Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women

Phosphodiesterase type 5 (PDE5) inhibitors in erectile dysfunction: the proper drug for the proper patient

INTRODUCTION

Erectile dysfunction (ED) is a very common multidimensional disorder affecting men worldwide. Physical illness, reaction to life stresses, or an unhappy couple relationship influence clinical outcome. Phosphodiesterase type 5 (PDE5) inhibitors are recognized as efficacious and well tolerated, and are the first-line treatment for ED. Sildenafil, tadalafil, and vardenafil are the most widely used and studied PDE5 inhibitors. Data acquired during a routine diagnostic workup for ED should be taken into account when choosing the best PDE5 inhibitor for the individual patient, creating an individualized treatment plan, and going beyond "experience-based" subjective opinion and unfounded ideas and prejudice regarding currently available drugs.

AIM

As the process of matching a given patient's profile to any selected PDE5 inhibitor often relies more on physician's personal convictions than on solid evidence, the aim of this review is to identify the main clinical, demographic, and relational factors influencing the choice of the PDE5 inhibitor to be used for the treatment of ED.

METHODS

A systematic literature search and current treatment guidelines were evaluated in a systematic manner.

MAIN OUTCOME MEASURES

The main clinical, cultural, and demographical factors to be considered for the treatment of ED have been identified.

RESULTS

Main factors influencing the choice of the treatment for ED have been described. A short list of items that may help in choosing the right PDE5 inhibitor for the treatment of different patients in daily clinical practice has been prepared.

CONCLUSIONS

The simple algorithms prepared should be a useful tool to be used in daily practice, which may help in choosing the right treatment for each subject affected by ED.

Recreational use of phosphodiesterase type 5 inhibitors by healthy young men

INTRODUCTION

In recent years, PDE5 inhibitors (PDE5i) use has become more popular among men without ED to enhance sexual performance. However, reports in the literature are scarce.

AIM

The aim of this study was to evaluate the recreational use of PDE5i in healthy young men.

MAIN OUTCOME MEASURES

We evaluated the recreational use of PDE5i among young and healthy men, their main reasons for use, how they were obtained these drugs, and the combination with alcohol or other drugs.

METHODS

Descriptive, transversal study consisting in 400 brief surveys with structured multiple choice and open questions. Nonprobability samples (quota samples) included young men between 18 and 30 years of age in a public area (high schools, universities, and gyms) between August and November 2009. Collecting the questionnaires in a sealed box enforced confidentiality. The survey included demographic and sexual health data and PDE5i use characteristics. For statistical analysis we used Fisher's exact and Mann-Whitney tests.

RESULTS

A total of 321 questionnaires were appropriate for the purposes of evaluation. Mean age and standard deviation were 25.1±3.3 years old. Regarding PDE5i use, 69 men (21.5%) mentioned trying the pill (being sildenafil the most commonly used one) at least one time in their lives and 37 (53.4%) men combined it with alcohol or drugs. Referred sources of acquisition PDE5i were 75.4% (N=52) from a friend, 17.4% (N=15) from a pharmacy/drugstore without a medical prescription, 4.3% (N=3) prescribed by a physician and 2.9% (N=2) through Internet. There were several reasons for taking PDE5i related to sexual confidence, erection quality, and better sexual performance.

CONCLUSION

According to our results, 21.5% of healthy men between 18 and 30 years old used PDE5i as a recreational drug, mostly associated with alcohol or other drugs without medical control. This could have led to misuse and a public health problem. Further studies are needed to evaluate not only PDE5i recreational use prevalence, but also psychosocial determinants, long term safety, misuse, and abuse related to it.

A new era in the treatment of erectile dysfunction: chronic phosphodiesterase type 5 inhibition

Historically, oral phosphodiesterase type 5 inhibitors (PDE5-i) have been prescribed with an 'as-necessary' regimen for treating erectile dysfunction (ED), thus addressing primarily symptom relief. However, approximately 30% of patients are unresponsive to on-demand PDE5-i regimens due to both psychogenic and organic factors and, although it is difficult to estimate the proportion, discontinuation rates remain high. In recent years, a 2.5-5 mg daily dose of tadalafil has been proposed and was recently approved for treating ED. Chronic PDE-5 inhibition has the advantage of potentially 'curing' ED, on a daily basis, by interfering with pathophysiological factors of both psychogenic (anxiety related to planning sexual activity) and organic (endothelial dysfunction, penile structural homeostasis) origin, although further research is needed to better address these hypotheses. Clinical studies showed that chronic PDE5-i regimens are a safe and effective alternative to the classical on-demand dosage, and might improve the outcomes in a selected group of patients.

[Female sexual dysfunction]

Female sexual dysfunction (FSD) is a very common disorder in Germany with a prevalence of approximately 38%. FSD includes persistent or recurrent disorders of sexual desire, disorders of subjective or genital arousal and pain during intercourse. An overview of the epidemiology, the current definitions of the single domains of FSD, the pathophysiology and recommendations on the treatment of FSD is given.

The Premature Ejaculation Profile: validation of self-reported outcome measures for research and practice

OBJECTIVE

To evaluate the reliability and validity of the Premature Ejaculation Profile (PEP), a self-reported outcome instrument for evaluating domains of PE and its treatment, comprised of four single-item measures, a profile, and an index score.

SUBJECTS AND METHODS

Data were from men participating in observational studies in the USA (PE, 207 men; non-PE, 1380) and Europe (PE, 201; non-PE, 914) and from men with PE (1238) participating in a phase III randomized, placebo-controlled clinical trial of dapoxetine. The PEP contains four measures: perceived control over ejaculation, personal distress related to ejaculation, satisfaction with sexual intercourse, and interpersonal difficulty related to ejaculation, each assessed on five-point response scales. Test-retest reliability, known-groups validity, and ability to detect a patient-reported global impression of change (PGI) in condition were evaluated for the individual PEP measures and a PEP index score (the mean of all four measures). Profile analysis was conducted using multivariate analysis of variance.

RESULTS

All PEP measures showed acceptable reliability (intraclass correlation coefficients ranged from 0.66 to 0.83) and mean scores for all measures differed significantly between PE and non-PE groups (P < 0.001). Men who reported a reduction in PE with treatment in the phase III trial had significantly greater scores on each of the four measures. The PEP profiles of men with and without PE differed significantly (P < 0.001) in both observational studies; higher levels of PGI were associated with higher PEP profiles (P < 0.001). The PEP index score also showed acceptable reliability and was significantly different between the PE and non-PE groups (P < 0.001). Men who reported an improvement in PE with treatment in the phase III trial had significantly greater PEP index scores. In the phase III trial, nausea was the most common adverse event with dapoxetine.

CONCLUSION

The PEP provides a reliable, valid, and interpretable measure for use in monitoring outcomes of men with PE.

Management of sexual dysfunction in postmenopausal breast cancer patients taking adjuvant aromatase inhibitor therapy

Treatment with aromatase inhibitors for postmenopausal women with breast cancer has been shown to reduce or obviate invasive procedures such as hysteroscopy or curettage associated with tamoxifen-induced endometrial abnormalities. The side effect of upfront aromatase inhibitors, diminished estrogen synthesis, is similar to that seen with the natural events of aging. The consequences often include vasomotor symptoms (hot flushes) and vaginal dryness and atrophy, which in turn may result in cystitis and vaginitis. Not surprisingly, painful intercourse (dyspareunia) and loss of sexual interest (decreased libido) frequently occur as well. Various interventions, both non-hormonal and hormonal, are currently available to manage these problems. The purpose of the present review is to provide the practitioner with a wide array of management options to assist in treating the sexual consequences of aromatase inhibitors. The suggestions in this review are based on recent literature and on the recommendations set forth both by the North American Menopause Association and in the clinical practice guidelines of the Society of Gynaecologists and Obstetricians of Canada. The complexity of female sexual dysfunction necessitates a biopsychosocial approach to assessment and management alike, with interventions ranging from education and lifestyle changes to sexual counselling, pelvic floor therapies, sexual aids, medications, and dietary supplements-all of which have been reported to have a variable, but often successful, effect on symptom amelioration. Although the use of specific hormone replacement-most commonly local estrogen, and less commonly, systemic estrogen with or without an androgen, progesterone, or the additional of an androgen in an estrogenized woman (or a combination)-may be highly effective, the concern remains that in patients with estrogen-dependent breast cancer, including those receiving anti-estrogenic adjuvant therapies, the use of these hormones may be attended with potential risk. Therefore, non-hormonal alternatives should in all cases be initially tried with the expectation that symptomatic relief can often be achieved.First-line therapy for urogenital symptoms, notably vaginal dryness and dyspareunia, should be the non-hormonal group of preparations such as moisturizers and precoital vaginal lubricants. In patients with estrogen-dependent breast cancer (notably those receiving anti-estrogenic adjuvant therapies) and severely symptomatic vaginal atrophy that fails to respond to non-hormonal options, menopausal hormone replacement or prescription vaginal estrogen therapy may considered. Systemic estrogen may be associated with risk and thus is best avoided. Judicious use of hormones may be appropriate in the well-informed patient who gives informed consent, but given the potential risk, these agents should be prescribed only after mutual agreement of the patient and her oncologist.

ORIGINAL RESEARCH—PSYCHOLOGY: Correlation Between Sexual Function and Postrenal Transplant Quality of Life: Does Gender Matter?

INTRODUCTION

Subjective health perceptions affect sexual function differently in males and females; such differences, however, have not hitherto been studied comprehensively in kidney-transplant recipients.

AIM

This study sought to investigate gender effect on the correlation between sexual function and quality-of-life (QOL) subdomains in kidney-transplant recipients by evaluating intercourse frequency (IF) and intercourse satisfaction (IS).

METHODS

In a cross-sectional study, 124 married kidney-transplant recipients, who were randomly selected, were interviewed. The bivariate correlations between QOL subdomains, and IF and IS were analyzed with the Pearson test in the males and females, separately.

MAIN OUTCOME MEASURE

The IF and IS using the relationship and sexuality scale, and also the QOL using Short Form 36 (SF-36) were assessed.

RESULTS

Sixty-seven subjects (54%) reported having no intercourse within the preceding months. Fifty subjects (40%) reported having no intercourse satisfaction. While IF and IS correlated with the total SF-36 score in the males (r = 0.252 and 0.263, P < 0.05), there was no such correlation in the females. In the males, IS correlated with physical health (r = 0.281, P < 0.05) and physical function (r = 0.274, P < 0.05), and there was a correlation between IF and role limitation due to emotional problems (r = 0.250, P < 0.05). In the females, whereas IF correlated with general health (r = 0.372, P < 0.05) and mental health (r = 0.305, P < 0.05), there was no correlation between IS and QOL subdomains (P > 0.05).

CONCLUSION

Sexual function and satisfaction seem to be correlated with mental and physical health in female and male kidney-transplant recipients, respectively. Although in the two genders, both physical and mental health should be equally evaluated; improving of the sexual function may be better achieved through different approaches.

Sexual Function after Radical Hysterectomy for Early-Stage Cervical Cancer

INTRODUCTION

For early-stage cervical cancer, treatment with radical surgery appears effective with excellent survival. However, the treatment is associated with significant morbidities. Sexual dysfunction is the leading cause of symptom-induced distress after the treatments for early-stage cervical cancer. There has been no study that evaluates the effect of surgical treatments for cervical cancer on sexual function in the Eastern/Asian patients.

AIM

To examine the effect of radical hysterectomy on postoperative sexual function in women with early-stage cervical cancer. MAIN OUTCOME MEASURES. The visual analog score on seven aspects of sexual function: overall satisfaction with sexual intercourse, sexual desire, vaginal lubrication, vaginal elasticity, orgasmic satisfaction, patient-perceived partner satisfaction, and associated anxiety.

METHODS

Thirty patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical cancer undergoing radical hysterectomy and pelvic lymphadenectomy at the Chiang Mai University Hospital were recruited. All of the patients were interviewed by questionnaire on sexual function at preoperative hospital admission and then at 3 and 6 months after surgery. Relevant clinical and pathologic data were also prospectively collected.

RESULTS

The mean age of the patients was 45.3 +/- 6 years (range 28-59). Seven (23%) of the patients were postmenopausal. Almost all (97%) had FIGO stage IB1 disease. Fourteen (46.7%) patients had bilateral salpingo-oophorectomy, and one (3.3%) patient had unilateral salpingo-oophorectomy. Squamous-cell carcinoma and adenocarcinoma were diagnosed in 83% and 17%, respectively. At 3 and 6 months after operation, 63% and 93% of the patients had sexual intercourse, respectively. Considering the overall sexual satisfaction, the patient-rated visual analog score appeared comparable at preoperative and 6-month postoperative assessment (4.2 +/- 2.5 vs. 3.6 +/- 2.2, P > 0.05).

CONCLUSION

Radical hysterectomy using the current technique has a minimal short-term impact on sexual function. A comparative study with long-term follow-up would provide clearer information on permanent effect of radical hysterectomy on sexual function.

Daily Administration of Phosphodiesterase Type 5 Inhibitors for Urological and Nonurological Indications

OBJECTIVES

Although the discovery of phosphodiesterases (PDEs) was made soon after the identification of cyclic adenosine monophosphate nearly half a century ago, their true importance in medicine has taken many decades to be realised. The recognition of the important role PDE enzymes play and the impact of altering intracellular cyclic nucleotide levels became significant for most urologists and clinicians in the early 1990s with the discovery of sildenafil, a PDE5 inhibitor (PDE5-I). Once approved around the world, on-demand use of PDE5-Is became the gold standard. Recently, the potential beneficial effects of PDE5-Is on the pulmonary, vascular, and other systems has led to examination of alternative dosing regimens. In this review, we have synthesised the available published peer-reviewed literature to provide a critical contemporary view of evolving indications for PDE5-Is and how alternative dosing regimens may impact on sexual and other functions.

METHODS

MEDLINE search of all peer-reviewed English literature for the period 1990-2007.

RESULTS

The plethora of articles detailing potential uses of PDE5-I in multiple fields of medicine was uncovered. Use of alternative dosing regimens shows great promise across a number of clinical indications, including post-radical retropubic prostatectomy, pulmonary hypertension, endothelial dysfunction, and salvage of on-demand PDE5-I nonresponders.

CONCLUSIONS

Use of PDE5-I on a daily basis may evolve into a major form of drug administration both for men with erectile dysfunction and for those with a myriad of other conditions shown to benefit from this approach.

Erectile Dysfunction: Monitoring Response to Treatment in Clinical Practice—Recommendations of an International Study Panel

INTRODUCTION

Clinical practice guidelines for management of erectile dysfunction (ED) provide limited direction in defining appropriate treatment goals with phosphodiesterase type 5 (PDE5) inhibitor therapy.

AIM

To establish an evidence-based position on treatment goals in ED, including the role of erection hardness, with the potential to improve self-esteem, confidence, and overall sexual and relationship satisfaction.

MAIN OUTCOME MEASURE

The target of ED therapy is optimization of a rigid erectile response, as assessed by the 4-point Erection Hardness Score (EHS). Methods. An international panel of experts in urology, psychology, and primary care convened to evaluate retrospective data from worldwide phase 2, 3, and 4 clinical trials, involving over 10,000 men with ED, as well as data from recent prospective studies, concerning the role of erection hardness in defining the response to treatment with PDE5 therapy.

RESULTS

Significant positive correlations were found between EHS and the Quality of Erection Questionnaire and the International Index of Erectile Function (IIEF) erectile function domain score and other IIEF measures. Significant positive correlations were also found between erection hardness and psychosocial measures such as self-esteem, confidence, and relationship satisfaction (assessed by the Self-Esteem And Relationship questionnaire), and satisfaction with medical treatment (assessed by the Erectile Dysfunction Inventory of Treatment Satisfaction). A shift in most frequent erection from EHS 3 (hard enough for penetration but not fully hard) at baseline to EHS 4 (completely hard and fully rigid) at the end of treatment was accompanied by significant improvements in intercourse and relationship satisfaction, psychosocial benefits, and satisfaction with ED treatment.

CONCLUSIONS

Support is found for monitoring and treating patients with ED to their full erectile potential. Quantitative assessment of erection hardness in clinical practice will lead to improved outcomes in overall sexual experience and optimal treatment satisfaction.

Taking a sexual history

Why should you inquire about sexual concerns? The importance of sexual health to a woman's quality of life and general health and well-being cannot be overstated, yet the topic is too often ignored by gynecologists and primary care physicians. This article has been geared toward helping overcome some of the barriers to physicians simply opening the door to the topic and conducting at least a basic sexual history and screening of sexual concerns. Although treatment options are addressed elsewhere in this issue, the most effective treatment of all is to ask. You cannot treat a problem if you do not know it exists.

Sexual Dysfunction

Female sexual dysfunction or dissatisfaction is a common complaint among obstetric-gynecology patients. These complaints may result from medical treatments and procedures, or may secondarily complicate the management and patient compliance of treatment for other medical issues. Therefore, it is important that clinicians treating females obtain basic information regarding human sexual function and dysfunction. This chapter presents an integration of the clinical research as well as the author’s experience regarding sexual function and the management of sexual problems often presented in an obstetricgynecology practice.

REVIEWS: Pelvic Floor Involvement in Male and Female Sexual Dysfunction and the Role of Pelvic Floor Rehabilitation in Treatment: A Literature Review

INTRODUCTION

The sphincteric and supportive functions of the pelvic floor are fairly well understood, and pelvic floor rehabilitation, a specialized field within the scope and practice of physical therapy, has demonstrated effectiveness in the treatment of urinary and fecal incontinence. The role of the pelvic floor in the promotion of optimal sexual function has not been clearly elucidated.

AIM

To review the role of the pelvic floor in the promotion of optimal sexual function and examine the role of pelvic floor rehabilitation in treating sexual dysfunction.

MAIN OUTCOME MEASURE

Review of peer-reviewed literature.

RESULTS

It has been proposed that the pelvic floor muscles are active in both male and female genital arousal and orgasm, and that pelvic floor muscle hypotonus may impact negatively on these phases of function. Hypertonus of the pelvic floor is a significant component of sexual pain disorders in women and men. Furthermore, conditions related to pelvic floor dysfunction, such as pelvic pain, pelvic organ prolapse, and lower urinary tract symptoms, are correlated with sexual dysfunction.

CONCLUSIONS

The involvement of the pelvic floor in sexual function and dysfunction is examined, as well as the potential role of pelvic floor rehabilitation in treatment. Further research validating physical therapy intervention is necessary.

Evaluating the Impact of Overactive Bladder on Sexual Health in Women: What Is Relevant?

INTRODUCTION

To assess sexual health, relevant, valid, and reliable questionnaires need to be used.

AIM

To assess the relevance and content validity of three sexual health questionnaires in women with overactive bladder (OAB) and urinary incontinence.

MAIN OUTCOME MEASURES

Sexual Quality of Life Questionnaire--Female (SQoL-F), Sexual Function Questionnaire (SFQ), and Pelvic Organ Prolapse-Incontinence Sexual Function Questionnaire (PISQ).

METHODS

Women with OAB and urinary incontinence were recruited from five urology clinics in the United States; those who were interested in participating were mailed questionnaire packets with instructions. Each questionnaire item was followed by three questions regarding the understandability, relevance, and impact of bladder condition when responding to the question. Patients returned the completed questionnaires by mail; clinical information was obtained from chart review.

RESULTS

A total of 129 patients (74% response) returned the questionnaires. The mean age was 56 years; 78% were white; 64% were married. In this sample, 64% had urge incontinence; 32% had mixed incontinence; and 4% had stress incontinence. Participants experienced bladder symptoms for a mean of 12.2 years with the following treatments: surgery (43%), bladder training (26%), exercise/biofeedback (42%), and medications (67%). SQoL-F items were understood by more than 97% of the respondents, more than 89% for SFQ, and more than 82% for PISQ. There were two SQoL-F items, one SFQ item, and 11 PISQ items that less than 60% of the respondents deemed relevant to their bladder condition. Correlations among questionnaire items and relevance to bladder condition ranged from 0.04 to 0.64 for the SQoL-F, 0.04 to 0.47 for the SFQ, and 0.01 to 0.58 for the PISQ.

CONCLUSION

Women with OAB found the majority of items on all three questionnaires to be relevant to their bladder condition. Of these questionnaires, the SQoL-F had the highest understandability, fewest questions considered irrelevant, and correlated well with OAB symptoms.

ORIGINAL RESEARCH—EDUCATION: Sexual Counseling for Women in the Context of Physical Diseases—A Teaching Model for Physicians

INTRODUCTION

Chronic medical conditions are frequently associated with sexual difficulties and problems, which are often underreported and underdiagnosed. Patients may feel that sexual problems in the context of disease are not important enough to be mentioned to their physicians, and physicians may feel uncomfortable and sometimes incompetent. Furthermore, the diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders-IV and International Classification of Diseases-10 are focused on the phenomenology of the sexual response without any specificity regarding diseases.

AIM

To facilitate access for patients and physicians, we wanted to develop a tool for assessment and discussion of sexual problems in the context of disease. This tool should be broadly applicable, easy to use and learn for nonmental health professionals.

MAIN OUTCOME MEASURES

Content analysis with respect to the integration of general sexological and disease-specific dimensions. Formulation of a diagnostic and therapeutic algorithm that can be used as a teaching tool.

METHODS

Based on our experience as a liaison-consultation sexological division of the university hospital of Basel, we analyzed the sexological diagnostic workup performed with the following group of female patients: women with benign gynecologic conditions; women with incontinence; oncological patients (mammary carcinoma, genital carcinoma); neurological patients (multiple sclerosis, spine injury, Parkinson's); patients with metabolic and endocrine disorders (diabetes, metabolic syndrome, polycystic ovarian syndrome); and patients with mental health disorders (depression, anxiety disorder, schizophrenia). We extracted the commonly used steps in the workup to construct a tool with easy-to-remember elements, which would help the physician to evaluate patients' sexual problems and plan for referral or therapy.

RESULTS

We could differentiate three diagnostic dimensions. The first were person-related preexisting factors, such as sexual satisfaction and function, age, body image, and general well-being. The second were the disease-specific implications, which could be summarized under the 8 Ds: Danger, Destruction, Disfigurement, Disability and pain, Dysfunction, Dysregulation, Disease load, and Drugs. The third was the patient's and partner's general response to the disease determined by affective response, coping style, body image impact, and changes in relationship dynamics.

CONCLUSION

Sexual problems are frequent in many clinical conditions, but are not yet a routine part of diagnostic workup and therapeutic planning. We have developed a tool to help physicians in different clinical settings to evaluate sexual problems of the female patients with specific clinical conditions in order to facilitate access to recognition and possible treatment.

Guidelines for the diagnosis and management of premature ejaculation

INTRODUCTION

Until recently, premature ejaculation (PE) was believed to have a psychologic etiology requiring psychosexual therapy. Recognition of a neurobiologic component to the etiology of PE has since highlighted the need for diagnostic and management guidelines for this common sexual problem. One major medical organization-the American Urological Association (AUA)--has established such guidelines. In addition, the Second International Consultation on Sexual Dysfunctions (ICSD) in 2003 developed a set of recommendations for PE, as well as for other sexual dysfunctions.

AIM

To review the current guidelines for the diagnosis and treatment of PE.

METHODS

The Sexual Medicine Society of North America hosted a State of the Art Conference on Premature Ejaculation on June 24-26, 2005 in collaboration with the University of South Florida. The purpose was to have an open exchange of contemporary research and clinical information on PE. There were 16 invited presenters and discussants; the group focused on several educational objectives.

MAIN OUTCOME MEASURE

Data from the AUA Guideline on the Pharmacologic Management of Premature Ejaculation and the Second ICSD.

RESULTS

Both documents emphasize the importance of a sexual history in diagnosing PE, and each of these two documents recognizes that diagnosis involves a shortened intravaginal latency time as well as patient reports of poor control over ejaculation and patient distress over the condition.

CONCLUSIONS

Condensed guidelines for the diagnosis and treatment of PE are presented. Once diagnosis is suspected, optimal treatment regimens should be established utilizing randomized placebo-controlled trials.

COMMENTARY: Subclinical Erectile Dysfunction: Proposal for a Novel Taxonomic Category in Sexual Medicine

The definition of erectile dysfunction currently used and accepted worldwide does not encompass all possible changes to male erection. Partial, temporary, or episodic absence of erection is not considered as true erectile dysfunction. This leads to a lack of diagnosis and therapy and perhaps even the risk of the subsequent development of overt impotence. The lack of an evidence-based diagnosis of such a condition may be due to the widespread, pernicious self-prescription of erection drugs, obtained from the illegal market. To define the pathological condition of men experiencing a lack of erection who are unaffected by erectile dysfunction, we propose herein a new taxonomic category, based on new sexological criteria. In addition, we suggest research into biochemical markers to define this condition, which we have named subclinical erectile dysfunction.

ORIGINAL RESEARCH—EPIDEMIOLOGY: Sexual Problems Among a Specific Population of Minority Women Aged 40–80 Years Attending a Primary Care Practice

INTRODUCTION

Clinicians are embarrassed about discussing sex with patients and do not know how to ask about sexual problems in a way that will optimize honest and open responses. Learning about inquiry responses and the prevalence of sexual problems among specific groups of women, including minority women, can help identify appropriate inquiry and management pathways.

AIM

To better understand useful inquiry techniques as well as to describe the prevalence of sexual problems among a specific group of minority women aged 40-80 years.

MAIN OUTCOME MEASURES

Responses to two styles of sexual problem inquiry, direct vs. ubiquity, were compared among sexually active subjects. Prevalence of sexual problems and interest in discussing problems with personal clinician were determined.

METHODS

Minority women aged 40-80 years receiving care at one of two Family Health Centers in Brooklyn, New York who could speak English met inclusion criteria. A cross-sectional survey of 212 subjects, the majority being Afro-Caribbean, identified those who were sexually active and then randomly asked about sexual problems using one of two inquiry types: (i) a direct question, such as "Do you have a problem during sex," or (ii) a ubiquity-style question, such as "Many women with diabetes have sexual problems, how about you?" Sexual problems were characterized by recognized phases of female sexual activity. Interest in discussing sexual problems with a personal clinician was determined.

RESULTS

Of the 212 women surveyed, 108 (50.9%) were sexually active with 37 (34.3%) of these women responding "yes" when asked about sexual problems using one of the two inquiry techniques. Stratified analysis by age group showed significantly higher reporting of sexual problems when a ubiquity-style inquiry was used among older women aged 61-80 years (P = 0.028) but not among younger ones. The prevalence of sexual problems was 14.8% reporting pain, 12.0% lack of interest, 9.2% lack of excitation, 5.5% lack of orgasm, and 6.5%"other." Forty-three percent of women with problems said they would like to discuss their problem(s) with their clinician.

CONCLUSIONS

In a specific minority group of women aged 40 years and older, especially those over age 60 years, ubiquity-style inquiries may encourage more open and honest responses about sexual problems. The most common sexual problem among this group of women was pain. There is willingness and even interest in talking with clinicians about sexual issues. Recognition of sexual problem prevalences helps clarify the high number of women who could be potentially helped with current and future pharmacologic and psychosocial treatments.

Phosphodiesterase type 5 inhibitors: the day after

OBJECTIVE

Review the literature on phosphodiesterase type 5 inhibitors (PDE5-Is), addressing critical issues in their current and future use, assessing unanswered questions, and identifying research needs.

METHODS

A MEDLINE search was conducted on PDE5-Is, with emphasis on clinical trials and experience, for interpretation and analysis of their present and future role.

RESULTS

Although approximately 40 million patients with erectile dysfunction have been treated successfully worldwide with the three available PDE5-Is, inappropriate instructions, lack of follow-up, and lack of patient-centered care models are the main reasons for "non-response," leading to drop-out rates of >50%. Patients with severe neurologic damage, diabetes mellitus, or severe vascular disease may be resistant to PDE5-Is. Preservation of corporal smooth muscle with chronic administration of PDE5-Is has been reported and substantial evidence indicates that these drugs have beneficial effects on endothelium and cardiovascular function; sildenafil has been approved for the treatment of idiopathic pulmonary hypertension. Improvement of lower urinary tract symptoms in men with benign prostatic hyperplasia after PDE5-I administration has been also suggested.

CONCLUSIONS

The data indicate the necessity for (1) exploration of the pharmacologic characteristics of the three PDE5-Is; (2) research on their pharmacologic differences because some actions seems to be drug-specific; (3) development of alternative management strategies, such as chronic, low, everyday doses of PDE5-Is, if the monthly cost is affordable; and (4) clinical trials on use of PDE5-Is to treat other chronic conditions. The door for innovative therapeutic approaches will open, specifically for cross-risk factor treatment with PDE5-Is or their use in combination treatments or new multimodal pills that take advantage of drugs that exert pleiotropic vascular actions.

Pharmacologic treatment strategies for sexual dysfunction in patients with epilepsy and depression

Sexual dysfunction is a frequently encountered comorbid condition in patients with many medical and psychiatric conditions, such as epilepsy and depression. Most depressed patients experience some type of sexual dysfunction, decreased sexual desire being the most common. The association of sexual dysfunction with epilepsy is less clear. Changes in sex hormone levels are common in patients with epilepsy and may be attributable to the disease or to antiepileptic drugs (AEDs). Sexual dysfunction associated with depression or epilepsy is generally treated according to standard guidelines for the management of sexual disorders, since data from special populations are not available. The most common forms of female sexual dysfunction are lack of sexual desire and difficulty achieving orgasm. There are no approved pharmacotherapies for female hypoactive sexual desire disorder or female orgasmic disorder. Female sexual arousal disorder is treated with estrogen replacement therapy when indicated or vaginal lubricants. The most common male sexual dysfunction disorders are premature ejaculation and erectile dysfunction. Phosphodiesterase type-5 inhibitor drugs are now the first-line treatment for erectile dysfunction, and selective serotonin reuptake inhibitors and topical anesthetic creams are nonapproved but effective treatments for premature ejaculation. Testosterone and aromatase inhibitors have been used investigationally to treat sexual dysfunction in men taking AEDs. Patient education and follow-up appointments are essential to ensure optimal outcomes of pharmacologic treatments for sexual dysfunction.

Sexual Dysfunction in Patients with Gynecologic Neoplasms: A Retrospective Pilot Study

INTRODUCTION

Little is known regarding the impact of a sexual health program on the sexual functioning of patients with a history of a gynecologic malignancy.

AIM

To evaluate as a pilot study the prevalence of common sexual health symptoms and evaluate the effects and compliance with clinical recommendations in gynecologic oncology patients.

METHODS

A retrospective cohort study of 259 female cancer patients who attended a survivorship program at an academic medical center from March 1, 2003 through December 31, 2004. Patients received symptomatic treatment recommendations including hormone therapy alternatives, psychosexual counseling, minimally absorbed vaginal estrogen suppositories, and vaginal dilators.

MAIN OUTCOME MEASURES

Patient self-report of the severity of sexual symptomology at follow-up visit.

RESULTS

Ninety-six patients (37%) had gynecologic neoplasms and the most common gynecologic malignancy seen was ovarian (27%). Median age at initial visit was 51 years (range 25-76) and 88 patients (92%) were postmenopausal. The most frequent presenting complaint encountered was dyspareunia (72%), atrophic vaginitis (65%), hypoactive desire (43%), and orgasmic dysfunction (17%). At a median of 6 months (range 0-20), 60 patients (63%) received follow-up, and of them 42 (70%) self-reported improvement in their symptoms.

CONCLUSIONS

The establishment of a well-structured sexual health program in a cancer setting can result in a 63% compliance rate with a 70% subjective improvement in sexual health complaints. Further research with objective measures of sexual dysfunction is needed to better evaluate patients' progress in this setting.

Phosphodiesterase type 5 inhibitors' extended duration of response as a variable in the treatment of erectile dysfunction

The phosphodiesterase type 5 (PDE5) inhibitors, sildenafil, tadalafil and vardenafil, are a class of medications that are safe and effective in treating erectile dysfunction (ED). Yet, resuming sexual activity following a period of abstinence in response to ED may be anxiety-provoking for the man, his partner and their relationship, causing the sexual encounter to become a stressful event. The differences between PDE5 inhibitors in terms of duration of action can be successfully utilized by healthcare professionals to mitigate some of the psychosocial barriers that interfere with treating ED. PDE5 inhibitors with a longer duration of responsiveness provide some men with ED and their partners, a treatment option that may offer greater flexibility and potentially less anxiety surrounding the resumption of sexual activity. Shorter-acting PDE5s may be preferred by men/couples with predictable sexual scripts, excellent communication strategies and concerns regarding the duration of side effects.

Female Hypoactive Sexual Desire Disorder: History and Current Status

INTRODUCTION

Hypoactive sexual desire disorder (HSDD) is a common problem that is often treatment refractory. This refractoriness to treatment is reflective of our lack of knowledge concerning the determinants of sexual libido in women.

AIM

To review the development and current status of information concerning the diagnosis and treatment of HSDD.

METHODOLOGY

Literature on HSDD published between 1950 and 2005 was reviewed.

RESULTS

Historically, HSDD was considered to be a psychiatric disorder. Thus, the diagnostic criteria utilized in studies of interventions for this disorder are based on the Diagnostic and Statistical Manual of the American Psychiatric Association. This system was never designed to encompass organic causes of sexual dysfunction and has evolved by expert opinion. If the syndrome is poorly defined by these diagnostic criteria, this could limit progress in this field. Epidemiological studies have found that approximately 24-43% of women complain of low sexual desire in the preceding year. The percentage of the population meeting diagnostic criteria for HSDD is probably much lower. There has been considerable progress in the development of psychometrically sound instruments for the assessment of libido. The development of approaches to treatment was reviewed. Approaches to treatment have evolved in three major areas: psychological, hormonal, and use of psychopharmacological agents. There is some evidence of efficacy utilizing all three approaches. The major evidence of efficacy concerns the use of testosterone therapy. Long-term safety data concerning this treatment are absent.

CONCLUSION

There is a rapidly expanding knowledge base concerning the diagnosis and treatment of HSDD. However, the contemporary clinician is faced with the absence of an approved treatment for this disorder and the lack of clear guidelines concerning the indications and safety of the use of non-approved agents.

Practical aspects in the management of vaginal atrophy and sexual dysfunction in perimenopausal and postmenopausal women

INTRODUCTION

The decline in circulating estrogen levels in peri- and postmenopause has a wide range of physiological effects, including atrophy of tissues in the urogenital tract. Vaginal atrophy is an important contributor to postmenopausal sexual dysfunction.

AIM

To provide a framework for clinical evaluation and clinical management of sexual dysfunction secondary to vaginal atrophy.

METHOD

Conduct a brief overview of literature on evaluation and treatment of vaginal atrophy, augmented with the authors' clinical observations and experience.

RESULTS

Estrogen decline disrupts many physiological responses characteristic of sexual arousal, including smooth muscle relaxation, vasocongestion, and vaginal lubrication; genital tissues depend on continued estrogen and androgen stimulation for normal function. An upward shift in vaginal pH as the result of vaginal atrophy alters the normal vaginal flora. Reduced lubrication capability and reduced tissue elasticity, in addition to shortening and narrowing of the vaginal vault, can lead to painful and/or unpleasant intercourse. At the same time, diminished sensory response may reduce orgasmic intensity. Other contributors to peri- and postmenopausal sexual dysfunction include reduced androgen levels, aging of multiple body systems, and side-effects of medications. Workup of sexual health problems starts by taking a comprehensive sexual, medical, and psychosocial history, followed by complete physical examination and laboratory evaluation. Clinical management includes measures to preserve and enhance overall health, adjustment of medication regimes to reduce or avoid side-effects, and topical or systemic hormone supplementation with estrogens and/or androgens.

CONCLUSIONS

No single therapeutic approach is appropriate for every woman with peri- or postmenopausal sexual dysfunction; instead, treatment should be based on a comprehensive evaluation and consideration of medical and psychosocial contributors to the individual's dysfunction. Further research is required to establish optimal regimens of hormonal and nonhormonal agents, including dosages/dosage forms and duration of treatment, for specific subtypes of sexual dysfunction.

Women's sexual function improves when partners are administered vardenafil for erectile dysfunction: a prospective, randomized, double-blind, placebo-controlled trial

INTRODUCTION

There are limited data concerning the sexual function of women whose male partners receive pharmacological treatment for erectile dysfunction (ED).

AIM

One objective of this research was to prospectively compare the efficacy of vardenafil vs. placebo administered to men with ED in improving men's and women partners' sexual function and satisfaction. Another goal was to assess the relationship of erectile function changes in men with ED receiving treatment with sexual function changes in women partners not directly receiving treatment.

METHODS

A randomized, double-blind, placebo-controlled, multi-institutional comparison of vardenafil vs. placebo was performed in 229 couples (treated man with ED>6 months and untreated woman partner). Co-primary outcomes for which this research was statistically powered were Sexual Encounter Profile (SEP3) (treated man with ED) and Sexual Life Quality Questionnaire (mSLQQ-QOL) (untreated woman partner).

MAIN OUTCOME MEASURES

Erectile function changes in men with ED receiving vardenafil vs. placebo were compared at last observation carried forward (LOCF) in SEP3, International Index of Erectile Function (IIEF-EF) and Erection Quality Scale (EQS). Sexual function at LOCF in women partners was determined by mSLQQ-QOL and Female Sexual Function Index (FSFI).

RESULTS

Compared with placebo at LOCF, vardenafil significantly increased least square (LS) mean scores in: (i) overall per-treated male SEP3 success rate, IIEF-EF, and EQS; and (ii) mSLQQ-QOL, total FSFI and sexual desire, subjective arousal, lubrication, orgasm and satisfaction FSFI domains in untreated women partners. Treatment-related improvement in erectile function as assessed by IIEF-EF and EQS was correlated reliably with improvement in women partners' FSFI total and individual domain scores.

CONCLUSIONS

Vardenafil is an effective ED treatment in men that also significantly improves sexual function/satisfaction in untreated women partners. Women partners' sexual function improvements relate significantly and consistently to treatment-related improvements in men's erectile function. ED management should emphasize both members of the couple.

EAU Guidelines on erectile dysfunction: an update

The introduction of new oral therapies has completely changed the diagnostic and therapeutic approach to erectile dysfunction. A panel of experts in this field has developed guidelines for the clinical evaluation and treatment based on the review of available scientific information.

Educating Physicians to Treat Erectile Dysfunction Patients: Development and Evaluation of a Course on Communication and Management Strategies

PURPOSE

To describe the development and assess the outcome of a workshop on erectile dysfunction (ED) management based on participating physicians evaluations.

METHOD

The study involved physicians who attended a workshop offered throughout the country, during a 3-year period. The workshop included tutorials, video-based dramatizations, and role-play sessions. A pilot study investigated the workshop's impact on physicians' attitudes toward patient-centeredness and sexual behavior issues; Patient-Practitioner Orientation Scale (PPOS) and Cross Cultural Attitude Scale (CCAS) were administered before and after the course. New knowledge acquisition, quality of presentation, and workshop's usefulness in their clinical practice were the dimensions used for workshop's evaluation. Analysis used quantitative and qualitative methods.

RESULTS

A total of 194 questionnaires were administered during the pilot study and the response rate was 53.6%. A shift in attitudes toward patient-centeredness and less judgmental attitude toward patients' sexual attitudes were revealed (total PPOS score and Sharing subscale: P < 0.05, CCAS: P < 0.001). Six hundred physicians were asked to evaluate the workshops and the response rate was 62.3%. The tutorial session for "medical treatment of ED" (P < 0.001) and the role-play on sexual history taking (P < 0.05) received higher evaluation scores. Qualitative analysis showed that the most frequently reported category referred to the appropriateness of role-play as a teaching and awareness-raising technique (31.25%); a need for changes in clinical practice and communication patterns was identified by 20% of the participants who stressed the necessity for multidisciplinary approach, as well as the adoption of a nonjudgmental attitude toward patients.

CONCLUSION

Training courses on ED management, using a combination of tutorial and interactive sessions, constitute an effective way of providing knowledge, enhancing physicians' communication skills with ED patients, and influencing attitudes toward patient-centeredness in sexual issues. Such results strongly support the establishment of sexual medicine courses at continuing medical education curricula.

ORIGINAL RESEARCH—EDUCATION: Sexual Communication Skills in Residency Training: The Robert Wood Johnson Model

Few medical schools or residency programs offer adequate training in sexual medicine. Using the experience gained in our long-standing program in human sexuality for medical students, we have pilot tested a half-day intensive workshop curriculum for residents that focuses on sexual communication skills and management of sexual problems. Unlike our medical school program, this residency course was offered on an elective, one-day basis. The current report describes the successful implementation of our pilot program with 46 medical residents from subspecialty and primary care residency programs. Before the workshop, 22 (48%) residents indicated that they were uncomfortable with open discussion of sexual issues and would not feel comfortable in addressing the topic with their patients. A number of factors were identified as barriers to communication, including lack of time, inadequate training, and personal discomfort. After the workshop, the participants rated themselves as more comfortable with the topic and as more likely to address sexual issues with their patients. The participants evaluated the workshop positively overall and responded well to the interactive format and audience-response components. Most of the participants showed interest and willingness to participate in further training in sexual medicine skills. Our program offers a model for training of residents in communication skills and management of sexual problems. The difficulties in implementation and overcoming institutional barriers to curriculum reform are addressed.

Prevention and management of cardiovascular disease and erectile dysfunction: toward a common patient-centered, care model

Erectile dysfunction (ED) is highly prevalent in men with cardiovascular disease (CVD), yet it is frequently underrecognized and underdiagnosed in clinical practice. Even among clinicians who acknowledge the relevance of addressing sexual issues in their patients, there is a general lack of awareness of the optimal approach for sexual problem identification and management. Additionally, cardiac rehabilitation programs typically neglect the role of sexual function. The trajectory of CVD and ED may necessitate continuous adjustment by both patients and their partners as they adapt to the chronicity of heart disease and the changing reality of their sexual lives. Health professionals typically approach management of these disorders from a disease-centered perspective, which often fails to incorporate the patient's needs and perspectives. In turn, patients frequently complain of a lack of sensitivity or awareness on the part of their physicians. From a patient-centered perspective, greater emphasis is placed on life satisfaction and quality of life as primary outcomes of treatment. Finally, a patient-centered framework is relevant for both treatment and prevention of cardiac risk in men with ED, in addition to ED management in patients with or without overt CVD.

Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference)

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended.

EFFECT OF TADALAFIL ON SEXUAL TIMING BEHAVIOR PATTERNS IN MEN WITH ERECTILE DYSFUNCTION: INTEGRATED ANALYSIS OF RANDOMIZED, PLACEBO CONTROLLED TRIALS

PURPOSE

Tadalafil, a new phosphodiesterase type 5 inhibitor, has an extended period of responsiveness compared with other agents in this class. The distinct pharmacological profile of tadalafil may allow more flexibility for men to establish individual sexual timing behavior patterns. We determined if patients took advantage of the pharmacological profile of tadalafil by assessing the frequency, timing and success of intercourse attempts in men with erectile dysfunction.

MATERIALS AND METHODS

Data on Eastern European countries were combined from 2 identically designed, randomized, double-blind, placebo controlled, parallel group studies. Patients self-administered 20 mg tadalafil (406) or placebo (108) as needed for 12 weeks.

RESULTS

Of the men 63% made at least a quarter of their attempts and 42% made at least half of their attempts more than 4 hours after dose. At least 1 attempt was made after 8, 12 or 24 hours after dose by 87%, 75% and 52% of the men, respectively. Throughout a 36-hour post-dose period tadalafil was associated with significantly higher intercourse success rates than placebo (p <0.001) with 61% to 69% of tadalafil treated patients reporting success rates of greater than 75% compared with 19% to 30% of those on placebo (p <0.001). Tadalafil was well tolerated.

CONCLUSIONS

In this study various use patterns of the tadalafil period of effectiveness were apparent, reflecting differences in the sexual timing behavior of patients. Tadalafil may provide men with erectile dysfunction more flexibility in deciding when to attempt intercourse in accordance with their sexual habits and attitudes.

HEALTH ISSUES OF MEN: PREVALENCE AND CORRELATES OF ERECTILE DYSFUNCTION

PURPOSE

The Cross-National Survey on Men's Health Issues was a population based, international survey of men using the health care systems of participating countries. The prevalence of erectile dysfunction (ED) and its correlation with patient age, overall health and comorbidities were assessed.

MATERIALS AND METHODS

Men who were 20 to 75 years old in the United States, Germany, United Kingdom, France, Italy and Spain were recruited to participate in the study. During visits to physician offices participants completed a screening questionnaire about their overall health, and problems with prostate, urination and penile erection. Men who reported ED completed a followup questionnaire.

RESULTS

A cohort of 28,691 men completed the screening questionnaire and provided their age. Respondents in the oldest age group (70 to 75 years) were at 14-fold higher relative risk for ED than respondents in the youngest age group (20 to 29 years). ED correlated positively with poor overall health, and prostate and urinary problems. The prevalence of comorbid conditions increased with ED severity. Only a small percent of men with ED (2% to 8%) were using nitrates for comorbid cardiac disorders. Approximately 10% to 20% of men were on beta-blockers.

CONCLUSIONS

The results of this survey are consistent with those of other population based reports showing a high correlation between ED prevalence and patient age, and ED and lower urinary tract symptoms. The prevalence of comorbidities, such as vascular conditions, increased with ED severity, which may indicate that ED is a prognostic marker of overall health and an important medical condition.