic pain and allodynia; 18 without pain) were recruited. Both groups were randomly assigned to receive 3 strokes of a benign stimulus on the abdomen at differing frequencies: 10, 30, or 100 seconds. Each group included 6 women. Pain was assessed using a rating scale of 1 to 10. Data were analyzed using the multivariate approach to repeated measures analysis of variance.ResultsThe pattern of pain scores differed significantly between women with and without chronic pain (P = 0.002). Women with chronic pelvic pain and allodynia showed a statistically significant increase in pain with successive strokes of the cotton-tipped applicator (P = 0.012 for stroke 1 vs. 2, P = 0.026 for stroke 2 vs. 3, and P = 0.005 for stroke 1 vs. 3).ConclusionWomen with chronic pelvic pain and allodynia showed significant worsening of pain with successive strokes of a cotton-tipped applicator. This finding indicates that pain wind-up and central sensitization are present in women with chronic pelvic pain and allodynia. Identification of summation is further evidence of neuroplasticity, which is helpful in innovative therapies for chronic pelvic pain.     

Relationship between Premature Ejaculation and Chronic Prostatitis/Chronic Pelvic Pain Syndrome

IntroductionChronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common etiology of premature ejaculation (PE). However, the current data are insufficient to explain this relationship and to support routine screening of men with PE.AimsThis study aims to evaluate the relationship between PE and CP/CPPS.MethodsA cross‐sectional study was conducted that included 8,261 men who had participated in a health examination. The Premature Ejaculation Diagnostic Tool (PEDT), the National Institutes of Health‐Chronic Prostatitis Symptom Index (NIH‐CPSI), and the International Index of Erectile Function‐5 (IIEF) were used for assessment of symptoms. A full metabolic work‐up and serum testosterone level checks were also performed. We then investigated the relationship using the Spearman correlation test, multiple linear regression, and logistic regression analyses.Main Outcome MeasuresAssociations of PEDT with NIH‐CPSI.ResultsThe mean age was 50.4 ± 5.5 years. In total, 2,205 (24.9%) men had prostatitis‐like symptoms (NIH‐CPSI pain score of ≥4 and perineal or ejaculatory pain), and 618 (7.0%) men had moderate to severe symptoms (NIH‐CPSI pain score of ≥8). Additionally, 2,144 men (24.2%) were classified as demonstrating PE (PEDT > 10). The PEDT score was found to have a significant positive correlation with the NIH‐CPSI pain domain score (correlation coefficient = 0.206; P < 0.001). After adjusting for age, metabolic syndrome status, testosterone level, and IIEF score, there was no change in the positive correlation between the NIH‐CPSI pain domain score and PEDT score (Beta = 0.175; P < 0.001). After adjusting for age, testosterone level, metabolic syndrome, and IIEF score, the odds ratio (OR) for PE significantly increased with the severity of pelvic pain (mild prostatitis‐like symptoms, OR for PE: 1.269, 95% confidence interval: 1.113–1.447; moderate to severe symptoms, OR for PE: 2.134: 95% confidence interval: 1.782–2.557).ConclusionsOur data showed a significant correlation between the PEDT score and the NIH‐CPSI score. We suggest routine screening for CP/CPPS in men with PE and PE in men with CP/CPPS. Lee JH and Lee SW. Relationship between premature ejaculation and chronic prostatitis/chronic pelvic pain syndrome. J Sex Med 2015;12:697–704.     

Pain Catastrophizing,Fear of Pain,and Depression and Their Association with Female Sexual Pain

IntroductionPainful sexual intercourse or dyspareunia is a common complaint among women, affecting 12–21% of premenopausal women. Recent studies have begun to focus on the role of fear avoidance and pain catastrophizing (PC) in genital pain and have consistently highlighted the importance of psych-affective factors in sexual pain.AimTo establish the importance of PC, fear of pain, and depression for the development and maintenance of female sexual pain.MethodsThis longitudinal study was conducted in the United Kingdom to assess sexual pain at 2 different time points, in 2009 and 2013, in a convenience sample of N = 979 British women.Main Outcome MeasureWell-validated questionnaires including the Pain Catastrophizing Scale, the Pain Anxiety Symptom Scale, and the Female Sexual Function Index (recent and lifelong version) were applied.ResultsMultilevel modeling showed a strong increase of short-lived sexual pain over the 4 years (π₀₁ = –0.33; P < .001). According to the moderation analyses, only depression influenced the change in short-lived pain over the 4 years (π₁₁ = 0.46; P = .016). Similarly, only depression turned out to be independently associated with sexual pain when entered into the multiple regression model, as women reporting higher depression levels also reported more sexual pain (P < 0.05).Clinical ImplicationsClinicians should be aware that the mechanisms influencing short-lived sexual pain and changes in sexual pain seem to be different from the more enduring psychological factors that lead to the development and maintenance of “chronic” sexual pain.Strengths & LimitationsA very generic and unidimensional definition of sexual pain was used without information on pain frequency or intensity, and no information on the possible underlying (medical or psychological or both) causes was available. However, as far as we know this represents the first study to use repeated measures to assess how pain changes over a 4-year period and to explore the role of potential psychoaffective risk factors.ConclusionAmong the variables studied, symptoms of depression seemed to be the only independent predictor of lifelong sexual pain, overriding potential influences of pain catastrophizing or fear of pain.Burri A, Hilpert P, Williams F. Pain Catastrophizing, Fear of Pain, and Depression and Their Association with Female Sexual Pain. J Sex Med 2020;17:279–288.     

Psychosexual Causes of Pelvic Pain

Theories and definitions of chronic pelvic pain are acknowledging emotional and stress factors as significant aetiologic contributors to this problem. Psychologic factors that play a major role in this complaint include depression, abuse, substance abuse, and relationship dysfunction. Sexual factors contribute to or result from the symptom of chronic pelvic pain. Lack of desire, lack of arousal, painful intercourse, and anorgasmia contribute collectively or independently. Assessment and management of the woman with chronic pelvic pain require attention to all of these factors to ensure avoidance of surgical mistreatment of the patient.     

The Association Between Pelvic Discomfort and Erectile Dysfunction in Adult Male Bicyclists

BackgroundBicycle riding's impact on erectile function remains a topic of great interest given cycling's popularity as a mode of transportation and exercise.AimWe evaluated risk factors for sexual dysfunction in male cyclists with the primary intention of determining if genital/pelvic pain and numbness are associated with erectile dysfunction (ED).MethodsWe surveyed male cyclists using an online anonymous questionnaire. Cyclists were queried on their demographics, cycling experience, and sexual function using the Sexual Health Inventory for Men (SHIM). ED was diagnosed when a completed SHIM score was <22. Regression analysis was used to evaluate the risk of ED in men with genital/pelvic pain or numbness after riding. The survey was designed in the United States.OutcomesQuantitative characterization of cycling habits, onset and timing of genital pain and numbness, and SHIM score.ResultsA total of 1635 participants completed the survey. A majority of men were over the age of 50 (58%, 934/1,607), Caucasian (88%, 1,437/1,635), had been active cyclists for over 10 years (63%, 1,025/1,635) and used road bikes (97%, 1,578/1,635). Overall, 22%, 30%, and 57% of men reported ED, genital pain, and genital numbness, respectively. While controlling for cohort demographics, body mass index, cycling intensity and equipment, and medical comorbidities, no saddle characteristics were associated with the risk of developing genital numbness. However, men reporting penile numbness were at higher risk of reporting ED (odds ratio [OR] = 1.453, P = .048). In addition, quicker onset of numbness and resolution of numbness within a day was associated with impaired erectile function. For example, numbness occurring less than 1 hour after cycling had greater odds of leading to ED than numbness after 5 hours (OR = 2.002, P = .032). Similarly, genital pain occurring less than 1 hour (OR = 2.466, P = .031) after cycling was associated with higher ED risk.Strengths & LimitationsStrengths include a large sample size of high-intensity cyclists and validated questionnaire use. Limitations include reliance on anonymous self-reported survey data and minimal inquiry into the riding preferences and terrain traversed by cyclists.ConclusionsPelvic pain and numbness are common complaints among male riders in the United States. Men with such complaints are more likely to also report ED especially if it occurs earlier in the ride. Although direction of causality and temporality are uncertain, alleviation of factors resulting in pelvic discomfort may reduce cycling's impact on sexual function. Such interventions are critical given that cycling for both active travel and aerobic exercise confers numerous health benefits.Balasubramanian A, Yu J, Breyer BN, et al. The Association Between Pelvic Discomfort and Erectile Dysfunction in Adult Male Bicyclists. J Sex Med 2020;17:919–929.     

Effect of Vaginal Stretching and Photobiomodulation Therapy on Sexual Function in Women With Pelvic Floor Myofascial Pain - A Randomized Clinical Trial

BackgroundSpasm or increased tonus of the pelvic floor muscles (PFM) can cause myofascial pain (MP), which may result in painful intercourse and sexual dysfunction.AimThe effect of vaginal stretching (VS) with photobiomodulation therapy (PBMT) is compared to VS with sham PBMT in overall sexual function, rate and severity of painful intercourse at baseline and after treatment in women with pelvic floor MP.MethodsA double-blind randomized clinical trial of 103 women with MP: 1 group received 10 sessions of VS with PBMT (4 Joules of near-infrared light-808 nm at 3 points), and the other group received VS with sham PBMT.OutcomesImpact of treatment was measured by the number of women experiencing painful intercourse, Pain severity was measured by Visual Analog Scale and sexual function was assessed by the FSFI questionnaire. Variables were assessed at baseline and after ten sessions in the intervention groups.ResultsAfter treatment, the number of women experiencing painful intercourse was significantly lower in both the VS with PBMT group (90.2–55%, P = .001), and VS with sham PBMT group (86.6–46.2%, P < .001). There was a significant reduction in pain measure by Visual Analog Scale (P < .001, [VS with PBMT group: P = .002; VS with sham PBMT group: P < .001]). There was a significant decrease in the number of participants with sexual dysfunction (FSFI score ≤26.55) after the treatment in the VS with PBMT group (92.2–74.5%, P = .003) and in the VS with sham PBMT group (90.4–76.9%, P = .035). Both groups showed improvement in the FSFI pain domain after treatment (P < .001, [VS with PBMT group: P = .038; VS with sham PBMT group: P = .005]). Only the VS with sham PBMT group had a significant increase in FSFI desire and total score (P < .001) after treatment.Clinical ImplicationsWe found that VS associated or not with PBMT may be effective in reducing complaints of painful intercourse, alleviating pain severity, and reducing the number of women with pelvic floor MP suffering from sexual dysfunction.Strengths & LimitationsStrengths of this study are the randomized design and use of validated questionnaires. Limitation of the study is the lack of a long follow-up period and the lack of a usual care comparison group hampers generalizability of the results.ConclusionVS only and VS with PBMT have short-term efficacy in reducing painful intercourse and reducing a number of women with sexual dysfunction.Frederice CP, de Mira TAA, Machado HC, et al. Effect of Vaginal Stretching and Photobiomodulation Therapy on Sexual Function in Women With Pelvic Floor Myofascial Pain - A Randomized Clinical Trial. J Sex Med 2022;19:98–105.     

Pelvic Radiotherapy and Sexual Function in Men and Women

IntroductionDespite the decrease in overall cancer incidence and mortality rates in developed countries since the early 1990s, cancer remains a major public health problem. Sexual dysfunction is one of the more common consequences of cancer treatment.AimTo shortly review the literature and level of evidence on sexual dysfunction in men and women following pelvic radiotherapy.Main Outcome MeasuresMale and female sexual dysfunction.MethodsLiterature review.ResultsSexual dysfunction in cancer patients is multidimensional and may result from biological, psychological, and social factors. Anatomic changes caused by surgery and/or radiotherapy, physiological changes following hormonal manipulation, and the secondary effect of medical intervention may impede or preclude sexual functioning, even when sexual desire is intact. Pelvic irradiation constitutes the primary or adjuvant treatment for a large number of both female and male cancers. No randomized controlled trials could be identified regarding the effect of radiotherapy on sexual dysfunction. However, prospective and clinical controlled trials all demonstrated a severe negative effect on sexual functioning in men and women following radiotherapy for a pelvic cancer.Following pelvic radiotherapy for prostate cancer, a positive effect of phosphodiesterase type 5 inhibitors on erectile dysfunction has been demonstrated, whereas no significant effect on female sexuality was found. Few studies evaluated treatment of female sexual dysfunction following radiotherapy; hormone replacement therapy and the use of vaginal dilator in combination with psycho‐educational support is recommended.ConclusionPelvic radiotherapy plays a significant negative role in the complex scenario of male and female sexual dysfunction. The literature has focused on sexual dysfunction and intervention in prostate and cervical cancer patients. Sexual dysfunction following pelvic radiotherapy for cancer in other pelvic organs, e.g., bladder, rectum, and anus, requires more attention in future studies. Health care providers should pay attention to and provide psychological and medical support regarding sexual dysfunction to all patients who have received pelvic radiotherapy. Incrocci L and Jensen PT. Pelvic radiotherapy and sexual function in men and women. J Sex Med 2013;10(suppl 1):53–64.     

Erectile Dysfunction Might Be Associated With Chronic Periodontal Disease: Two Ends of the Cardiovascular Spectrum

IntroductionBoth chronic periodontal disease (CPD) and erectile dysfunction (ED) are associated with cardiovascular disease and its risk factors, including smoking and diabetes mellitus. However, the association between ED and CPD has never been studied.AimTo study the association between ED and CPD.Main Outcome MeasuresPrevalence of ED, prevalence of CPD, ED severity.Methods:The study population consisted of 305 men who filled the Sexual Health Inventory for Men (SHIM) questionnaire in order to detect ED and assess its severity, and underwent a pair of standardized posterior dental bitewing radiographs in order to detect CPD. SHIM questionnaire scores 21 or less represented ED. Alveolar bone loss of ≥6 mm represented CPD.ResultsThe mean age of included men was 39.5 ± 6.7 years. Overall, 70 (22.9%) men had ED and 13 (4.3%) had CPD. CPD was significantly more prevalent among men with mild ED (P = 0.004) and moderate to severe ED (P = 0.007) in comparison to men without ED.ConclusionsED might be associated with CPD. These preliminary findings are consistent with theories that associate these conditions with systemic inflammation, endothelial dysfunction, and atherosclerosis. Zadik Y, Bechor R, Galor S, Justo D, and Heruti RJ. Erectile dysfunction might be associated with chronic periodontal disease: Two ends of the cardiovascular spectrum. J Sex Med **;**:**–**.     

Validity of Erectile Function Assessment Questionnaires in Premature Ejaculation Patients: A Comparative Study Between the Abridged Forms of the International Index of Erectile Function and Proposal for Optimal Cutoff Redefinition

BackgroundPatients with premature ejaculation (PE) are often diagnosed as having a comorbid erectile dysfunction (ED). When evaluating erectile function in PE patients with the popular International Index of Erectile Function-5 (IIEF-5, or Sexual Health Inventory for Men [SHIM]), question #5 (Q5) about sexual satisfaction in the intercourse often lowers the total score of the questionnaire, giving false-positive results for the presence of ED.AimWe aimed to compare SHIM with the other abridged form of IIEF, which is IIEF-EF, and to discriminate which tool has the best diagnostic accuracy in the evaluation of erectile function in PE patients.MethodsThe study was conducted from March 2019 to January 2020. A total of 189 heterosexual males with lifelong PE (117, 61.9%) or acquired PE (72, 38.1%) were included. They all compiled Premature Ejaculation Diagnostic Tool, IIEF-15, SHIM, and IIEF-EF and underwent a full clinical examination to evaluate their erectile function.OutcomesThe scores of the 2 erectile function assessment questionnaires (SHIM and IIEF-EF) were compared in terms of their sensitivity and specificity in the diagnosis of ED in PE patients.ResultsIn terms of diagnosing ED in PE patients, the sensitivity of SHIM is 100% while the specificity is only 36%; meanwhile, the sensitivity of IIEF-EF is 100% but specificity is 77.2%. Further analysis demonstrates that decreasing cutoff of SHIM to 17.5 would provide an increased specificity of 82.5%, while sensitivity would lower to 96.0%. However, the highest area under the curve (0.966 vs 0.941) is given by the IIEF-EF with 100% sensitivity and 80.7% specificity at the cutoff of 24.5, which is one point lower than the usual cutoff value of 25.5.Clinical ImplicationsOur study suggests that when evaluating erection function in PE patients, the cutoff of both SHIM and IIEF-EF should be amended.Strengths & Limitations.We proposed the solution for the bias of erectile function assessment in PE patients. However, other trials are needed to further validate in larger cohorts of PE patients.ConclusionWe suggest that the cutoff of SHIM and IIEF-EF should be amended (SHIM at 17.5 and IIEF-EF at 24.5, respectively) when assessing erectile function among PE population.Xi Y, Colonnello E, Ma G, et al. Validity of Erectile Function Assessment Questionnaires in Premature Ejaculation Patients: A Comparative Study Between the Abridged Forms of the International Index of Erectile Function and Proposal for Optimal Cutoff Redefinition. J Sex Med 2021;18:440–447.     

Chronic Pelvic Pain: An Enigma

Chronic pelvic pain (CPP) remains a clinical enigma whose origins are obscure and the treatment of which is generally unproven. Conventional disease-based models have consistently failed to explain chronic pain that is felt in the pelvis. Despite its uncertain aetiology, CPP is estimated to occur in two to ten percent of outpatient gynaecological referrals, and accounts for up to 35 percent of laparoscopic examinations. Reported rates for pelvic disease vary enormously in patients with CPP, and over one-third of patients have no demonstrable lesions. Chronic pelvic pain is defined as persistent pain, apparently of gynaecological origins, but for which no causative lesion is found. The presence of a pelvic lesion does not, de facto, explain the patient’s pain, and often such lesions are coincidental. Also, surgical removal of organs that show pathological changes often fails to relieve pain. Clinicians should make a clear distinction between chronic pelvic lesions that are painful, including endometriosis, and chronic painful conditions for which so far no pathological basis has been identified. It is necessary to improve diagnostic accuracy to avoid inappropriate and needless therapies for patients with CPP. This review provides a summary of current information on the mechanisms of visceral pain, and proposes a new model of CPP based on neurochemical alterations within the central nervous system.     

Female Assessment of Male Erectile Dysfunction Detection Scale (FAME): Development and Validation

IntroductionAlthough erectile dysfunction (ED) affects both members of the couple, no tools exist for the detection of ED by the female partner.AimThe aim of this study was to develop a scale for the detection of ED, as assessed by the female partner.MethodsDevelopment and validation of the Female Assessment of Male Erectile dysfunction detection scale (FAME) consisted of five stages: (i) two focus group discussions conducted among female partners of ED sufferers; (ii) item construction; (iii) initial content validation to document face validity and reduce number of items; (iv) final selection of items and investigation of concurrent validity and reliability, sensitivity and specificity of the scale in 83 Spanish-speaking couples; and (v) multicenter study conducted in a group of 106 English-speaking couples. Concurrent validity was assessed using Spearman's rho correlation coefficients between FAME and clinical diagnosis, the Sexual Health Inventory for Men (SHIM), and the erectile function domain of the International Index of Erectile Function (IIEF-EF). Reliability was tested using Cronbach's alpha, and sensitivity and specificity was investigated using clinical diagnosis as the gold standard criterion.Main Outcome MeasuresValidity, reliability, specificity, and sensitivity of the FAME scale when correlated with SHIM, IIEF-EF, and clinical diagnosis.ResultsQualitative analysis yielded 44 clues; 21 items demonstrated statistical significance as the best discriminating items using a t-test for independent samples. A final scale of six items was tested for validity, reliability, specificity, and sensitivity. FAME correlated significantly with clinical diagnosis (0.791, P < 0.001), the SHIM (0.788, P < 0.001), and the IIEF-EF (0.777, P < 0.001). Additional support for discriminant validity was obtained with receiver operating characteristics analysis. Cronbach's alpha was 0.941. Sensitivity was 96.1% and specificity 86.0%.ConclusionsAccurate detection of ED in men by the female partner is possible. In this study, FAME demonstrated concurrent validity and very good reliability, as well as excellent sensitivity and specificity. Rubio-Aurioles E, Sand M, Terrein-Roccatti N, Dean J, Longworth J, Eardley I, Brock G, Lee J, Arango de Montis I, and Rampazzo-Bonaldo C. Female assessment of male erectile dysfunction detection scale (FAME): Development and validation. J Sex Med 2009;6:2255–2270.