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PubMed2006

Uterosacral ligament vault suspension: five-year outcomes.

OBJECTIVE: To evaluate the five-year anatomic and functional outcomes of the high uterosacral vaginal vault suspension. METHODS: One hundred ten patients with advanced symptomatic uterovaginal or posthysterectomy prolapse treated between January 1997 and January 2000 were identified and 72 (65%) consented to participate in this study. Anatomic outcomes were obtained by Pelvic Organ Prolapse Quantification. Functional results were obtained subjectively and with quality-of-life questionnaires, including the short-form Incontinence Impact Questionnaire (IIQ) and Urogenital Distress Inventory (UDI), and Female Sexual Function Index. RESULTS: The mean follow-up period was 5.1 years (range 3.5-7.5 years). Vaginal hysterectomy (37.5%), anterior colporrhaphy (58.3%), posterior colporrhaphy (87.5%), and suburethral slings (31.9%) were performed as indicated. Surgical failure (symptomatic recurrent prolapse of stage 2 or greater in one or more segments) was 11 of 72 (15.3%). Two patients (2.8%) had recurrence of apical prolapse of stage 2 or greater. For those sexually active preoperatively and postoperatively (n=34), mean postoperative Female Sexual Function Index scores for arousal, lubrication, orgasm, satisfaction, and pain were normal, whereas the desire score was abnormal (mean= 3.2). However, 94% (n=29) were currently satisfied with their sexual activity. Postoperative IIQ/UDI scores were significantly improved in all three domains (irritative, P= .01; obstructive, P<.001; stress, P=.03) and overall (IIQ-7, P<.001; UDI, P<.001) compared with preoperatively. Bowel dysfunction occurred 33.3% preoperatively compared with 27.8% postoperatively (P=.24). CONCLUSION: Uterosacral ligament vaginal vault fixation seems to be a durable procedure for vaginal repair of enterocele and vaginal vault prolapse. Lower urinary tract, bowel, and sexual function may be maintained or improved.

Aged↗
PubMedDate not supplied

Sexual dysfunction in women with premature menopause.

OBJECTIVE: To discuss assessment and management of sexual dysfunctions associated with premature menopause. DESIGN: Literature review plus clinical observations. RESULTS: Studies on assessment and management of sexual dysfunctions associated with premature menopause are minimal. Premature menopause affects sexual identity, sexual function, and sexual relationship. Major modulating factors include etiology, life cycle stage, factors personal to the woman, and family and societal influences. Loss of ovarian function in adolescence may delay psychosexual maturity via psychological and biological mechanisms. Maternity becomes impossible, unless ovodonation is feasible, accepted, and legally available. Loss of sexual desire, subjective and genital arousal, and orgasm may be highly distressing. Reduction of sex hormones and psychological reactions of both partners to the prematurity and infertility are etiologically important. Estrogen therapy is usually indicated, but long-term safety data in this population are lacking. Testosterone therapy, also lacking in safety data and mainly investigational, may be needed to restore sexual arousability. Presence, age, and sexual health of the partner, having children, and quality of intimacy in previous and present relationships modulate coping attitudes and clinical outcome. CONCLUSIONS: An interdisciplinary medical and psychosexual approach comprises individualized hormone therapy and specific psychosexual treatment(s). Research into optimal management of sexual dysfunction with premature menopause is urgently needed.

Estrogen Replacement Therapy↗
PubMed2005

The role of testosterone therapy in postmenopausal women: position statement of The North American Menopause Society.

OBJECTIVE: To create an evidence-based position statement regarding the role of exogenous testosterone in postmenopausal women. DESIGN: The North American Menopause Society (NAMS) enlisted a panel of clinicians and researchers acknowledged to be experts in the field of testosterone therapy to review the evidence obtained from the medical literature, compile supporting statements and conclusions, and reach consensus on recommendations. The document was reviewed and approved by the NAMS Board of Trustees. RESULTS: Endogenous testosterone levels have not been clearly linked to sexual function in postmenopausal women. Published evidence from randomized controlled trials, although limited, indicates that exogenous testosterone, both oral and nonoral formulations, has a positive effect on sexual function, primarily desire, arousal, and orgasmic response, in women after spontaneous or surgically induced menopause. Data are inadequate to support recommending testosterone use for any other indication, including preserving or increasing bone mineral density, reducing hot flashes, increasing lean body mass, or improving well-being. Hirsutism and acne have been associated with testosterone therapy, but the actual risks are not well defined. It is not known whether testosterone therapy increases the risk of breast cancer, cardiovascular disease, or thromboembolic events. There are few data regarding the safety and efficacy of testosterone therapy in women not using concomitant estrogen therapy or for the use of testosterone therapy for longer than 6 months. Clinically available laboratory assays do not accurately detect testosterone concentrations at the values typically found in women, and no testosterone level has been clearly linked to a clinical syndrome of hypoandrogenism or testosterone insufficiency. CONCLUSIONS: Postmenopausal women with decreased sexual desire associated with personal distress and with no other identifiable cause may be candidates for testosterone therapy. Testosterone treatment without concomitant estrogen therapy cannot be recommended because of a lack of evidence. When evaluating a woman for testosterone therapy, recommendations are to rule out causes not related to testosterone levels (eg, physical and psychosocial factors, medications) and to ensure that there is a physiologic cause for reduced testosterone levels (eg, bilateral oophorectomy). Laboratory testing of testosterone levels should be used only to monitor for supraphysiologic levels before and during therapy, not to diagnose testosterone insufficiency. Monitoring should also include subjective assessments of sexual response, desire, and satisfaction as well as evaluation for potential adverse effects. Transdermal patches and topical gels or creams are preferred over oral products because of first-pass hepatic effects documented with oral formulations. Custom-compounded products should be used with caution because the dosing may be more inconsistent than it is with government-approved products. Testosterone products formulated specifically for men have a risk of excessive dosing, although some clinicians use lower doses of these products in women. Testosterone therapy is contraindicated in women with breast or uterine cancer or in those with cardiovascular or liver disease. It should be administered at the lowest dose for the shortest time that meets treatment goals. Counseling regarding the potential risks and benefits should be provided before initiating therapy.

Androgens↗
PubMedDate not supplied

Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo-controlled trial.

OBJECTIVE: Evaluation of the use of testosterone therapy for hypoactive sexual desire disorder (HSDD) after oophorectomy has mostly involved women treated with oral estrogen preparations. We investigated the efficacy and safety of a testosterone patch in surgically menopausal women receiving concurrent transdermal estrogen. DESIGN: Women with HSDD after oophorectomy, for whom this was a concern, who were using transdermal estrogen, were recruited to a 24-week, randomized, double-blind, placebo-controlled trial in Europe and Australia. Patients were randomly allocated to placebo (n = 40) or testosterone 300 microg/day (n = 37) treatment. Primary endpoints were changes in sexual desire measured by the sexual desire domain of the Profile of Female Sexual Function and the frequency of satisfying sexual activity at 24 weeks. RESULTS: Sixty-one women (79%) completed the trial. All subjects who received at least one application of study medication were included in analysis. The testosterone-treated group experienced a significantly greater change from baseline in the domain sexual desire score compared with placebo (change from baseline, 16.43 versus 5.98; P = 0.02). The domain scores for arousal, orgasm, decreased sexual concerns, responsiveness, and self-image as well as decreased distress were also significantly greater with testosterone therapy than placebo. The frequency of satisfactory sexual events increased but was not statistically different between treatment groups (P = 0.06) Adverse events occurred with similar frequency in both groups, and no serious risks of therapy were observed CONCLUSIONS: In this study, transdermal testosterone therapy via a skin patch improved sexual desire and other sexual function domains. It was well tolerated in these oophorectomized women with HSDD receiving concomitant transdermal estrogen.

Administration, Cutaneous↗
PubMed2003

Antidepressants and ejaculation: a double-blind, randomized, fixed-dose study with mirtazapine and paroxetine.

A double-blind, fixed-dose study in healthy men with lifelong early ejaculation was performed to evaluate potential differences in their effects on ejaculation latency, between clinically relevant doses of the selective serotonin reuptake inhibitor paroxetine and the noradrenergic and specific serotonergic antidepressant mirtazapine. Twenty-four men with an intravaginal ejaculation latency time (IELT) less than 1 minute were randomly assigned to paroxetine (20 mg/d) or mirtazapine (30 mg/d) for a period of 6 weeks; half the dosage was given in the first week. During the preceding 1-month baseline and 6-week treatment period, intravaginal ejaculation latency times were measured at home using a stopwatch procedure. The trial was completed by 18 men. Analysis of variance revealed a between-group difference in the development of the delay in intravaginal ejaculation latency time over time (P < 0.001); the intravaginal ejaculation latency time after paroxetine and mirtazapine gradually increased from 15 to 119 s and from 23 to 28 s, respectively, after 6 weeks. Paroxetine 20 mg/d exerted a strong delay (maximum 5.7-fold increase), whereas mirtazapine 30 mg/d did not delay ejaculation (0.9-fold increase). These results confirm earlier findings that paroxetine, but not mirtazapine, significantly delays orgasm and ejaculation in men with early ejaculation, whereas mirtazapine is devoid of any effect on it.

Adolescent↗
PubMed2004

Bupropion sustained release for the treatment of hypoactive sexual desire disorder in premenopausal women.

Premenopausal women meeting operational criteria for idiopathic, acquired, global hypoactive sexual desire disorder were studied in a randomized, double-blind, placebo-controlled, multiple-site escalating dose 112-day trial of bupropion sustained release. Outcome was measured by investigator-rating and self-administered questionnaires. All measures indicated greater sexual responsiveness in women receiving bupropion. The Changes in Sexual Functioning Questionnaire indicated that bupropion had significant effects on increasing measures of sexual arousal, orgasm completion, and sexual satisfaction.

Adult↗
PubMed2006

Bupropion improves sexual functioning in depressed minority women: an open-label switch study.

Minority women often have a unique set of beliefs and expectations about medical treatment. At this time, there is a dearth of research looking at how depressed minority women respond to pharmacological interventions for the sexual concomitants of depression. This was the first study to examine the impact of a medication switch, from a selective serotonin reuptake inhibitor to bupropion SR, on the sexual functioning of depressed minority women. Eighteen minority women (5 Hispanic, 10 African American, 2 Asian American, and 1 Native American), who were experiencing poor tolerability and/or lack of efficacy on an adequate trial of a selective serotonin reuptake inhibitor for depression, along with low sexual desire, were enrolled in this prospective open-label study. The selective serotonin reuptake inhibitor and bupropion SR were cross-tapered with a target dose of 150 to 300 mg of bupropion SR. The patients were followed for 10 weeks, and measures of sexual functioning and depression (Hamilton Rating Scale for Depression) were administered in an academic medical setting. Data were collected from July 2003 to December 2004. In the group as a whole, there were significant improvements in desire (F1,17 = 34.86, P < 0.001), arousal (F1,17 = 25.99, P < 0.001), and orgasm (F1,17 = 20.16, P < 0.001), on the Changes in Sexual Functioning Questionnaire. African-American women demonstrated the greatest improvement in depression (F1,16 = 9.55, P = 0.006), desire (F1,16 = 8.62, P = 0.01), and arousal (F1,16 = 8.83, P = 0.009) after the medication switch. Overall, this intervention appeared to be an effective treatment of low sexual desire in a diverse group of depressed minority women. The majority of women successfully completed the trial and planned to continue using bupropion SR after their participation in the study.

Adult↗
PubMed2006

Effectiveness of sildenafil in treating erectile dysfunction in PTSD patients: a double-blind, placebo-controlled crossover study.

OBJECTIVE: Post Traumatic Stress Disorder (PTSD) is known to be associated with Erectile Dysfunction (ED). Sildenafil citrate was shown to be effective treatment for ED among different clinical populations. However, to date, no placebo-controlled trial has assessed sildenafil's effectiveness for treating ED in PTSD patients. The goal of the present study was to address this question using a double-blind placebo controlled crossover design. METHODS: A four-week double-blind crossover trial of sildenafil (50 mg up to 100 mg per usage) versus placebo was conducted on 21 outpatients diagnosed with chronic PTSD accompanied by ED. Erectile function was assessed biweekly using the International Inventory of Erectile Function (IIEF). Depressive symptoms, PTSD symptoms and subjective well-being scores were assessed as well. RESULTS: Analysis of IIEF scores revealed a main effect of treatment phase (E = 33.361, df =2, P < 0.000). Pairwise comparisons showed that sildenafil IIEF scores (mean = 45.19 +/- 15.05) were significantly higher compared to baseline scores (mean = 20.00 +/- 12.32, P = 0.000) and placebo scores (mean = 33.04 +/- 12.99). Compared to placebo, a significant improvement was also observed during the sildenafil phase in erectile function, orgasmic function and sexual desire. There was no significant change in depression, PTSD symptoms or subjective well-being. CONCLUSION: The results of this study suggest that sildenafil citrate treatment for ED in PTSD patients was accompanied with improvement of ED symptoms and was found to be significantly better than placebo. Nevertheless, this effect should be considered marginal since patients still meet the criteria of ED after treatment. Larger, parallel group studies are warranted.

Adolescent↗
PubMed2003

Is quality of life different for men with erectile dysfunction and prostate cancer compared to men with erectile dysfunction due to other causes? Results from the ExCEED data base.

PURPOSE: To our knowledge the relationship between the underlying etiology of erectile dysfunction and its impact on health related quality of life has not been studied. Such a study is important for men with prostate cancer, as the potential negative quality of life impact of erectile dysfunction may affect clinical decision making in newly diagnosed disease. We compare health related quality of life in impotent men with prostate cancer to that of impotent men without prostate cancer using the Exploratory and Comprehensive Evaluation of Erectile Dysfunction (ExCEED, TAP Pharmaceutical Products, Inc., Lake Forest, Illinois) data base, which is a multicenter, observational disease registry of men with erectile dysfunction. MATERIALS AND METHODS: The cohort included 168 men in ExCEED who had baseline health related quality of life measurement. Of these men 47 reported a history of prostate cancer while 121 did not. Appropriate univariate and multivariate analyses were performed comparing health related quality of life outcomes between impotent men with and without prostate cancer. RESULTS: Men with erectile dysfunction and prostate cancer had worse sexual self-efficacy, erectile function, intercourse satisfaction and orgasmic function than those with erectile dysfunction without prostate cancer (all p <0.001). However, men with erectile dysfunction and prostate cancer experienced less psychological impact of erectile dysfunction on sexual experience (p = 0.05) and emotional life (p = 0.03) than those with erectile dysfunction without prostate cancer. The findings regarding the psychological impact of erectile dysfunction persisted in multivariate linear regression models. CONCLUSIONS: Men with erectile dysfunction and prostate cancer appear to have better disease specific health related quality of life than those with erectile dysfunction and no history of prostate cancer. This finding has important ramifications for clinicians when counseling patients newly diagnosed with prostate cancer and also when treating patients who present with erectile dysfunction of various etiologies.

Aged↗
PubMed2003

Determinants of long-term sexual health outcome after radical prostatectomy measured by a validated instrument.

PURPOSE: We combined the strengths of previous patient reported studies (that is use of a validated instrument) with the assets of previous single surgeon, physician reported series (that is prospective collection of operative data) by performing a multiple surgeon study to identify demographic and operative determinants of post-prostatectomy sexual health related quality of life outcomes. MATERIALS AND METHODS: Sexual outcome was measured after prostatectomy in 671 prostate cancer cases with a followup of 4 to 52 months treated by any of 7 urologists at a high volume medical center and 112 age matched controls by cross-sectional health related quality of life assessment using the Expanded Prostate Cancer Index Composite validated questionnaire. Multivariable ANCOVA was done to identify the baseline determinants affecting post-prostatectomy sexual health outcomes among 17 clinical and demographic factors. RESULTS: Factors independently associated with better sexual health outcome in patients included younger age (p <0.0001), nerve sparing technique (p <0.0001), time since prostatectomy (p = 0.0001), smaller prostate size (p = 0.003), higher education level (p = 0.02), and higher household income (p = 0.02). Orgasm was achieved at a higher rate than erection. In controls only age (p = 0.0004) and having a partner (p = 0.04) were significantly associated with sexual health. CONCLUSIONS: Larger prostate size adversely affected sexual health outcome after radical prostatectomy independent of all other measured factors. Patient sexual outcome did not differ significantly among surgeons who performed a broad range of such procedures yearly, suggesting that surgical expertise cannot be measured simply by the number of such operations that a surgeon performs. Stratifying patient reported sexual function by the principal determinants of age, nerve sparing and prostate size provides a basis for counseling patients.

Aged↗
PubMed2004

Sexual function in ankylosing spondylitis: a study of 65 men.

PURPOSE: We evaluated sexual function in male patients with ankylosing spondylitis (AS) using the validated International Index of Erectile Function (IIEF). We also assessed the frequency and association of erectile dysfunction with patient age, disease duration, morning stiffness, laboratory activity, disease severity, depression status and medication use in this patient group. MATERIALS AND METHODS: We evaluated sexual function, in particular erectile dysfunction (ED), using the IIEF in male patients with AS followed regularly at the outpatient clinic of rheumatology and compared results with those in healthy controls. Patient age, disease duration, morning stiffness, laboratory activity, disease severity and medication use were obtained by reviewing the medical record. Affective patient and control states were measured by the Beck Depression Inventory. The Bath AS Functional Index was used to measure functional status in AS cases. RESULTS: To our knowledge this is the first study of the frequency of ED in men with AS (8 of 65 or 12%). Compared to healthy controls patients with AS had significantly lower erectile function, orgasmic function, intercourse satisfaction and overall satisfaction scores according to the IIEF, whereas sexual desire scores were also lower, although not significantly. According to self-reported patient data ED was a prominent characteristic of our population. We were not able to relate any clinical features or laboratory findings to ED except the duration of morning stiffness. The 22 men with a high degree of morning stiffness (greater than 4 hours) had lower erectile function scores compared to the 12 with AS and a low degree of morning stiffness (less than 2 hours) (18.3 +/- 1.6 vs 26.5 +/- 2.4, p <0.05). Of 65 patients with AS 25 (38%) were depressed in our study group according to the Beck Depression Inventory, while no healthy controls were depressed when a score of greater than 13 was used as the cutoff. CONCLUSIONS: ED can be seen in the course of AS. The pathogenesis of ED in patients with AS is thought to be multifactorial with disease and treatment related factors. Thus, male patients with AS, in particular those with a high degree of morning stiffness, should be encouraged to talk about their sexuality.

Adult↗
PubMed2004

Randomized study of testosterone gel as adjunctive therapy to sildenafil in hypogonadal men with erectile dysfunction who do not respond to sildenafil alone.

PURPOSE: We compare the efficacy of testosterone gel (T-gel) versus placebo as adjunctive therapy to sildenafil in hypogonadal men with erectile dysfunction who do not respond to sildenafil alone. MATERIALS AND METHODS: A randomized, placebo controlled, double-blind, parallel group, multicenter study was performed. A total of 75 hypogonadal men (18 to 80 years old, morning serum total testosterone 400 ng/dl or less) with confirmed lack of response to sildenafil monotherapy were randomized (1:1) to receive a daily dose of 1% T-gel or 5 gm placebo gel as adjunctive therapy to 100 mg sildenafil during a 12-week period. Subjects were evaluated for sexual function, primarily based on the International Index of Erectile Function (IIEF), quality of life and serum testosterone levels at baseline and weeks 4, 8 and 12. RESULTS: Testosterone treated subjects had greater improvement in erectile function compared to those who received placebo, reaching statistical significance at week 4 (4.4 vs 2.1, p = 0.029, 95.1% CI 0.3, 4.7). Similar trends were observed for improvements in orgasmic function, overall satisfaction, total IIEF score and percentage of IIEF responders. T-gel significantly (p < or =0.004) increased total and free testosterone levels throughout the study, although no significant correlations were made between testosterone levels and the IIEF at end point. CONCLUSIONS: T-gel taken with sildenafil may be beneficial in improving erectile function in hypogonadal men with erectile dysfunction who are unresponsive to sildenafil alone.

Adolescent↗
PubMed2004

Cystectomy and orthotopic ileal neobladder: the impact on female sexuality.

PURPOSE: January 1986 and September 2003 cystectomy and formation of an ileal neobladder were performed in 86 female patients. In this retrospective study we focused on the impact of orthotopic reconstruction on female sexuality. MATERIALS AND METHODS: To assess female sexuality the standardized self-reporting instrument female sexual function index was mailed to 44 patients who were 70 years or younger at cystectomy with a recurrence-free followup of greater than 1 year, no pelvic irradiation and no concomitant diseases impairing sexual functions. The questionnaire analyzes 6 domains (desire, arousal, lubrication, orgasm, satisfaction and pain) with 19 items. It was returned by 29 patients (65.9%) with a median age of 65.0 years. The indication for cystectomy was benign disease in 8 cases and malignancy in 21. RESULTS: Factors influencing female sexuality were age younger than 60 years, benign disease, partnership at surgery and current partnership. Clean intermittent catheterization, urinary stress incontinence and hormonal therapy did not affect the results. The 11 of 17 patients who remained sexually active after cystectomy even had slight improvement in all female sexual function items. Six patients ceased to be sexually active postoperatively due to erectile dysfunction or partner death. One patient with interstitial cystitis became sexually active following cystectomy due to the loss of pelvic pain. Another 12 patients remained sexually inactive postoperatively. CONCLUSIONS: All aspects of female sexuality may remain unchanged following cystectomy and ileal neobladder formation as long as sexual activity is not ceased due to other reasons. Even fertility can be preserved when the internal genitalia do not have to be removed.

Aged↗
PubMed2005

Anatomy of the clitoris.

PURPOSE: We present a comprehensive account of clitoral anatomy, including its component structures, neurovascular supply, relationship to adjacent structures (the urethra, vagina and vestibular glands, and connective tissue supports), histology and immunohistochemistry. We related recent anatomical findings to the historical literature to determine when data on accurate anatomy became available. MATERIALS AND METHODS: An extensive review of the current and historical literature was done. The studies reviewed included dissection and microdissection, magnetic resonance imaging (MRI), 3-dimensional sectional anatomy reconstruction, histology and immunohistochemical studies. RESULTS: The clitoris is a multiplanar structure with a broad attachment to the pubic arch and via extensive supporting tissue to the mons pubis and labia. Centrally it is attached to the urethra and vagina. Its components include the erectile bodies (paired bulbs and paired corpora, which are continuous with the crura) and the glans clitoris. The glans is a midline, densely neural, non-erectile structure that is the only external manifestation of the clitoris. All other components are composed of erectile tissue with the composition of the bulbar erectile tissue differing from that of the corpora. The clitoral and perineal neurovascular bundles are large, paired terminations of the pudendal neurovascular bundles. The clitoral neurovascular bundles ascend along the ischiopubic rami to meet each other and pass along the superior surface of the clitoral body supplying the clitoris. The neural trunks pass largely intact into the glans. These nerves are at least 2 mm in diameter even in infancy. The cavernous or autonomic neural anatomy is microscopic and difficult to define consistently. MRI complements dissection studies and clarifies the anatomy. Clitoral pharmacology and histology appears to parallel those of penile tissue, although the clinical impact is vastly different. CONCLUSIONS: Typical textbook descriptions of the clitoris lack detail and include inaccuracies. It is impossible to convey clitoral anatomy in a single diagram showing only 1 plane, as is typically provided in textbooks, which reveal it as a flat structure. MRI provides a multiplanar representation of clitoral anatomy in the live state, which is a major advantage, and complements dissection materials. The work of Kobelt in the early 19th century provides a most comprehensive and accurate description of clitoral anatomy, and modern study provides objective images and few novel findings. The bulbs appear to be part of the clitoris. They are spongy in character and in continuity with the other parts of the clitoris. The distal urethra and vagina are intimately related structures, although they are not erectile in character. They form a tissue cluster with the clitoris. This cluster appears to be the locus of female sexual function and orgasm.

Anatomy↗
PubMed2005

Female sexual dysfunction: principles of diagnosis and therapy.

Female sexual dysfunction is a common health problem, affecting approximately 43% of women. Female sexual dysfunction is defined as disorders of libido, arousal, orgasm, and sexual pain that lead to personal distress or interpersonal difficulties. It is frequently multifactorial in etiology, with physiological and psychologic roots. Approaching female sexual dysfunction involves an open discussion with the patient, followed by a thorough physical examination and laboratory testing. Therapy consists of patient and partner education, behavior modification, and may include individualized pharmacotherapy. Ultimately, as awareness and research in the field grows, it is hoped that a better understanding of the physiology and pharmacology of the female sexual response will be achieved.

Androgens↗
PubMed2003

Long-term results in patients after rectosigmoid vaginoplasty.

Many methods are used for vaginoplasty, including the split-thickness skin graft, full-thickness skin graft, and inverted penile skin flap. However, these procedures are not entirely satisfactory in cases of reconstructed vaginal stenosis, inadequate vaginal length, or poor lubrication. The small intestine, ascending colon, and sigmoid colon can be used in the intestinal flap method, and the authors modified the operation first described by Baldwin in which a loop of rectosigmoid is isolated, closed at one end, and brought down on its vascular pedicle as a neovagina and then anastomosed to the perineum. Vaginoplasty using the rectosigmoid was performed in 36 patients (28 male-to-female transsexual patients, five patients with congenital vaginal atresia, and three with cervical cancer). The follow-up period ranged from 1 to 10 years. The postoperative results were analyzed through physical examination and interview regarding the patient's functional status and satisfaction during sexual intercourse. The mean depth and width of the vaginal cavity were 12.5 cm and 3.9 cm, respectively. Excessive mucosal discharge was seen in 8.3 percent, and malodor was found in 8.3 percent. All patients who had partners were able to have sexual intercourse; 2.8 percent of patients used lubricants and 5.6 percent used dilators before intercourse for more than a year postoperatively. During intercourse, 88.9 percent of the patients experienced orgasm. The cosmetic and functional results of rectosigmoid vaginoplasty were excellent. Thus, the advantages of rectosigmoid vaginoplasty are (1) rare contraction of the reconstructed vagina, (2) vaginal width and depth maintained without long-term vaginal stent, (3) spontaneous mucus production facilitating sexual intercourse, (4) avoidance of the malodor frequently accompanying skin graft, and (5) texture and appearance similar to that of the natural vagina. The authors concluded that rectosigmoid vaginoplasty is the best choice for transsexual patients who have previously undergone penectomy and orchiectomy, patients with unfavorable previous vaginoplasty, those with short vaginal length after cervical cancer surgery, and patients with congenital vaginal atresia.

Adult↗
PubMed2003

Glans, urethra, and corporeal body reconstruction by free osteocutaneous forearm flap transfer.

A 30-year-old man presented with short penile corporeal bodies hosting a 3-cm fibular graft, absence of glans, and proximal penile hypospadias. The patient underwent a forearm flap transfer with an "umbrella-like" skin flap for glans and urethra reconstruction and a radial bone strut to allow for rigidity. The postoperative course was uneventful and the patient was followed-up with fluximetry tests at 2 weeks, 4 weeks, 2 months, and 6 months, showing no stenoses and normal stable values. Masturbation started at month 3 postoperatively and intercourse began at month 4, with both resulting in orgasm. At 6 months postoperatively, touch sensation, pain, and sensibility to heat were present, but sensibility to cold was absent. Light touch pressure was detected with 4.74 Semmes-Weinstein monofilament, and static two-point discrimination was 20 mm at the neoglans. One year postoperatively, a stable increased length up to 9 cm at rest and 13 cm at erection with a satisfactory anatomic definition could still be proved.

Adult↗
PubMed2005

Formation of functional neovagina with vertical rectus abdominis musculocutaneous (VRAM) flap after total pelvic exenteration.

BACKGROUND: Pelvic exenteration may be the only curative option for women with recurrent pelvic malignancies. After total pelvic exenteration, the resultant perineal defect heals slowly if left to do so by secondary intention. Reconstruction with the vertical rectus abdominis musculocutaneous (VRAM) flap brings a generous bulk of healthy tissue into the defect, speeding recovery by facilitating primary healing. METHODS: Six women underwent reconstruction of a neovagina using a vertical rectus abdominis musculocutaneous flap. All 6 had total pelvic exenteration for advanced gynecologic malignancy. Primary diagnosis was cervical carcinoma (n = 3), vulvar carcinoma (n = 1), nonsmall cell vaginal cancer (n = 1), and vaginal melanoma (n = 1). Four patients had received adjuvant radiotherapy preoperatively. RESULTS: All flaps remained 100% viable postoperatively. There were no cases of fistula, infection, or bowel obstruction. Two patients died of cardiovascular arrest postoperatively. The 4 other patients report satisfaction with reconstruction. Three had vaginal intercourse with orgasm. CONCLUSION: The inferiorly based vertical rectus abdominis musculocutaneous flap is a dependable source of tissue for pelvic reconstruction and is the flap of choice in the Division of Plastic Surgery. In addition to facilitating healing, the VRAM flap (neovagina) improves a woman's psychosocial well-being.

Carcinoma↗