ORIGINAL RESEARCH–SURGERY: Treatment of Penile Deep Dorsal Venous Leakage of Erectile Dysfunction by Embedding the Deep Dorsal Vein of the Penis: A Single Center Experience with 17 Patients

IntroductionThe common surgery for venous leakage was not very successful; unsatisfactory long-term results have reduced the indications for venous surgery for erectile dysfunction (ED).AimsTo assess the outcomes of embedding the deep dorsal vein of the penis (EDDVP), a new surgical technique used in patients with penile deep dorsal venous leakage of ED.MethodsBetween December 2001 and November 2007, 17 patients diagnosed with penile deep dorsal venous leakage of ED underwent embedding the deep dorsal vein of the penis.Main Outcome MeasuresAll cases were available for follow up by using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system and penile color Doppler ultrasound. Dynamic cavernosography were also assessed in three patients at 3 months postoperatively.ResultsAfter surgery, 14 patients were able to achieve satisfactory intercourse and three had sufficient erection after oral sildenafil (50–100 mg). The IIEF-5 scoring changed from a preoperative mean IIEF-5 score of 8.8 ± 3.9 to 20.8 ± 4.1 (P < 0.05). Peak systolic velocity (average of right and left cavernosal arteries) changed from 41.9 ± 7.7 cm/second to 44.2 ± 9.2 cm/second (P > 0.05), resistance index changed from 0.79 ± 0.1 to 1.00 ± 0.0 (P < 0.05), and venous velocity changed from 8.4 ± 4.0 cm/second to 0.0 ± 0.0 cm/second (P < 0.05). Dynamic cavernosography demonstrated a smooth flow of the deep dorsal vein during the flaccid phase. During the tumescent phase, the deep dorsal vein of the penis was compressed between the dilated sinusoidal spaces and the tunica albuginea and resulted in venous drainage blockade. And then the hardness of erection was improved and maintained.ConclusionsThe new surgical technique of EDDVP is a simple operative procedure, which seems to be efficient in the treatment of penile deep dorsal venous leakage of ED. Zhang B, Chen J, Xiao H, Zhang Y, Cai L, Tao X, Qi T, and Ban D. Treatment of penile deep dorsal venous leakage of erectile dysfunction by embedding the deep dorsal vein of the penis: A single center experience with 17 patients. J Sex Med 2009;6:1467–1473.     

ORIGINAL RESEARCH—PEYRONIE'S DISEASE: Use of Penile Extender Device in the Treatment of Penile Curvature as a Result of Peyronie's Disease. Results of a Phase II Prospective Study

IntroductionPilot experiences have suggested that tension forces exerted by a penile extender may reduce penile curvature as a result of Peyronie's disease.AimTo test this hypothesis in a Phase II study using a commonly marketed brand of penile extender.MethodsPeyronie's disease patients with a curvature not exceeding 50° with mild or no erectile dysfunction (ED) were eligible. Fifteen patients were required to test the efficacy of the device assuming an effect size of >0.8, consistent with an “important” reduction in penile curvature. Changes in penile length over baseline and erectile function (EF) domain scores of the International Index of Erectile Function (IIEF) constituted secondary end points.Main Outcome MeasuresPatients were counselled on the use of the penile extender for at least 5 hours per day for 6 months. Photographic pictures of the erect penis and measurements were carried out at baseline, at 1, 3, 6, and 12 months (end of study). The IIEF-EF domain scores were administered at baseline and at the end of study. Treatment satisfaction was assessed at end of study using a nonvalidated institutional 5-item questionnaire.ResultsPenile curvature decreased from an average of 31° to 27° at 6 months without reaching the effect size (P = 0.056). Mean stretched and flaccid penile length increased by 1.3 and 0.83 cm, respectively at 6 months. Results were maintained at 12 months. Overall treatment results were subjectively scored as acceptable in spite of curvature improvements, which varied from “no change” to “mild improvement.”ConclusionsIn our study, the use of a penile extender device provided only minimal improvements in penile curvature but a reasonable level of patient satisfaction, probably attributable to increased penile length. The selection of patients with a stabilized disease, a penile curvature not exceeding 50°, and no severe ED may have led to outcomes underestimating the potential efficacy of the treatment. Gontero P, Di Marco M, Giubilei G, Bartoletti R, Pappagallo G, Tizzani A, and Mondaini N. Use of penile extender device in the treatment of penile curvature as a result of Peyronie's disease. Results of a phase II prospective study. J Sex Med 2009;6:558–566.     

ORIGINAL RESEARCH—SURGERY: Physician and Patient Satisfaction with the New AMS 700 Momentary Squeeze Inflatable Penile Prosthesis

IntroductionA single-armed, prospective, multicenter study evaluated the redesigned American Medical Systems (AMS) 700 Momentary Squeeze (MS) pump inflatable penile prosthesis (IPP) with enhanced features for ease of implantation and patient manipulation. The device incorporates design changes to all components: pump, cylinders, rear-tip extenders, and reservoir.AimTo assess physician and patient satisfaction with the new AMS 700 MS pump.MethodsPatients were selected from the existing population experiencing erectile dysfunction (ED) without previous prosthetic implantation.Main Outcome MeasuresSurvey questionnaires were used to capture physician feedback on ease of implantation and patient education. Patient satisfaction with the device and existence of autoinflation were assayed.ResultsSixty-nine patients were implanted at seven U.S. sites. Mean age was 60.1 ± 9.6 years. History of ED was >5 years in 34 (44.7%) patients. Main ED etiology was organic, nonspecific (32%). Eighty-four percent of the physicians felt proximal cylinder insertion was easier because of the smaller angle of cylinder input tubing and narrower base diameter. The new pump was felt easier to implant than the previous model by 57% of the physicians. The patients found the manipulation of the pump simple at device activation, with 96% easily locating the inflation bulb and 94% deflating the device with one push of the deflation button. Reviews were mixed among physicians concerning ease of training compared with the Tactile pump. Patient training was easier in 71%, harder in 21%, and same in 8%. Nevertheless, 67% of the patients were trained in 6 minutes or less. At 6 months, 77% of the patients were very satisfied, 9% somewhat satisfied, and 14% dissatisfied. Autoinflation occurred in two patients (3%).ConclusionThe new AMS 700 MS IPP seems a distinct improvement over previous devices with most physicians feeling implantation and patient instruction were easier. The device also satisfied 86% of the users and virtually eliminated autoinflation. Knoll LD, Henry G, Culkin D, Ohl DA, Otheguy J, Shabsigh R, Wilson SK, and Delk J II. Physician and patient satisfaction with the new AMS 700 Momentary Squeeze inflatable penile prosthesis. J Sex Med 2009;6:1773–1778.     

ORIGINAL RESEARCH—WOMEN'S SEXUAL HEALTH: Conceptualizing Women's Sexual Function: Linear vs. Circular Models of Sexual Response

IntroductionThe lack of an adequate empirical base for models of female sexual response is a critical issue within the female sexual dysfunction (FSD) literature.AimThe current research compared the extent to which a linear model of sexual response and Basson's circular model of female sexual response represent the sexual function of women with and without FSD.Main Outcome MeasuresWomen's levels of sexual function/dysfunction were assessed with the Female Sexual Function Index and additional items measured women's endorsement of models of female sexual function as representing their own sexual experience.MethodsAn anonymous online survey assessing female sexual response and associated aetiological factors was completed by a random sample of 404 women.ResultsAlthough the linear model of sexual response was a good fit for women with and without sexual dysfunction, the relationship between sexual arousal and orgasm was mediated by sexual desire for women with FSD. The fit of the initial circular model of women's sexual response was poor for both groups. Following pathway modification, the modified circular model adequately represented the responses of both groups and revealed that a number of the relationships between sexual response variables were stronger for women with FSD.ConclusionsThe linear model was a more accurate representation of sexual response for women with normal sexual function than women with FSD and sexual arousal and orgasm was mediated by sexual desire for women with FSD. The modified circular model was a more accurate representation of the sexual response of women with FSD than women with normal sexual function. Giles KP, and McCabe MP. Conceptualizing women's sexual function: Linear vs. circular models of sexual response. J Sex Med 2009;6:2761–2771.     

ORIGINAL RESEARCH—SURGERY: Sexual Function after Loop Electrosurgical Excision Procedure for Cervical Dysplasia

IntroductionLoop electrosurgical excision procedure (LEEP) is an effective tool for management of cervical dysplasia. However, removal of a part of the cervix might have a negative impact on sexual function.AimTo examine the effect of LEEP on overall sexual satisfaction and other specific aspects of sexual function in women with cervical dysplasia.MethodsEighty-nine premenopausal women with cervical dysplasia who had undergone LEEP at least 3 months previously were interviewed once on post-LEEP follow-up visits with a questionnaire on pre- and post-procedural sexual function. Data on frequency of sexual intercourse, the presence of dysmenorrhea, dyspareunia, and postcoital bleeding were compared using the McNemar test. Data on specific aspects of sexual function rated by the 6-point Likert scale were analyzed using Wilcoxon signed ranks test.Main Outcome MeasureThe main outcome is the overall sexual intercourse satisfaction.ResultsThe mean age was 41.7 years. The median interval from LEEP to the time of interview was 29.3 weeks. The time of resumption of sexual intercourse after LEEP was 8.1 weeks on the average. The changes in the frequency of sexual intercourse, dysmenorrhea, and dyspareunia after LEEP were not statistically significant. The changes in overall satisfaction, vaginal elasticity, and orgasmic satisfaction appeared statistically significant (P < 0.05).ConclusionHaving LEEP done along with other “non-surgical” parts of cervical pre-cancer management is associated with small but statistically significant decreases in overall sexual satisfaction, vaginal elasticity, and orgasmic satisfaction when interviewed near to the procedure at 29.3 weeks post-operation. However, the changes on other aspects of sexual function are insignificant. The LEEP procedure itself appears to have a minimal, if any, clinically important adverse effect on sexual function. Inna N, Phianmongkhol Y, and Charoenkwan K. Sexual function after loop electrosurgical excision procedure for cervical dysplasia.     

ORIGINAL RESEARCH—PEYRONIE'S DISEASE: Penile Sonographic and Clinical Characteristics in Men with Peyronie's Disease

IntroductionUltrasonography of the penis is readily available to the urologist and gives good anatomic detail of soft tissue structures. It has not been widely utilized in the assessment of Peyronie's disease (PD).AimsTo describe the sonographic characteristics of the penis in PD and the relationship between clinical and sonographic features.MethodsThis cross-sectional study enrolled patients from a single clinical practice. A PD-specific questionnaire was administered and sonographic evaluations were performed.Main Outcome MeasuresSonographic characteristics of men with PD.ResultsTunical thickening, calcifications, septal fibrosis, and intracavernosal fibrosis, were observed at initial clinical evaluation in 50%, 31%, 20%, and 15% of men, respectively. Men aged 40–49 (OR 2.4, P = 0.02) and men aged 50–59 (OR 2.4, P = 0.004) were more likely to have sub-tunical calcifications relative to men under age 40. Men with septal fibrosis had fewer chronic medical conditions such as diabetes (OR 0.3, P = 0.04), hypertension (OR 0.5, P = 0.03), and coronary artery disease (OR 0.2, P = 0.05), and presented within 1 year of disease onset (OR 2.1, P = 0.001). Men with septal fibrosis were less likely to have lost penile length (OR 0.5, P = 0.04) and more likely to be able to have intercourse (OR 1.9, P = 0.05). Men with intracavernosal fibrosis were less likely to have penile pain (OR 0.5, P = 0.05), but more likely to have penetration difficulty during intercourse (OR 1.9, P = 0.008), an additional penile deformity (OR 1.8, P = 0.02), or rapid onset of disease (OR 1.7, P = 0.04). Tunical thickening was associated with a decreased ability to have intercourse (OR 2.3, P < 0.001).ConclusionPD is a clinically and sonographically heterogeneous condition. Sonography is a safe, low-cost, and rapid means of objectively characterizing lesions in this condition. This may help track the evolution of the condition in individual patients and in the future may be useful for tailoring treatment strategies. Smith JF, Brant WO, Fradet V, Shindel AW, Vittinghoff E, Chi T, Huang YC, Davis CB, Conti S, and Lue TF. Penile sonographic and clinical characteristics in men with Peyronie's disease. J Sex Med 2009;6:2858–2867.     

ORIGINAL RESEARCH—INTERSEX AND GENDER IDENTITY DISORDERS: A Report from a Single Institute's 14-Year Experience in Treatment of Male-to-Female Transsexuals

IntroductionGender identity disorder or transsexualism is a complex clinical condition, and prevailing social context strongly impacts the form of its manifestations. Sex reassignment surgery (SRS) is the crucial step of a long and complex therapeutic process starting with preliminary psychiatric evaluation and culminating in definitive gender identity conversion.AimThe aim of our study is to arrive at a clinical and psychosocial profile of male-to-female transsexuals in Italy through analysis of their personal and clinical experience and evaluation of their postsurgical satisfaction levels SRS.MethodsFrom January 1992 to September 2006, 163 male patients who had undergone gender-transforming surgery at our institution were requested to complete a patient satisfaction questionnaire.Main Outcome MeasuresThe questionnaire consisted of 38 questions covering nine main topics: general data, employment status, family status, personal relationships, social and cultural aspects, presurgical preparation, surgical procedure, and postsurgical sex life and overall satisfaction.ResultsAverage age was 31 years old. Seventy-two percent had a high educational level, and 63% were steadily employed. Half of the patients had contemplated suicide at some time in their lives before surgery and 4% had actually attempted suicide. Family and colleague emotional support levels were satisfactory. All patients had been adequately informed of surgical procedure beforehand. Eighty-nine percent engaged in postsurgical sexual activities. Seventy-five percent had a more satisfactory sex life after SRS, with main complications being pain during intercourse and lack of lubrication. Seventy-eight percent were satisfied with their neovagina's esthetic appearance, whereas only 56% were satisfied with depth. Almost all of the patients were satisfied with their new sexual status and expressed no regrets.ConclusionsOur patients' high level of satisfaction was due to a combination of a well-conducted preoperative preparation program, competent surgical skills, and consistent postoperative follow-up. Imbimbo C, Verze P, Palmieri A, Longo N, Fusco F, Arcaniolo D, and Mirone V. A Report from a single institute's fourteen year experience in treatment of male-to-female transsexuals. J Sex Med 2009;6:2736–2745.     

ORIGINAL RESEARCH—MEN'S SEXUAL HEALTH: Botulinum Toxin A (Botox) for Relieving Penile Retraction

IntroductionThe flaccid penis undergoes retraction upon contraction of the dartos muscle. These contractions are most pronounced in the situations of cold, stress, and upon exercising, and can be the source of embarrassment to those who have a hyperactive retraction reflex, especially when exposed to their partners or to others in showers and dressing rooms, despite a normal and satisfactory length in the erect state.AimIn this work, we propose an alternative to surgery and penile extenders for alleviating penile retraction, by injection of botulinum toxin into the dartos to induce muscle relaxation. This is the first report of the technique.MethodsTen male patients complaining of a short penis exclusively in the flaccid state, despite normal and satisfactory erect and outstretched lengths, were selected for the study. One hundred units of BOTOX were injected into the dartos muscle.Main Outcome MeasuresFrequency and amplitude of penile retraction, flaccid unstretched length, and patient satisfaction.ResultsSeven out of 10 cases (70%) subjectively reported a decrease in the frequency and amplitude of penile retraction, as well as improvement in flaccid length. Clinical measurements were less pronounced but still showed an improvement that was mainly in terms of less retraction rather than more length. No side effects were reported. Improvement faded completely by the 6th month.ConclusionThis preliminary report of botulinum toxin A (Botox) injection into the dartos muscle shows that Botox may have a potential effect in temporarily decreasing penile retractions in terms of frequency and amplitude. Shaeer O, Shaeer K, and Shaeer A. Botulinum toxin A (Botox) for relieving penile retraction. J Sex Med 2009;6:2788–2794.     

ORIGINAL RESEARCH—SURGERY: Anatomical Radical Retropubic Prostatectomy in Patients with a Preexisting Three-Piece Inflatable Prosthesis: A Series of Case Reports

IntroductionOnly few reports addressed the outcome of patients submitted to anatomical radical retropubic prostatectomy (RRP) with an indwelling inflatable penile prosthesis (IPP).AimTo assess the feasibility and safety of RRP in patients with clinically localized prostate cancer and a previously implanted with an IPP.Main Outcome MeasuresWe evaluated the surgical parameters and the follow-up functional results in this particular patient population.MethodsFour patients previously submitted to IPP implant for severe erectile dysfunction underwent RRP for organ-confined prostate cancer. Patients' charts were carefully reviewed to investigate pre- and perioperative details. Patients were evaluated by the International Index of Erectile Function (IIEF) preoperatively and at 6 months postoperatively. Patients were then contacted to assess long-term functional and oncological outcome.ResultsThe outcome of the procedures was comparable to a normal population in terms of operating time, estimated blood loss, hospitalization time, and pathological outcome. No injury to the preexisting penile implant was reported. Continence was obtained in 3 (75%) patients at catheter removal, and in 1 (25%) patient at the 1-month follow-up. No major intra- and postoperative complications were reported. All patients were able to use their prosthesis after RRP. No statistical difference in pre- and post-RRP EF domain scores was found.ConclusionThe presence of an IPP in patients with prostate cancer is not a contraindication to perform an anatomical RRP. Surgery can be performed safely without injuring the implant and the clinical outcome in these patients is satisfactory. Postoperative implant use is not affected by RRP. Deho' F, Salonia A, Briganti A, Zanni G, Gallina A, Rokkas K, Guazzoni G, Rigatti P, and Montorsi F. Anatomical radical retropubic prostatectomy in patients with a preexisting three-piece inflatable prosthesis: A series of case reports. J Sex Med 2009;6:578–583.     

Surgical Management of Penile Fracture and Long‐Term Outcome on Erectile Function and Voiding

IntroductionPenile fracture is an emergency in urology. Surgical management is recommended, but objective data of postoperative long‐term effects, especially regarding voiding and erectile function, vary.AimTo assess long‐term results of patients undergoing surgical therapy for penile fracture.MethodsPatients presenting with suspicion of penile fracture were included in this study. Diagnosis of penile fracture was made by clinical assessment and surgery performed thereafter. The defect of the tunica albuginea was closed by absorbable suture. In case of concomitant urethral lesion, the defect was repaired simultaneously. Voiding and erectile function were evaluated at long‐term follow‐up by mail. Patients' status before penile fracture was assessed retroactively.Main Outcome MeasuresErectile function was assessed by the International Index of Erectile Function questionnaire and voiding function by the International Prostate Symptom Score questionnaire.ResultsN = 34 patients were included. Penile fracture was suspected in 28/34 (82.4%) patients. Twenty‐six of the 28 (92.9%) patients underwent surgery. Only less than half of confirmed fracture patients presented with the classical triad of an audible crack, detumescense, and hematoma. Fourteen of the 26 (53.8%) patients after surgery were available for follow‐up. Mean follow‐up was 45.6 months (range: 3.6–128.4). In 13/14 (92.9%) patients, penile fracture was confirmed by surgery. At follow‐up, 7/13 (53.8%) patients had impaired erectile function, with 3/13 (23.1%) patients needing medical treatment. Four of the 13 (30.8%) patients showed deterioration of voiding including occurrence of urethral fistula.ConclusionsPenile fracture is an emergency for which surgery should be offered. Clinical suspicion of fracture should be high even with hematoma alone. Concomitant urethral injury is common, particularly with bilateral corporal rupture and/or initial hematuria. Preoperative counseling should include discussion of long‐term erectile and voiding dysfunction, penile deformity, and urethral fistula both with and without surgery. Close patient follow‐up is required.     

ORIGINAL RESEARCH—ED PHARMACOTHERAPY: Post-Radical Prostatectomy Pharmacological Penile Rehabilitation: Practice Patterns Among the International Society for Sexual Medicine Practitioners

IntroductionDespite the fact that there is minimal evidence-based data supporting it, the concept of pharmacological penile rehabilitation following radical prostatectomy (RP) is receiving great attention.AimTo define attitudes and practice patterns of clinicians who were members of the International Society for Sexual Medicine (ISSM) and/or its affiliated societies.MethodsMembers of the ISSM and its regional affiliates were invited to participate in a web-based survey.Main Outcome MeasuresDemographic factors, current practice status, and opinions regarding post-RP erectile dysfunction and penile rehabilitation. The statistical methods used included chi-square, Student's t-tests, and logistic regression analysis.ResultsThree hundred-one physicians from 41 countries completed the questionnaire (82% were urologists). Sixty-five percent of the responders had formal sexual medicine specialty training, 44% had uro-oncology specialty training, and 60% performed RPs. Eighty-seven percent performed some form of rehabilitation. As part of the primary rehabilitation strategy, 95% used phosphodiesterase type 5 inhibitors (PDE5), 30% used vacuum device, 75% used intracavernosal injections, and 9.9% used intraurethral prostaglandin. Fifty-four percent commenced rehabilitation immediately/just after urethral catheter removal, and 37% within the first 4 months after RP. Neither the number of years in medical practice, clinician age, nor country/region of practice differed between rehabilitation performers and nonperformers. With regard to the primary reason for avoiding rehabilitation: 50% responded said it is the cost; 25% said the fact that it is not evidence-based; and 25% said they were not familiar with the concept. Performing rehabilitation was positively associated with urologic oncology training (P = 0.03), performing RP (P < 0.001), and seeing over 50 post-RP patients per year (P = 0.011).ConclusionsAmong ISSM members post-RP penile rehabilitation is widely practiced, commenced early, and based predominantly on PDE5 inhibitors and intracavernosal injections. Clinicians who perform RP or see over 50 such patients per year are the most likely to perform rehabilitation. Cost represents the most common reason for rehabilitation neglect. Teloken P, Mesquita G, Montorsi F, and Mulhall J. Post-radical prostatectomy pharmacological penile rehabilitation: Practice patterns among ISSM practitioners. J Sex Med 2009;6:2032–2038.     

ORIGINAL RESEARCH—ERECTILE DYSFUNCTION: Evaluation of Microalbuminuria in Patients with Erectile Dysfunction

IntroductionThe recent sophisticated diagnostic procedures aimed at identifying the exact cause of erectile dysfunction (ED) are often complicated in clinical application, invasive, or highly expensive. Microalbuminuria, a test easy to perform and of low cost, is a marker of extensive endothelial dysfunction, and it has been suggested to be linked to ED.AimThe aim of this study was to investigate the eventual role of microalbuminuria in differentiating patients with arteriogenic and non arteriogenic ED.MethodsThe diagnosis of ED was based on the International Index of Erectile Function 5-questionnaire, and patients were classified as arteriogenic (N = 29) and non-arteriogenic (N = 49) in relation to the results of echo-color-doppler examination of cavernosal arteries in basal conditions and after intracavernous injection of 10 µg prostaglandin E₁.Main Outcome MeasuresThe microalbuminuria of 78 males without the most common atheriosclerotic risks and with ED was measured.ResultsMicroalbuminuria, defined as urinary albumin/creatinine ratio, was not significantly (P > 0.05) different between patients of the two groups.ConclusionsOur data show that in ED patients the cavernosal arteries damage, as assessed by dynamic echo-color-doppler, may be independent on or precede extensive endothelial dysfunction, and that microalbuminuria cannot be predictive of penile arteriogenic etiology. Barassi A, Pezzilli R, Morselli-Labate AM, Porreca W, Piediferro G, Ciociola F, Colpi G, and Melzi d'Eril G. Evaluation of microalbuminuria in patients with erectile dysfunction.     

ORIGINAL RESEARCH—OUTCOMES ASSESSMENT: Development and Validation of the Female Genital Self-Image Scale

IntroductionWomen's sexual function may be influenced by various factors including medical conditions, trauma or abuse, medications, relationship dynamics, relaxation, mood, and body image. However, few studies have explored the influence of a woman's genital self-image on her sexual function or behaviors.AimsThe purpose of this study was to establish a reliable and valid measure of female genital self-image, the Female Genital Self-Image Scale (FGSIS), and to assess the relationship between scores on the FGSIS and women's sexual function.MethodsThe FGSIS was developed in two stages. Phase One involved an analysis of cross-sectional paper-based survey data and a review of the literature. Phase Two involved a cross-sectional internet-based administration of the scale items to a total of 1,937 women.Main Outcome MeasuresPsychometric properties of the scale were evaluated through the use of reliability analysis, factor analysis, and score differences based on women's experience of orgasm from receiving cunnilingus or from self-masturbation with a vibrator. Correlation analysis was used to explore the relationship between female genital self-image and scores on the Female Sexual Function Index (FSFI).ResultsThe scale was found to have sufficient reliability (Cronbach's alpha = 0.88) and one factor that explained 59.23% of the variance. Women who had ever experienced orgasm as a result of cunnilingus or self-masturbation with a vibrator and women who reported having had a gynecological exam in the previous 12 months had significantly higher FGSIS scores than those who had not (P < 0.001). Scores on the FGSIS were positively and significantly correlated with scores on all FSFI domains (P < 0.001), including the Total score, with the exception of the Desire domain.ConclusionThe FGSIS was initially found to be a reliable and valid measure though further research is needed to understand its properties in diverse populations. In addition, female genital self-image was found to be positively related to women's sexual function. Herbenick D, and Reece M. Development and validation of the female genital self image scale.     

ORIGINAL RESEARCH—COUPLES' SEXUAL DYSFUNCTIONS: Sexual Disorders in Infertile Couples

IntroductionSexuality and the desire for a child are strongly interconnected. The same applies to sexual disorders and the unfulfilled desire for a child.AimThis article indicates the relations between sexual disorders and the unfulfilled desire for a child and outlines the potential effects of diagnostics and treatment in the context of reproductive medicine on the couples' sexuality.MethodsA research drive was undertaken in well-established medical and psychological literature database with the keywords “infertile” or “infertility” and “sexual dysfunction” or “sexual satisfaction.”ResultsSexual dysfunctions (of organic or of psychic origin) as a cause of involuntary childlessness are relatively unusual. By contrast (temporary) sexual disorders resulting from diagnosis and medical therapy are common in couples with fertility problems, with women more frequently affected than men.ConclusionsCounseling for couples with the unfulfilled desire for a child should invariably include explicit and appropriately tactful reference to sexuality and (functional) sexual disorders by the therapist. Wischmann TH. Sexual disorders in infertile couples.     

ORIGINAL RESEARCH—BASIC SCIENCE: Initial Characterization of Hydrogen Sulfide Effects in Female Sexual Function

IntroductionIn our male animal models, hydrogen sulfide (H₂S) displayed significant vasodilatory and smooth muscle relaxant effects suggestive of an endogenous physiological role in erectile process.AimIn this first exploratory study, we aimed to identify the existence and mechanism of H₂S pathway in female sexual physiology.MethodsVaginal and clitoral cavernosal smooth muscle strips from New Zealand white rabbits (N = 12) were exposed to stable H₂S donor, sodium hydrosulfide hydrate (NaHS.xH₂O, 100 µM–1.6 mM), in isometric tension studies. The NaHS responses were repeated after incubations with (i) N^ω-nitro-L-arginine (50 µM), 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ) (10 µM) or cis-N-[2-phenylcyclopentyl]-azacyclotridec-1-en-2-amine (MDL 12,330A) (10 µM); and (ii) potassium chloride medium (high K⁺ 60 mM/low K⁺ 10 mM), tetraethylammonium (10 mM) or glibenclamide (100 µM). Relaxant effect of NaHS was also compared with those of nitroglycerine (0.18–78.2 µM) and sildenafil (0.084–25.3 µM). Additionally, samples (N = 16) were collected for estimations of plasma and tissue H₂S and expression levels of cystathionine γ-lyase (CSE) and cystathionine β-synthase (CBS) proteins.Main Outcome MeasuresIn vitro evidences for H₂S formation and its physiopharmacological effects.ResultsNaHS produced significant concentration-dependent relaxation of vaginal and cavernosal smooth muscles with inhibitions by combination of ODQ and MDL 12,330A (26.4%), N^ω-nitro-L-arginine (22.2%), high K⁺ (15.1%) or glibenclamide (10.1%). Based on molar potency, NaHS was 18.3 and 6.3 times weaker than nitroglycerine and sildenafil, respectively. Quantitative assays indicated that plasma H₂S level was 16.5 ± 2.58 µM, and H₂S was synthesized in the clitoral and vaginal smooth muscles (1.8 and 3.9 nmol/mg soluble protein compared with 26.5 nmol/mg in the liver: positive control). Similarly, western blotting identified the protein expression bands of CSE (44.5 kDa) and CBS (63 kDa) in these genital tissue samples.ConclusionThese pilot studies clearly indicate the smooth muscle relaxant effect of H₂S in female genital tract, mediating through cyclic adenosine 3′:5′-monophosphate, nitric oxide-cyclic guanosine monophosphate and K⁺_ATP channels. Taken together with biochemical and molecular evidences for endogenous formation, H₂S pathway could be a contributing factor in female sexual responses. Srilatha B, Lingxu H, Adaikan GP, and Moore PK. Initial characterization of hydrogen sulfide effects in female sexual function. J Sex Med 2009;6:1875–1884.     

ORIGINAL RESEARCH—PEYRONIE'S DISEASE: Peyronie's Disease Following Radical Prostatectomy: Incidence and Predictors

IntroductionBoth prostate cancer and Peyronie's disease (PD) are prevalent in men after their fifth decade of life. The evidence to support or refute a link between radical prostatectomy (RP) and PD is limited.AimsTo define the incidence of PD in men who had RP and determine possible predictors of PD development after RP.MethodsA review of a prospectively built sexual medicine database, years 2002–2008, looking at subjects who had RP as a monotherapy for localized prostate cancer. We identified and characterized subjects who developed PD within 3 years after RP and compared them with subjects who did not.Main Outcome MeasuresThe incidence of PD among men who attended a sexual medicine clinic after they had RP, predictors of PD development after RP.ResultsThe study population included 1,011 subjects, and PD incidence in this population was 15.9%. Mean time to develop PD after RP was 13.9 ± 0.7 months. Mean curvature magnitude was 31 + 17 degrees. On univariate analysis, younger age (mean age of 59 + 7 in men with PD vs. 60 + 7 years in men without PD, P = 0.006) and white race (vs non-white, 18% vs. 7%, P < 0.001) were predictive of PD development after RP, but post-op erectile function was not a predictor of PD development. On multivariate analysis, younger age (odds ratio (OR) = 1.3, for 5-year decrease in age) and white race (OR = 4.1, vs. non-white) remained independent significant predictors.ConclusionsMen presenting with sexual dysfunction after RP have higher PD incidence then the general population. Therefore, they should be routinely evaluated for PD. Younger men and men of white race are at increased risk for PD. Prospective controlled studies are needed to elucidate the incidence of PD following RP and to conclude if RP has a causative role in the pathogenesis of PD. Tal R, Heck M, Teloken P, Siegrist T, Nelson CJ, and Mulhall JP. Peyronie's disease following radical prostatectomy: Incidence and predictors.     

ORIGINAL RESEARCH—EPIDEMIOLOGY: Correlates of Sexually Related Personal Distress in Women with Low Sexual Desire

IntroductionSexual distress is an important component of diagnostic criteria for sexual dysfunctions, but little is known about the factors associated with sexual distress in women with low sexual desire.AimTo investigate the correlates of sexual distress in women with self-reported low sexual desire.MethodsThe Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking study was a cross-sectional, nationally representative, mailed survey of U.S. adult women. There were 31,581 respondents (response rate 63.2%) to the 42-item questionnaire that measured sexual function, sexual distress, demographic, and health-related factors. Multivariable logistic regression was used to explore the correlates of distress.Main Outcome MeasuresLow sexual desire was defined as a response of “never” or “rarely” to the question, “How often do you desire to engage in sexual activity?” Sexual distress was measured with the Female Sexual Distress Scale (range 0–48), with a score of 15 or higher indicating presence of distress.ResultsOf 10,429 women with low desire, 2,868 (27.5%) had sexual distress (mean age 48.6 years, 81% with a current partner). Women without distress were 10 years older on average, and 44% had a current partner. Having a partner was strongly related to distress (odds ratio 4.6, 95% confidence interval 4.1–5.2). Other correlates were age, race, current depression, anxiety, lower social functioning, hormonal medication use, urinary incontinence, and concurrent sexual problems (arousal or orgasm). Dissatisfaction with sex life was more common in women with low desire and distress (65%) than in those without distress (20%).ConclusionsAge has a curvilinear relationship with distress, and the strongest correlate of sexual distress was having a current partner. Sexual distress and dissatisfaction with sex life are strongly correlated. Distress is higher in women with low sexual desire in a partner relationship; further research on this factor is needed. Rosen RC, Shifren JL, Monz BU, Odom DM, Russo PA, and Johannes CB. Correlates of sexually related personal distress in women with low sexual desire. J Sex Med 2009;6:1549–1560.     

ORIGINAL RESEARCH—EJACULATORY DISORDERS: The Role of Short Frenulum and the Effects of Frenulectomy on Premature Ejaculation

IntroductionThe role of short frenulum and the effects of frenulectomy on premature ejaculation (PE) were never investigated.AimsThe aims of this study were to evaluate the prevalence of short frenulum in a population of patients affected by lifelong PE and to investigate the role of frenulectomy as first-line treatment for this condition.MethodsWe performed frenulectomy to patients complaining of lifelong PE in which we found the presence of a short frenulum at physical examination. We evaluated intravaginal ejaculatory latency time (IELT) and the score of a validated PE questionnaire at baseline and after frenulectomy.Main Outcome MeasuresWe evaluated the change in mean IELT and in mean PE questionnaire score.ResultsWe found the presence of a short frenulum in 59 out of 137 (43%) subjects who came to our center complaining of lifelong PE. Mean age of study population was 38.2 years (±5.3 standard deviation). At baseline period, mean IELT was 1.65 minutes (±1.15), and mean PE questionnaire score was 15.8 (±2.85). No complications related to surgery occurred. Mean follow-up time was 7.3 months (±3.18). After frenulectomy, mean IELT was 4.11 minutes (±1.77), and mean PE questionnaire score was 9.85 (±3.2). An increase in mean IELT of 2.46 minutes (P < 0.0001) and a reduction in mean PE questionnaire symptoms score of 5.95 (P < 0.0001) were noted.ConclusionShort frenulum is a genital anomaly found in 43% of individuals affected by lifelong PE in our data set. We suggest always ruling out at physical examination the presence of a short frenulum in all patients complaining of PE and to propose frenulectomy as first-line treatment in these cases. Gallo L, Perdonà S, and Gallo A. The role of short frenulum and the effects of frenulectomy on premature ejaculation.