The female prostate revisited: perineal ultrasound and biochemical studies of female ejaculate

IntroductionMany speculations have been made on the possible existence of a “female prostate gland” and “female ejaculation.” Despite several reports on the subject, controversy still exists around the “female prostate” and whether such a gland might be the source of fluid emitted during orgasm (ejaculation).AimTo investigate the ultrasonographic, biochemical, and endoscopic features in two women who reported actual ejaculations during orgasm.Main Outcome MeasuresPerineal ultrasound studies, as well as biochemical characteristics of ejaculate and urethroscopy, have been performed in two women.MethodsTwo premenopausal women—44 and 45 years of age—who actually reported fluid expulsion (ejaculation) during orgasm have been investigated. Ultrasound imaging, biochemical studies of the ejaculated fluid, and endoscopy of the urethra have been used to identify a prostate in the female. Ejaculated fluid parameters have been compared to voided urine samples.ResultsOn high-definition perineal ultrasound images, a structure was identified consistent with the gland tissue surrounding the entire length of the female urethra. On urethroscopy, one midline opening (duct) was seen just inside the external meatus in the six-o’clock position. Biochemically, the fluid emitted during orgasm showed all the parameters found in prostate plasma in contrast to the values measured in voided urine.ConclusionsData of the two women presented further underline the concept of the female prostate both as an organ itself and as the source of female ejaculation. Wimpissinger F, Stifter K, Grin W, and Stackl W. The female prostate revisited: Perineal ultrasound and biochemical studies of female ejaculate.     

ORIGINAL RESEARCH—WOMEN'S SEXUAL HEALTH: Do Women with Female Ejaculation Have Detrusor Overactivity?

IntroductionQuestionnaire surveys suggest that 40–54% of women have experienced an expulsion of fluid at orgasm. Some of these women have coital incontinence, whereas others identify the fluid passed as female ejaculate.AimTo assess whether women who have experienced female ejaculation have detrusor overactivity or the bothersome lower urinary tract symptoms associated with coital incontinence.MethodsWe recruited six women who self-identified as having experienced female ejaculation and six controls who had not. Each woman completed a 3-day bladder diary and two validated bladder questionnaires: the Urgency Perception Scale (UPS) and the Incontinence Impact Questionnaire (IIQ). Each woman underwent short provocative ambulatory urodynamics, a modified form of urodynamics, with a high sensitivity for detrusor overactivity.Main Outcome MeasuresPrevalence of detrusor overactivity, 24-hour urinary frequency, IIQ and UPS scores.ResultsNo woman in either group had detrusor overactivity. The bladder diaries and questionnaire results were within the normal range for all women.ConclusionWomen who experience female ejaculation may have normal voiding patterns, no bothersome incontinence symptoms, and no demonstrable detrusor overactivity. Women who report female ejaculation, in the absence of other lower urinary tract symptoms, do not require further investigation, and may be reassured that it is an uncommon, but physiological, phenomenon. Cartwright R, Elvy S, and Cardozo L. Do women with female ejaculation have detrusor overactivity? J Sex Med 2007;4:1655–1658.     

The human female prostate-immunohistochemical study with prostate-specific antigen, prostate-specific alkaline phosphatase, and androgen receptor and 3-D remodeling

IntroductionThe constitution of glands surrounding the human female urethra has been under debate; especially regarding as to what extent they equal the male prostate. Defining their composition may help to understand the development of neoplasms arising from this tissue.AimsThe aim of this study was to define the existence, structure, and arrangement of a possible human female prostate.MethodsUrethras of 25 women were investigated by immunohistochemistry and stained with specific monoclonal antibodies against prostate‐specific antigen (PSA, mono‐ and polyclonal antibody), prostate specific alkaline phosphatase (PSAP), and androgen receptor (AR). From two urethras, which underwent a totally serial work up with PSA‐staining, a three‐dimensional model of the urethra and the prostatic glands was created to enable 3D‐perception of the results.Main Outcome MeasureThe main outcome measures used in this study were identifying glandular structures in hematoxylin‐eosin‐staining, positive staining with the respective antibodies, and 3‐D orientation of described glands.ResultsFourteen of 25 patients had glandular structures encircling the urethra. Twelve of 14 showed positive staining for PSA, PSAP, and AR in gland acini, while the excretory ducts, the urethra, and the surrounding stroma did not express those proteins. The strongest PSA and PSAP expression was found in apical cytoplasm of the glandular cells, and AR was confined to cell nuclei. Prostatic glands were located laterally to the distal half of the urethra.ConclusionA female prostate was found in every second woman in this study and can be discriminated from other urethral caverns and immature paraurethral ducts. Possible neoplasms of this source tissue expressing the prostate‐specific markers may therefore be denominated as female prostate tumors. Dietrich W, Susani M, Stifter L, and Haitel A. The human female prostate—immunohistochemical study with prostate‐specific antigen, prostate‐specific alkaline phosphatase, and androgen receptor and 3‐D remodeling. J Sex Med 2011;8:2816–2821.     

Female Ejaculation Orgasm vs. Coital Incontinence: A Systematic Review

IntroductionWomen may expel various kinds of fluids during sexual arousal and at orgasm. Their origins, quantity, compositions, and expulsion mechanisms depend on anatomical and pathophysiological dispositions and the degree of sexual arousal. These are natural sexual responses but may also represent symptoms of urinary incontinence.AimThe study aims to clarify the etiology of fluid leakage at orgasm, distinguish between associated physiological sexual responses, and differentiate these phenomena from symptoms of illness.MethodsA systematic literature review was performed. EMBASE (OvidSP) and Web of Science databases were searched for the articles on various phenomena of fluid expulsions in women during sexual arousal and at orgasm.Main Outcome MeasuresArticles included focused on female ejaculation and its variations, coital incontinence (CI), and vaginal lubrication.ResultsFemale ejaculation orgasm manifests as either a female ejaculation (FE) of a smaller quantity of whitish secretions from the female prostate or a squirting of a larger amount of diluted and changed urine. Both phenomena may occur simultaneously. The prevalence of FE is 10–54%. CI is divided into penetration and orgasmic forms. The prevalence of CI is 0.2–66%. Penetration incontinence occurs more frequently and is usually caused by stress urinary incontinence (SUI). Urodynamic diagnoses of detrusor overactivity (DOA) and SUI are observed in orgasmic incontinence.ConclusionsFluid expulsions are not typically a part of female orgasm. FE and squirting are two different physiological components of female sexuality. FE was objectively evidenced only in tens of cases but its reported high prevalence is based mostly on subjective questionnaire research. Pathophysiology of squirting is rarely documented. CI is a pathological sign caused by urethral disorder, DOA, or a combination of both, and requires treatment. An in-depth appreciation of these similar but pathophysiologically distinct phenomena is essential for distinguishing normal, physiological sexual responses from signs of illness. Pastor Z. Female ejaculation orgasm vs. coital incontinence: A systematic review.     

Recurrent Postcoital Hematuria. A Case of Fibroepithelial Urethral Polyp in an Adult Female

IntroductionIn males, an isolated gross postcoital hematuria is a very rare clinical phenomenon. No cases of postcoital macroscopic hematuria have been previously reported in females.AimTo report a case of female urethral fibroepithelial polyp (FEP) associated with recurrent postcoital hematuria.MethodsA young (31 years old), eumenorrheic woman complained of three episodes of postcoital macrohematuria. The patient was assessed with a detailed history, with a bimanual pelvic examination and with bidimensional and tridimensional ultrasonographic and color Doppler analyses of the internal genitalia and of the urethrovaginal space.Main Outcomes MeasuresTransvaginal two‐dimensional (2‐D) ultrasonographic evaluation of internal genitalia, bladder and urethra and three‐dimensional (3‐D) analysis of the urethra and paraurethral structures.ResultsThe 2‐D transvaginal evaluation and the 3‐D reconstruction showed a polypoid hypervascularized structure arising from the anterior urethral wall. A cystourethroscopy confirmed the presence of a FEP arising from the anterior wall of the urethra and allowed its removal.ConclusionsA gross postcoital hematuria may be associated with a urethral polyp. The ultrasonographic evaluation of the urethrovaginal space can facilitate the diagnosis. Battaglia C, Battaglia B, Ramacieri A, Paradisi R, and Venturoli S. Recurrent postcoital hematuria. A case of fibroepithelial urethral polyp in an adult female.     

In Vivo Imaging–Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology

BackgroundMyths, misconceptions, and taboos about sexual anatomy and physiology are common and can affect sexual health and maintain harmful practices and beliefs.AimTo construct a female and a preliminary male 3-dimensional (3D) pelvic model on the basis of in vivo imaging, which could be studied in sex education and clinical practice.MethodsWe retrospectively studied the images of 200 female pelvic magnetic resonance examinations and reviewed the literature to choose the optimum magnetic resonance imaging (MRI) protocol for the study of the clitoris and surrounding organs. We also conducted a cross-sectional study of 30 women who were undergoing a pelvic MRI. 15 women had undergone female genital mutilation/cutting involving the clitoris and 15 had not. The best-quality MRI images of 3 uncut and 1 cut clitoris, together with the principal surrounding pelvic organs, were selected to generate 3D reconstructions using dedicated software. The same software was used to reconstruct the anatomy of the penis and the principal surrounding pelvic organs, based on contrast-enhanced computer tomography images. Images of both models were exported in .stl format and cleaned to obtain single manifold objects in free, open source software. Each organ model was sliced and 3D printed. A preliminary feedback was collected from 13 potential users working in urology, gynaecology, sexual medicine, physiotherapy, and education.OutcomesThe main outcomes of this study are a kit of 3D pelvic models, 2-dimensional figures of female and male sexual anatomy, and files for 3D printing.ResultsWe present a kit containing 3D models and 2-dimensional figures of female and male sexual anatomy, based on in vivo imaging and, feedbacks and suggestions received from potential users.Clinical TranslationOur kit can be used in anatomy and sex education among and by health professionals, teachers, sex educators, students, and the general population.Strengths & LimitationsThe strengths are that the models were based on in vivo imaging, can be dismantled/reassembled, and show analogous anatomic structures of the clitoris and the penis. The female models represent diversity, including women with female genital mutilation/cutting. The limitations are that the male model is preliminary and can be improved if based on an MRI; that imaging-based anatomic representations can differ from anatomic dissections; and that the models represent the sexual organs at rest or during an unknown state of arousal only.ConclusionOur kit can be studied in anatomy, biology, and sex education, as well as in clinical practice.Abdulcadir J, Dewaele R, Firmenich N, et al. In Vivo Imaging–Based 3-Dimensional Pelvic Prototype Models to Improve Education Regarding Sexual Anatomy and Physiology. J Sex Med 2020;17:1590–1602.     

Congenital paraurethral cysts in two newborn girls: differential diagnosis, management strategies, and spontaneous resolution

BackgroundAt least five types of interlabial masses of different etiologies may present in a female neonate. The more serious type of interlabial mass must be differentiated from the benign and self-resolving paraurethral or hymenal cyst. Clues include appearance and color of the mass and the location of the mass in relation to the urethral meatus and the vaginal opening. Clinicians should be able to distinguish lesions that require aggressive intervention, i.e. surgery, from those that self-resolve and merely require observation.CaseTwo unrelated newborn girls each had a protruding faint-yellow-colored spherical interlabial cyst. The cyst was located anterior to the vaginal orifice and partially obscured the urethral meatus. Neither girl had any voiding problems. No other congenital anomalies were detected. Both cysts resolved rapidly and completely without surgical intervention.Summary and ConclusionParaurethral cysts of the newborn and hymenal cysts rarely cause urinary obstruction or spotting, and are self-resolving. When positively identified, no evaluation of upper urinary tract is required and neither aspiration of cyst contents or marsupialization procedure is necessary.     

New insights from one case of female ejaculation

IntroductionAlthough there are historical records showing its existence for over 2,000 years, the so‐called female ejaculation is still a controversial phenomenon. A shared paradigm has been created that includes any fluid expulsion during sexual activities with the name of “female ejaculation.”AimTo demonstrate that the “real” female ejaculation and the “squirting or gushing” are two different phenomena.MethodsBiochemical studies on female fluids expelled during orgasm.ResultsIn this case report, we provided new biochemical evidences demonstrating that the clear and abundant fluid that is ejected in gushes (squirting) is different from the real female ejaculation. While the first has the features of diluted urines (density: 1,001.67 ± 2.89; urea: 417.0 ± 42.88 mg/dL; creatinine: 21.37 ± 4.16 mg/dL; uric acid: 10.37 ± 1.48 mg/dL), the second is biochemically comparable to some components of male semen (prostate‐specific antigen: 3.99 ± 0.60 × 103 ng/mL).ConclusionsFemale ejaculation and squirting/gushing are two different phenomena. The organs and the mechanisms that produce them are bona fide different. The real female ejaculation is the release of a very scanty, thick, and whitish fluid from the female prostate, while the squirting is the expulsion of a diluted fluid from the urinary bladder. Rubio‐Casillas A and Jannini EA. New insights from one case of female ejaculation. J Sex Med **;**:**–**.     

Pontine Control of Ejaculation and Female Orgasm

IntroductionThe physiological component of ejaculation shows parallels with that of micturition, as both are essentially voiding activities. Both depend on supraspinal influences to orchestrate the characteristic pattern of activity in the pelvic organs. Unlike micturition, little is known about the supraspinal pathways involved in ejaculation and female orgasm.AimTo identify brainstem regions activated during ejaculation and female orgasm and to compare them with those activated during micturition.MethodsEjaculation in men and orgasm in women were induced by manual stimulation of the penis or clitoris by the participants' partners. Positron emission tomography (PET) with correction for head movements was used to capture the pattern of brain activation at the time of sexual climax.Main Outcome MeasuresPET scans showing areas of activation during sexual climax.ResultsEjaculation in men and orgasm in women resulted in activation in a localized region within the dorsolateral pontine tegmentum on the left side and in another region in the ventrolateral pontine tegmentum on the right side. The dorsolateral pontine area was also active in women who attempted but failed to have an orgasm and in women who imitated orgasm. The ventrolateral pontine area was only activated during ejaculation and physical orgasm in women.ConclusionActivation of a localized region on the left side in the dorsolateral pontine tegmentum, which we termed the pelvic organ‐stimulating center, occurs during ejaculation in men and physical orgasm in women. This same region has previously been shown to be activated during micturition, but on the right side. The pelvic organ‐stimulating center, via projections to the sacral parasympathetic motoneurons, controls pelvic organs involved in voiding functions. In contrast, the ventrolateral pontine area, which we term the pelvic floor‐stimulating center, produces the pelvic floor contractions during ejaculation in men and physical orgasm in women via direct projections to pelvic floor motoneurons. Huynh HK, Willemsen ATM, Lovick TA, and Holstege G. Pontine control of ejaculation and female orgasm. J Sex Med 2013;10:3038–3048.     

A urethral diverticulum presenting with pure stress urinary incontinence

ObjectiveTo report the management for a urethral diverticulum presenting with pure stress urinary incontinence (SUI).Case ReportA 67-year-old postmenopausal woman resorted to urogynecological outpatient department for the treatment of bothersome SUI. She denied other lower urinary tract symptoms and previous pelvic surgeries. On examination, there was stage I anterior vaginal wall prolapse. Urinalysis showed negative findings. Urodynamic studies revealed negative findings. An ultrasound disclosed a complex paraurethral lesion and no urethral hypermobility. A magnetic resonance image of the pelvis revealed a 4-cm circumferential urethral diverticulum. A urethral diverticulectomy was performed. Histopathological examination confirmed the diagnosis of urethral diverticulum. The patient recovered uneventfully and reported freedom from SUI postoperatively.ConclusionIn women deemed uncomplicated stress urinary incontinence after undertaking a holistic urogynecological evaluation including detailed clinical history, physical examination, and urodynamic studies, further image studies investigating lower urinary tract is required for disclosing other rare conditions that necessitate different management from anti-incontinence surgery.     

3-D Ultrasonographic Appearance of Two Intermittent Paraurethral Cysts: A Case Report

IntroductionIn the adult female, a cyst of the Skene's duct is a rare event that may be either the late consequence of a congenital abnormality or the result of a chronic acquired inflammation.AimTo report a case of bilateral paraurethral Skene's duct cysts.MethodsA young (32 years old), eumenorrheic (menstrual cycle of >25 and <35 days) woman complained of a 6-month intermittent scarce lubrication during intercourse and a sensation of a small intravaginal “extraneous” body. The patient was repeatedly assessed with a detailed history, with a bimanual pelvic examination and with bi- and tridimensional ultrasonographic and color Doppler analyses of the urethrovaginal space.Main Outcomes MeasuresTransvaginal two-dimensional ultrasonographic evaluation of internal genitalia, bladder, and urethra and three-dimensional analysis of the paraurethral structures.ResultsThe evaluation of the structures comprised in the urethrovaginal space evidenced two small (1.7 and 1.1 cm in the maximum diameter) anechoic cysts with some debris in the most declivous part, laterally displaced to the middle/distal urethra. The cysts disappeared after a medical therapy.ConclusionsA sudden reduction of the vaginal lubrication requires a prompt gynecological and ultrasonographic evaluation of the urethrovaginal space. Battaglia C, and Venturoli S. 3-D ultrasonographic appearance of two intermittent paraurethral cysts: A case report.     

A Rare Interlabial Mass in a 9-Month-Old Infant: A Case Report and Review of Literature

BackgroundInterlabial masses in infants and children are quite rare. One of their rarest causes is urethral polyp or urethral caruncle. It is a benign fleshy outgrowth at the urethral meatus. Certain etiology is still unknown.CaseA healthy 9-month-old female infant presented with a mass protruding from the vulva with no other complaints. Examination with the patient under general anesthesia revealed an interlabial mass appearing as a pedunculated pinkish polyp, originating from the posterior lip of the external urethral meatus. Surgical excision of the mass was done and histopathology confirmed it to be a urethral polyp.Summary and ConclusionUrethral polyps are rare in the pediatric age group. Their occurrence in this age group might support a congenital etiology. Surgical resection of polyps allows histopathological examination and a high cure rate with no risk of recurrence.     

Urethral Corpus Spongiosum Amyloidosis Presenting with Urethrorrhagia During Erection

IntroductionUrethral amyloidosis is a rare, probably inflammatory condition usually presenting with hematuria and obstructive urinary symptoms, thus mimicking urethral malignancy. After histological confirmation of the diagnosis, treatment can be expectant or symptomatic.AimTo report an unusual cause of urethrorrhagia occurring only during erection in an otherwise healthy man.MethodsA 30-year-old man presented with a 5-month history of urethrorrhagia occurring only during erection, and with a painless palpable nodule in his penile urethra clearly visible on urethral US and magnetic resonance imaging, but not on urethroscopy.ResultsThe patient underwent wide surgical excision of the urethral nodule and grafting of the urethral defect with a pedicled preputial flap. Histological examination revealed isolated amyloid of urethral corpus spongiosum.ConclusionsIsolated urethrorrhagia during erection and without urinary symptoms can be the presenting sign of urethral amyloidosis involving corpus spongiosum rather than the urethral lumen; in such cases, surgical exploration, wide urethral excision and grafting are mandatory. Cormio L, Sanguedolce F, Pentimone S, Perrone A, Annese P, Turri FP, Bufo P, and Carrieri G. Urethral corpus spongiosum amyloidosis presenting with urethrorrhagia during erection. J Sex Med 2009;6:2915–2917.     

Male‐to‐Female Genital Reassignment Surgery: A Retrospective Review of Surgical Technique and Complications in 60 Patients

BackgroundPatients with male‐to‐female gender dysphoria (GD) require multidisciplinary assessment and management. Nowadays, more and more patients decide to undergo genital reassignment surgery (GRS) to have aesthetic and functional external female genitalia. Different techniques of this procedure have been described. Orchiectomy, penile disassembly, creation of a neovaginal cavity, repositioning of urethral meatus, and clitorolabioplasty may be identified as the five major steps in all of these techniques.MethodsWe conducted a retrospective study of 60 patients who underwent genital reassignment procedure for male‐to‐female GD at our department between November 2008 and August 2013 with a minimum follow‐up of 1 year. Data were collected on surgical technique, postoperative dilations protocol, complications, and functional and aesthetic outcomes. We describe and critically evaluate the surgical technique used in our department.ResultsFollow‐up ranged from 14 to 46 months. Two patients developed late neovaginal stricture, and two patients experienced rectovaginal fistulae (one required surgical revision with dermal porcine graft placement). Minor complications occurred in 13 patients and included urethral stenosis, partial wound dehiscence, and minor bleeding. Secondary aesthetic revision surgery was performed in 13 cases.ConclusionsGRS can provide good functional and aesthetic outcomes in patients with male‐to‐female GD. However, despite a careful planning and meticulous surgical technique, secondary procedures are frequently required to improve the function and appearance of the neovagina. Raigosa M, Avvedimento S, Yoon TS, Cruz‐ Gimeno J, Rodriguez G, and F ontdevila J. Male‐to‐female genital reassignment surgery: A retrospective review of surgical technique and complications in 60 patients. J Sex Med 2015;12:1837–1845.     

Climacturia After Radical Prostatectomy: MRI-Based Predictors

BackgroundAfter radical prostatectomy (RP), climacturia is a prevalent and distressing problem. To date, no specific predictors have been identified.AimIn this analysis, we sought to find associated pelvic magnetic resonance imaging (MRI) parameters.MethodsWe identified all men in our departmental database who (i) had climacturia post-RP, ≥3 episodes; (ii) underwent a pre-RP endorectal MRI; (iii) had no radiation or androgen deprivation therapy (ADT). Soft tissue and bony dimensions were measured by 2 raters blinded to clinical and pathological data.OutcomesMRI parameters included the following: maximum height, width, and depth of prostate, prostate volume, urethral width and length, lower conjugate of pelvis, bony femoral width, outer and inner levator distances and thickness. Point-biserial correlations were run on univariate associations. Logistic regression was used for the multivariable model.Results194 consecutive pre-RP MRI studies were reviewed (56 men with and 138 without climacturia). Mean age was 60 ± 7 years, average time post-RP at assessment, 7 ± 7 months. Of MRI parameters, urethral width (r = 0.13, P = .03) and lower conjugate (r = 0.12, P = .05) were associated with presence of persistent climacturia. 2 others met criteria for multivariable analysis, prostate depth and outer levator distance. Of the non-MRI parameters, none were significantly related to climacturia and only body mass index (BMI) met criteria for multivariable analysis. On multivariable analysis, only urethral width was associated with climacturia (OR = 1.23, 95% CI: 1.01–1.49, P = .04); the wider the urethra, greater the chance of climacturia.Clinical ImplicationsImproved ability to predict the occurrence of orgasm-associated incontinence in the preoperative setting.Strengths and LimitationsLimitations include the fact that the MRI endorectal probe may have distorted pelvic tissues during imaging and that our study population size was small. However, prospective data collection, blinded measurements by 2 trained readers, and rigorous statistical analysis should be considered strengths.ConclusionBy identifying preoperative risk factors, such as urethral width on MRI, we may be able to better understand the pathophysiology of this condition and furthermore may permit us to better counsel men regarding this postoperative outcome.Sullivan JF, Ortega Y, Matsushita K, et al. Climacturia After Radical Prostatectomy: MRI-Based Predictors. J Sex Med 2020;17:1723–1728.     

Urethral Diverticula in Pregnancy

Summary: In 4 cases, the clinical presentation of urethral diverticulum (UD) during pregnancy was a paraurethral mass (3), urinary incontinence (2), irritative symptoms (2), urinary tract infection (1), urethral pain and discharge (1) and voiding difficulty (1). The diagnosis of UD during pregnancy was made by trans vaginal ultrasonography (2), cystoscopy (1), and after pregnancy by a voiding cystourethrogram (1). Management during pregnancy involved antibiotics (2), diverticulum aspiration (2) and incision and drainage (1). Delivery was by the vaginal route in 2 women with diverticular aspiration being performed during the second stage to aid delivery in 1 woman. Caesarean section was performed in the other 2 women for reasons unrelated to the presence of the UD. Three women had diverticulectomy performed following pregnancy for persisting symptoms. Although uncommon, it is important to diagnose urethral diverticula given the associated morbidity and the potential for causing complications during pregnancy.     

The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis

BackgroundThe 3-piece inflatable penile prosthesis includes an easy-to-use pump and fluid filled reservoir which is placed in either the space of Retzius (SOR) or in an alternative ectopic location. Reservoir placement in the SOR is a blind procedure despite the SOR being surrounded by many critical structures. To date only a handful of cadaveric studies have described the relevant anatomy.AimTo use magnetic resonance imaging (MRI) as an in-vivo model to study relevant retropubic anatomy critical for SOR reservoir placement.MethodsThe study population included men with elevated prostate specific antigen or biopsy proven prostate cancer who (i) underwent pelvic MRI, (ii) without prior pelvic or inguinal surgery, and (iii) without pelvic radiation therapy. All MRIs were completed with a 3-Tesla scanner and endorectal coil. Both T1 and T2 weighted images were captured in both axial and sagittal planes. All images were reviewed by 2 independent reviewers under the supervision of a dedicated body MRI radiologist. Bladder volume was calculated using an ellipsoid formula.OutcomesRelevant measurements included (i) the distance between the external inguinal ring (EIR) at the level of the pubic tubercle to the external iliac vein (EIV), (ii) the distance from the EIR at the pubic tubercle to the bladder (accounting for bladder volume) and (iii) the distance from the midline pubic symphysis to the bladder (accounting for bladder volume). Pearson correlation was used to determine correlated measurements.ResultsA total of 24 patients were included. Median participant age was 63 years (interquartile range, 59-66). The mean EIR-EIV distance was 3.0 ± 0.4 cm, the mean EIR-bladder distance was 1.8 ± 1.0 cm and the mean distance from the superior pubic symphysis to bladder was 0.9 ± 0.3 cm. There was a weak correlation between bladder volume and distance between the EIR and bladder (r = -0.30, P = .16).Clinical ImplicationsThe use of MRI as an in-vivo model is a high-fidelity tool to study real time unaltered anatomy and allows for surgical preparation, diagnosis of anatomic variants and acts as a valuable teaching tool.Strengths & LimitationsThis is the first in-vivo model to report relevant retropubic anatomy in penile implant surgery. Our study is limited by sample size and inclusion of participants with no history of prior pelvic intervention.ConclusionWe demonstrate the utility of MRI as an in-vivo model, as opposed to cadaveric models, for the understanding of relevant retropubic anatomy for implant surgeons.Punjani N, Monteiro L, Sullivan J F et al. The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis. J Sex Med 2021;18:1830–1834     

Influence of Sildenafil on Genital Engorgement in Women with Female Sexual Arousal Disorder

IntroductionWe previously described dynamic, noncontrast magnetic resonance imaging (MRI) of the female genitalia as a reproducible, nonintrusive, objective means of quantifying sexual arousal response in women without sexual difficulties. These studies showed an increase in clitoral engorgement ranging from 50 to 300% in healthy women during sexual arousal.AimThis study sought to evaluate the genital arousal response in women with female sexual arousal disorder (FSAD) after administration of sildenafil and placebo. We performed a multicenter, double‐blind, placebo‐controlled, cross‐over study to assess the clitoral engorgement response using dynamic MRI in women with FSAD after administering sildenafil and placebo followed by audiovisual sexual stimulation (AVSS).MethodsNineteen premenopausal women with FSAD underwent two MRI sessions. Subjects were randomized to receive either (i) sildenafil 100 mg during the first session followed by placebo during the second session, or (ii) placebo followed by sildenafil. During each session, baseline MR images were obtained while subjects viewed a neutral video. Subjects then ingested sildenafil or placebo. After 30 minutes, a series of MRIs were obtained at 3‐minute intervals for 10 time points while subjects viewed AVSS.Main Outcome MeasuresA positive sexual arousal response was achieved if clitoral volume increased ≥50% from baseline.ResultsThirteen of 19 (68%) subjects achieved a ≥50% increase in clitoral engorgement from baseline when administered sildenafil or placebo 30 minutes after dose administration. At 60 minutes after administration, 17/19 (89%) subjects receiving sildenafil and 16/19 (84%) subjects receiving placebo had responded (P value 0.3173).ConclusionsSildenafil did not augment the genital response in women with FSAD. Secondarily, a majority of women in this study did not have impaired clitoral engorgement as measured by MRI, suggesting that FSAD is not predominantly a disorder of genital engorgement. Leddy LS, Yang CC, Stuckey BG, Sudworth M, Haughie S, Sultana S, and Maravilla KR. Influence of sildenafil on genital engorgement in women with female sexual arousal disorder. J Sex Med **;**:**–**.     

Painful love-"hispareunia" after sling erosion of the female partner

IntroductionSling erosion/extrusion is a complication after suburethral sling insertion for female stress urinary incontinence that occurs in approximately 6% of patients. Symptoms may include vaginal discharge, infections, postcoital bleeding, and alterations of the sexual function. Little is known about the effect of sling erosion on the sexual function of the male partner.AimThe aim of this study was to determine male sexual function in partners of women who had undergone sling insertion for stress urinary incontinence and who developed sling erosion postoperatively.Main Outcome MeasuresMain outcome measures were the Brief Male Sexual Function Inventory (BMSFI) and visual analog scale (VAS) scores.MethodsMale partners of patients who presented with sling erosion for various reasons were addressed and asked to fill in the BMSFI and assess sexual pain using the VAS before and 6 months after the sling erosion of their female partners was treated. Participants gave informed consent and those who had undergone prostate surgery during the past 12 months were excluded. For statistical analyses, SPSS version 10.0 (SPSS Inc., Chicago, IL, USA) was used.ResultsThirty-two males were included in the study and produced a full set of data. VAS scores as a measurement for “hispareunia” improved from a median score of 8 before to a median score of 1 after intervention. Some domains of male sexual function (sexual interest, sexual drive, ejaculation, and erection) were significantly improved whereas the strength of erection, problems with ejaculation, and problems with lack of interest were not statistically significantly changed.ConclusionsChanges of male sexual function and particularly pain after sling insertion in their female partners may be due to sling exposure. Sexual interest and drive may be negatively influenced. Male dyspareunia is a complaint that can be treated effectively by correcting the sling exposure. Mohr S, Kuhn P, Mueller MD, and Kuhn A. Painful Love—“Hispareunia” after sling erosion of the female partner.