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Sexual rehabilitation of women with a spinal cord injury.

STUDY DESIGN: Literature review and a qualitative study. OBJECTIVE: This article reviews literature examining the sexual rehabilitation of women following spinal cord injury (SCI). It includes recommendations for improvements in initial clinical rehabilitation efforts and counselling services. SETTING: United Kingdom, Denmark and Sweden. METHODS: Articles concerning sexual rehabilitation following SCI from the last two decades have been reviewed and critiqued. Qualitative results from discussions with women with SCI in Denmark and Sweden are presented. RESULTS: The literature focuses on the effect of neurological change on women's ability to achieve sexual arousal and orgasm. Urinary and bowel incontinence, spasticity, vaginal lubrication and autonomic dysreflexia are the physical consequences of SCI that appear to have most impact on sexual activity. More recent studies have acknowledged that psychosocial factors such as age and partnership status may also affect the successful sexual rehabilitation. Discussions with women with SCI in Denmark and Sweden on their reactions to information and counselling offered during rehabilitation revealed an overwhelming need for the exchange of information and experience with other women with SCI, and a desire for opportunities for counselling after initial rehabilitation. CONCLUSION: Successful sexual rehabilitation of women with SCI demands a holistic approach that considers individual neurological, physical and psychosocial circumstances. Peer-counselling could make a significant contribution to the sexual rehabilitation of women with SCI.

Autonomic Nervous System Diseases↗

Electrophysiological assessment of sexual dysfunction in spinal cord injured patients.

STUDY DESIGN: Survey. OBJECTIVES: To determine associations between sexual dysfunctions and electrophysiological examinations of the genital system in spinal cord injured patients. SETTING: Ege University Hospital, Izmir, Turkey. METHODS: In total, 25 patients (17 men, eight women) who were out of the spinal shock period were examined. Neurological levels were determined according to the American Spinal Injury Association (ASIA) impairment scale. Data about erection, ejaculation and vaginal lubrication were obtained via inquiry forms. Bulbocavernosus reflex (BCR), pudendal somatosensorial evoked potentials (pSEP) and perineal sympathetic skin responses (pSSR) were recorded by an electromyographer unaware of the sexual state or neurological level of the patient. RESULTS: BCRs could be obtained from all patients with lesion levels above the sacral centre. A significant association was found between reflex erection and BCR positivity, while psychogenic erection was shown to have a significant association with the preservation of pSSR in men. Despite the lack of statistical significance due to the small sample size of the women examined, a similar association with lubrication was observed. Ejaculation and orgasm were not shown to be significantly associated with any electrophysiological examination. However, ejaculation was preserved in all men with a lesion level below T12 and with positive pSSR. There was no significant relationship between pSEP and sexual functions. The relationship between the existence of sacral sensation and pSEP positivity was statistically significant. CONCLUSION: This study has proved that BCR and pSSR have an important role in the estimation of the remaining sexual function in spinal cord injured patients. STATEMENT ON ETHICS: We certify that all applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during the course of this research.

Adult↗

Defective sexuality and female circumcision: the cause and the possible management.

AIM: To verify the effect of circumcision on female sexuality and to define the need for clitorolabioplasty in these cases. METHODS: Thirty uncircumcised controls, 30 minorly circumcised, 30 minorly circumcised mutilated, and 57 circumcised cases having clitoral cysts were selected on random bases at Kasr El Aini School of Medicine. Sexuality was assessed by a special questionnaire sheet prepared by the authors to fit the circumcised cases. Clitorolabioplasty and clitoral cyst excision were also done in cases of sexual defects. RESULTS: Sexuality was not affected in minorly circumcised cases. However, sexuality was markedly affected in the mutilated cases. The scores for sex desire and arousal and for orgasm were especially affected in such cases. These defects were not detected in cases having clitoral cysts until late, when cysts enlarged. The role of clitorolabioplasty in restoration of sexuality was confirmed. The loss of certain clitoral and labial bulk, necessary for orienting the woman towards her genitalia and initiating her interest in their function, was responsible for the occurrence of such defects; this was able to be restored by surgery. CONCLUSION: Counseling parents about these sexual defects and asserting the need for correcting the mutilation, which resulted from these circumcisions, are effective steps in banning such procedures.

Adolescent↗

Optimum usage of prilocaine-lidocaine cream in premature ejaculation.

Premature ejaculation is a common male sexual disorder in which orgasm and ejaculation occur before the desired moment. The primary therapeutic approach to premature ejaculation has been behavioural and pharmacotherapy. In this study, we evaluated the efficacy and optimum usage of lidocaine-prilocaine cream 5% in preventing premature ejaculation. Forty patients were examined in the study group and randomized into four groups, each comprising 10 patients. Patients in group 1 applied lidocaine-prilocaine cream 5% for 20 min, the patients in group 2 applied it for 30 min, and the patients in group 3 applied the cream for 45 min before sexual contact, with all patients covering the penis with a condom. Patients in the fourth group applied a base cream as placebo. In group 1, the pre-ejaculation period increased to 6.71 +/- 2.54 min without any adverse effects. In group 2, although the pre-ejaculation period increased in four patients up to 8.70 +/- 1.70 min, six patients in this group and all patients in group 3 had erection loss because of numbness. In the placebo group, there was no change in their pre-ejaculation period. Therefore, lidocaine-prilocaine cream 5% is effective in premature ejaculation and 20 min of application time before sexual contact is the optimum period.

Administration, Topical↗

Age-related prevalence of erectile dysfunction in Japan: assessment by the International Index of Erectile Function.

BACKGROUND: The effects of age and concomitant chronic illness on male sexual function were investigated to obtain insight into the prevention of erectile dysfunction (ED). METHODS: A questionnaire from the International Index of Erectile Function (IIEF) was given to 2311 non-institutionalized men aged 23-79 years along with a survey of health status. The study sample consisted of 1517 men who provided complete responses to the questionnaire. For statistical analysis, ANOVA was conducted to evaluate the effect of aging on the sexual functions and a logistic regression model was used to identify significant independent risk factors for ED. RESULTS: There was a significant correlation between age and the scores for erectile function, orgasmic function, sexual desire and intercourse satisfaction. The prevalence of moderate and severe cases of ED were 1.8% and 0% for ages 23-29; 2.6% and 0% for ages 30-39; 7.6% and 1.0% for ages 40-49; 14.0% and 6.0% for ages 50-59; 25.9% and 15.9% for ages 60-69; and 27.9% and 36.4% for ages 70-79 years, respectively. Hypertension, diabetes mellitus, heart disease, chronic hepatitis, disc herniation and cerebral infarction under treatment with anticoagulants were significant independent risk factors for ED. CONCLUSIONS: The results obtained indicated a significant association between aging and chronic diseases and erectile function. Further epidemiologic research and analysis of individual risk factors are required to allow more effective future strategies for the treatment and prevention of ED.

Adult↗

Intracavernosal drug-induced erection therapy versus external vacuum devices in the treatment of erectile dysfunction.

OBJECTIVES: To determine if there is a significant difference between intracavernosal self-injection and external vacuum devices when compared directly for satisfaction, effectiveness and side-effects. PATIENTS AND METHODS: Fifty men were randomised into two groups and received either instruction on the use of the Osbon ErecAid system or self-injection therapy. After 15 uses, each group completed a questionnaire detailing efficacy, satisfaction and side-effects, and then changed to the other modality after appropriate instruction. A questionnaire was completed by study participants and their sexual partners after using both methods. Patients were followed for 18-24 months using telephone interviews. RESULTS: Forty-four patients (mean age 62.3 years, range 38-84) completed the study. Patients and their partners reported a superior quality of erections with the injection method but the difference did not reach statistical significance. The ability to attain orgasm and the overall satisfaction of the patient and partner with the sexual experience was significantly better when using injections. Side-effects were similar between the modalities. Subgroups analysed for age, duration and aetiology of impotence showed that younger patients (< 60 years), those with a shorter duration of impotence (< 12 months) and those impotent secondary to radical prostatectomy strongly favoured injection therapy (P < 0.05). Overall, of the 44 couples, the final preferences of the patients were 25 (57%), 12 (27%), six (14%) and one (2%) for the injection, vacuum device, both or neither, respectively, and of the partners were 22 (50%), 12 (27%), six (14%) and four (9%), respectively. At 18-24 months, 80% of patients were still using either the vacuum device, injections, or both. CONCLUSION: Both the vacuum device and injections are effective treatment modalities for impotence and are associated with good long-term success. Overall, there was a trend favouring injection therapy over the vacuum device which was most significant in younger patients, those with a shorter duration of impotence, and those impotent secondary to radical prostatectomy.

Adult↗

Severe hypospadias with genital ambiguity: adult outcome after staged hypospadias repair.

OBJECTIVE: To obtain the long-term follow-up information on children born with severe perineoscrotal hypospadias associated with genital ambiguity who underwent a staged surgical correction of their hypospadias and were raised as males. PATIENTS AND METHODS: The study comprised patients who had undergone a surgical correction of hypospadias before 1978 and were traced successfully. Postal questionnaires which were completed and returned by 19 patients and 28 general practitioners (GPs) were evaluated; in addition, nine cases were clinically reviewed. RESULTS: Of the 19 patients who completed and returned the questionnaire, four were married or living with a partner and 12 had had intercourse, with debut at a median age of 17 years. Satisfactory erection and orgasm were reported by 15 men but only seven had satisfactory ejaculation. Nine men had continued difficulties with micturition and urological function. Four men considered that their psychological well-being and quality of life had been markedly impaired by their condition and two other men had evidence of mild depression. Nine patients did not complete the questionnaires but allowed their GPs to provide information about them; only one was reported to have marked psychological impairment and impaired general health. Two of the patients who did not participate in the study are known to have significant psychiatric problems. CONCLUSIONS: Staged hypospadias repair in men with severe perineoscrotal hypospadias is associated with continued difficulty with both ejaculation and micturition, but is not usually associated with major psychiatric or psychological disturbance. The findings indicate the importance of follow-up in adolescence and adult life with adequate counselling when necessary.

Adolescent↗

Evaluation of sexual life after orchidectomy followed by radiotherapy for early-stage seminoma of the testis.

OBJECTIVE: To explore the changes perceived by patients in their sexual lives after orchidectomy and radiation therapy of the pelvic and para-aortic nodes for early-stage testicular seminoma (ST). PATIENTS AND METHODS: A questionnaire mainly based on two self-completed instruments, previously used to assess the sexual life of patients affected by testicular cancer (the UCLA/RAND sexual module and the Groningen sexual questionnaire) was mailed to a consecutive series of 143 patients treated for ST between 1961 and 1995, and who showed no signs of disease after primary treatment. RESULTS: Ninety-eight questionnaires (69%) were returned and were evaluable. The median age of the patients was 48 years (range 26-85) at the time they completed the questionnaire, with the median follow-up of 123 months (range 15-496). Most of the patients (86%) had been sexually active during the month before completing the questionnaire. Of these patients, 25% reported a low libido and 14% defined their sexual capacity as poor; 14% of the patients avoided sexual contact after treatment because of the disease and/or cancer therapies. After therapy, a minority of the patients found it more difficult to achieve and maintain an erection. Similarly, a few patients reached orgasm less intensely and less frequently. During the period after treatment, 24% reported a low semen volume, 14% premature ejaculation, 2% late ejaculation and 2% an absence of ejaculation. Most of the patients considered the information and counselling given by their physician about the sexual sequelae of therapy to be insufficient. However, the amount of information about the disease and treatment was considered to be good by, respectively, 64% and 61% of the patients. The only variable predictive of sexual adjustment was age at the time of the administration of the questionnaire. CONCLUSION: The sexual adjustment of patients treated with orchidectomy and radiation therapy for early-stage ST is generally good, but a few have negative experiences. Although the main predictive factor is age, communication is an important issue and better information tools could lead to better adjustment.

Adult↗

Priapism in adult Nigerians.

OBJECTIVES: To review the presentation and treatment of adult Nigerians with priapism. PATIENTS AND METHODS: Thirty-five men (mean age 35 years, range 20-54) were seen over a 12-year period. All patients underwent an immediate modified or conventional cavernospongiosus shunt and were assessed at 2, 6 and 12 weeks after discharge for erection, orgasm and fibrosis of corpora cavernosa. RESULTS: Ten patients initially presented to traditional healers and 13 presented early to qualified medical practitioners, and were managed conservatively. As a result, 21 of the 35 patients presented to the author's hospital 6-10 days after the onset of erection. Many did not realise that priapism was abnormal, or had no money to attend hospital. After surgical treatment detumescence was obtained in all patients and maintained. At 12 weeks, 14 patients had normal erections, 13 reduced erections and eight no erections. A local aphrodisiac was identified as the commonest predisposing factor, followed by sickle-cell disease. CONCLUSION: This study shows clearly that even if a patient with priapism presents late, vigorous treatment in the form of an adequate shunt should be undertaken as soon as possible, as this is the only chance the patient has to regain potency.

Adult↗

Long-term follow-up of female patients with congenital adrenal hyperplasia from 21-hydroxylase deficiency, with special emphasis on the results of vaginoplasty.

OBJECTIVE: To assess, in a long-term follow-up, female patients with congenital adrenal hyperplasia (CAH), with special emphasis on vaginal functional outcome and sexual activity after vaginoplasty. PATIENTS AND METHODS: Twenty-seven patients with CAH (aged 14-33 years; six Prader grade II, 14 grade III, six grade IV and one grade V) underwent surgery between 1972 and 1988. Three of the patients underwent clitoridectomy, 24 clitoroplasty and 25 vaginoplasty (24 with a Fortunoff flap and one a 'pull-through' procedure). In 20 patients the vaginoplasty was a one-stage procedure, undertaken at a mean (range) age of 3.6 (1-9) years, and in five patients a two-stage operation. The analysis was based on the patients' history and examination; the patients also completed a questionnaire, including a psychological profile. RESULTS: Nine of the 25 patients (36%) who underwent vaginoplasty developed intravaginal stenosis; of these nine, six were Prader grade III and three grade IV. All had undergone a single-stage procedure at a mean (range) age of 4.7 (2-9) years. Of the 16 patients who answered the questionnaire, 14 had problems with their overall body image; patients in whom vaginal stenosis was corrected were particularly anxious about sexual intercourse and had problems with orgasm. CONCLUSION: The main problem during the long-term follow-up was intravaginal stenosis; all the affected patients had undergone a single-stage procedure early in life to correct ambiguous genitalia. This high rate of vaginal stenosis suggests that vaginoplasty should be undertaken at the beginning of puberty, because higher oestrogen levels may prevent stenosis and, if necessary, dilatation can be performed by the patient. These data also underscore the importance of psychological support in the treatment of children with CAH.

Adolescent↗

A dose-escalation study to assess the efficacy and safety of sildenafil citrate in men with erectile dysfunction.

OBJECTIVE: To assess the efficacy and safety of sildenafil citrate (Viagra, Pfizer Inc., USA) in a double-blind, placebo-controlled, dose-escalation study over a period of 26 weeks in men with erectile dysfunction of a broad spectrum of aetiology. PATIENTS AND METHODS: In all, 315 patients from five countries were randomized to receive treatment with placebo (156 men) or sildenafil (159 men). Significant concomitant medical conditions were hypertension (20%), a history of pelvic surgery (19%), diabetes mellitus (15%), and ischaemic heart disease (10%). Patients randomized to treatment received a starting dose of 25 mg of sildenafil or matching placebo, which could be increased to 50 mg and then to 100 mg of sildenafil, based on efficacy and tolerability. Assessments of efficacy comprised the 15-item International Index of Erectile Function (IIEF), including question three (ability to achieve an erection) and question four (ability to maintain an erection), a partner questionnaire, an overall efficacy question, and event-log data. RESULTS: After 12 weeks of treatment, 26%, 32% and 42% of patients were taking 25, 50 and 100 mg of sildenafil, respectively. A similar distribution of doses was reported after 26 weeks of treatment. Treatment with sildenafil significantly improved the patients' abilities to achieve and maintain an erection compared with treatment with placebo (P < 0.001). Scores for four of the five sexual function domains of the IIEF (erectile function, orgasmic function, intercourse satisfaction and overall satisfaction) also improved significantly (P < 0.001). There was a significant improvement in the mean score for the erectile function domain, regardless of the aetiology of erectile dysfunction (P < 0.001). After 12 weeks and 26 weeks of treatment, 82% and 79% of patients receiving sildenafil reported improved erections, compared with 24% and 23% of patients receiving placebo, respectively (P < 0.001). Treatment-related adverse events were mild to moderate and occurred in 27% of patients receiving sildenafil, compared with 8% of patients receiving placebo. CONCLUSION: Sildenafil is an effective and well-tolerated treatment for men with erectile dysfunction of a broad spectrum of aetiology.

Administration, Oral↗

Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients.

OBJECTIVE: To report experience of a new surgical technique in male-to-female transsexual patients, the complications, and the functional and psychosocial long-term results. PATIENTS AND METHODS: From April 1995 to July 2000, 66 male patients underwent gender-transforming surgery at our institution and were registered prospectively. The operation should result in a normal appearing introitus, a vaginoplasty allowing for sexual intercourse and a sensitive clitoris. This was achieved by preserving the neurovascular bundle. The glans was transformed into a clitoris, the phallic cylinder used as a vagina and labia were formed from the scrotal folds. RESULTS: Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft. A long-term follow-up questionnaire about the functional and psychosocial aspects was completed by 31 patients. More than 90% of the patients were satisfied with the cosmetic result and capacity for orgasm; 58% reported having sexual intercourse. CONCLUSION: Male-to-female surgery can achieve excellent cosmetic and functional results. Although the operative technique is partly standardized, surgery remains challenging because of several possible complications. None of the present patients claimed to regret their decision to undergo gender-transforming surgery.

Adult↗

Serum leptin levels in patients with premature ejaculation before and after citalopram treatment.

OBJECTIVE: To evaluate serum leptin levels (an adipocyte hormone involved in the suppression of appetite) in patients with premature ejaculation before and after treatment with citalopram, a selective serotonin reuptake inhibitor, with the hypothesis that leptin levels might become normal during this treatment. PATIENTS AND METHODS: The inhibitory effect of serotonin on libido, ejaculation and orgasm is well documented. Although there is no direct evidence of an association involving brain pathways which are related to sexual behaviour, there is an interaction between leptinergic and serotonergic systems. In a previous study serum leptin levels were high in patients with premature ejaculation. The present study comprised 30 patients with premature ejaculation according to the Diagnostic and Statistical Manual of Mental Disorders Third Revised Version. Fifteen patients (group I) were randomly assigned to 8 weeks of citalopram treatment and the remainder (15, group II) received no therapy. The patients were asked to determine the average intravaginal ejaculation latency time, and their fasting serum leptin levels were measured at baseline and after 8 weeks. RESULTS: There was no significant difference in the mean intravaginal ejaculation latency time between the groups at baseline; it increased after 8 weeks of treatment with citalopram in group I, to a mean (sd) of 209 (72.1) s, but not in group II. No difference was detected in leptin levels between the groups at baseline, but at 8 weeks they were lower in group I. CONCLUSION: As hypothesized, leptin levels decreased in patients with premature ejaculation after treatment with citalopram, and this decrease seemed to be linked to the therapeutic effect. Further experimental studies are needed.

Adult↗

Urinary symptoms, quality of life and sexual function in patients with benign prostatic hypertrophy before and after prostatectomy: a prospective study.

OBJECTIVE: To evaluate urinary symptoms, sexual dysfunction and quality of life in patients with benign prostatic hypertrophy (BPH) before and after open prostatectomy, using the International Prostate Symptom Score (IPSS), the International Continence Society (ICS)-"BPH" (ICS-male, ICS-sex and ICS-QoL) and International Index of Erectile Function (IIEF) questionnaires. PATIENTS AND METHODS: Sixty men with BPH (mean age 68 years) underwent a digital rectal examination, transurethral ultrasonography, measurement of total prostatic specific antigen serum level and uroflowmetry. Their urinary symptoms, sexual function and quality of life were fully evaluated using the IPSS, ICS-"BPH" and IIEF before and 6 months after suprapubic prostatectomy. The body mass index (BMI) was also calculated for each patient. Univariate analysis was used to examine the relationship between symptom scores and age, tobacco use, alcohol intake and BMI. RESULTS: In a univariate analysis, age was the most important prognostic factor for both urinary and sexual symptoms. Prostatectomy resulted in a significant improvement in obstructive (mean 9.68 to 3.38) and irritative symptom (6.70 to 3.06), and quality-of-life scores (3.41 to 1.34). ICS-male scores were both significantly decreased, the mean voiding score from 13.72 to 10.28 and the incontinence score from 10.43 to 7.81. There was also a significant decrease in the ICS-QoL symptom score (from 9.20 to 7.27). Comparative results between IIEF and ICS-sex showed no improvement in sexual scores after open surgery, but there was a significant increase in sexual desire and overall satisfaction (both P = 0.035). CONCLUSIONS: The combined use of the IPSS, ICS-"BPH" and IIEF allows an evaluation of the relationship between age, prostatic symptoms and sexual dysfunction. Age may be considered both a direct and indirect (BPH-related) prognostic factor for sexual activity. Suprapubic prostatectomy resolves obstructive symptoms, and maintains sexual desire, overall sexual satisfaction and an improvement in quality of life. However, irritative symptoms, erection, orgasm and sexual intercourse satisfaction are not significantly altered.

Aged↗

Urogynaecological and obstetric issues in women with the exstrophy-epispadias complex.

OBJECTIVE: To review of the sexual and urogynaecological issues faced by a large cohort of women with the exstrophy-epispadias complex (EEC). PATIENTS AND METHODS: The study comprised 83 women and girls with EEC; a confidential survey was mailed to identify their social and sexual concerns. Fifty-six women had classical bladder exstrophy (CBE), 13 had female epispadias (FE) and 14 had cloacal exstrophy (CE). Data on the initial method of reconstruction and urogynaecological problems were obtained from a review of the hospital records. Information on continence, infection and sexual function was obtained from 34 completed surveys. RESULTS: The bladder was closed in 51 patients with CBE and 13 with CE. Urinary calculi developed in 10 patients with CBE, two with FE and three with CE. Vaginal and uterine prolapse occurred an earlier age in patients with EEC. Eight women had 13 pregnancies, eight of which resulted in normal healthy children. Overall continence was achieved in 85% of the women surveyed. Urinary tract infections remained a frequent problem for women with EEC; only 27% of respondents indicated that they were infection-free. Women aged > 18 years (24) who responded indicated that they had appropriate sexual desire; 16 were sexually active and the mean age for commencing sexual activity was 19.9 years. Six patients had dyspareunia and 10 indicated that they had orgasms. However, five additional patients indicated that they had restricted intercourse, as they were dissatisfied with the cosmesis of their external genitalia. CONCLUSIONS: Sexual and gynaecological issues become increasingly important in patients with EEC as they become adults. Understanding these issues faced by patients with EEC as they mature will permit better counselling of future patients.

Adolescent↗

Complicated coital cephalalgia. Three cases with benign evolution.

Three patients with a history of migraine and type-II coital cephalalgia with signs of vertebrobasilar deficiency are presented. Extensive studies including angiography did not show any vascular malformation. Together with the few reports in the literature our cases outline a benign form of complicated coital cephalalgia, possibly resulting from ischaemic disturbances triggered by haemodynamic changes occurring in orgasm.

Adult↗

Early clitoral carcinoma successfully treated by radiotherapy and bilateral inguinal lymphadenectomy.

A 42 year-old female presented with an early stage IB squamous cell carcinoma involving the clitoris. She was treated with radical radiotherapy to the clitoris and peri-clitoral region and bilateral inguinal lymphadenectomy. The treatment was well tolerated. The vulvar appearance, sensation and orgasmic function have not been impaired. There has been no recurrence during five years of follow-up. Radiotherapy and bilateral inguinal lymphadenectomy are an effective therapeutic option in early stage IB carcinoma involving the clitoris in sexually active females.

Journal Article↗

Sexual headache and stroke in a heavy cannabis smoker.

Sexual headaches usually develop during orgasm. Stroke complicating is rare. We report the case of a young man and heavy cannabis smoker who suffered posterior cerebral artery infarction during his first episode of coital headache.

Adult↗