The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores

The impact of a group psychoeducational appointment on women with sexual dysfunction

OBJECTIVE

There is little evidence to support many treatment modalities for women with sexual dysfunction. Cognitive-behavioral therapy and bibliotherapy are associated with improved sexual outcomes. We evaluated the impact of a group psychoeducational intervention on sexual function outcome measures in women with sexual concerns.

STUDY DESIGN

Women with concerns of sexual function were referred to a group sexuality appointment. Before the visit, the women completed the Female Sexual Function Index (FSFI). Class participants completed the FSFI at 1-, 3-, and 6-months after the intervention to evaluate changes in sexual function.

RESULTS

Thirty-three women attended the group appointment between January and December 2006. Twenty-five women with an age range from 28-70 years completed a demographic and baseline FSFI questionnaire. All participants showed a baseline FSFI score indicating sexual dysfunction. At least 1 postclass FSFI was completed by 64% of participants. Significant improvement in most FSFI domain scores and the full scale score (P = .0073) was seen in these women.

CONCLUSION

Participating in a group sexuality appointment improved quantitative outcome measures in women with sexual dysfunction. This intervention may provide an effective means for women's health care clinicians with limited time and expertise about sexual function to meet the needs of their patients with sexual concerns.

The inhibitory effects of nicotine on physiological sexual arousal in nonsmoking women: results from a randomized, double-blind, placebo-controlled, cross-over trial

INTRODUCTION

Extensive research suggests that long-term cigarette smoking is an independent risk factor for the introduction of sexual dysfunction in men. However, results of limited data investigating this relationship in women are mixed. No studies have examined the acute effects of tobacco or nicotine on physiological sexual response in women. Controlled experimental studies examining acute effects of isolated nicotine intake on female physiological sexual responses are necessary in order to help elucidate tobacco's potential role in the development and/or maintenance of sexual impairment in women.

AIM

To examine whether isolated nicotine intake acutely affects sexual arousal responses in nonsmoking women.

METHODS

Twenty-five sexually functional women (mean age = 20 years) each with less than 100 direct exposures to nicotine completed two counterbalanced conditions in which they were randomized to received either nicotine gum (6 mg) or placebo gum, both administered double-blind and matched for appearance, taste, and consistency, approximately 40 minutes prior to viewing an erotic film.

MAIN OUTCOME MEASURES

Physiological (changes in vaginal pulse amplitude via vaginal photoplethysmography) and subjective (continuous self-report) sexual responses to erotic stimuli were examined, as well as changes in mood.

RESULTS

Nicotine significantly reduced genital responses to the erotic films (P = 0.05), corresponding to a 30% attenuation in physiological sexual arousal. This occurred in 11 of 18 women with valid physiological assessments. Nicotine had no significant effect on continuous self-report ratings of sexual arousal (P = 0.45), or on mood (all Ps > 0.05).

CONCLUSIONS

Acute nicotine intake significantly attenuates physiological sexual arousal in healthy nonsmoking women. Our findings provide support to the hypothesis that nicotine may be the primary pharmacological agent responsible for genital hemodynamic disruption, thereby facilitating a cascade of biochemical and vascular events which may impair normal sexual arousal responses.

Menstrual cycle-related changes in circulating androgens in healthy women with self-reported normal sexual function

INTRODUCTION

There is currently neither a clinically useful, reliable and inexpensive assay to measure circulating levels of free testosterone (T) in the range observed in women, nor is there agreement on the serum free T threshold defining hypoandrogenism that is associated with female-impaired sexual function.

AIM

Following the Clinical and Laboratory Standards Institute guidelines, we generated clinically applicable ranges for circulating androgens during specific phases of the menstrual cycle in a convenience sample of 120 reproductive-aged, regularly cycling healthy European Caucasian women with self-reported normal sexual function.

METHODS

All participants were asked to complete a semistructured interview and fill out a set of validated questionnaires, including the Female Sexual Function Index, the Female Sexual Distress Scale, and the 21-item Beck's Inventory for Depression. Between 8 am and 10 am, a venous blood sample was drawn from each participant during the midfollicular (day 5 to 8), the ovulatory (day 13 to 15), and the midluteal phase (day 19 to 22) of the same menstrual cycle.

MAIN OUTCOME MEASURES

Serum levels of total and free testosterone, Delta(4)-androstenedione, dehydroepiandrosterone sulphate and sex hormone-binding globulin during the midfollicular, ovulatory and midluteal phase of the same menstrual cycle.

RESULTS

Total and free T levels showed significant fluctuations, peaking during the ovulatory phase. No significant variation during the menstrual cycle were observed for Delta(4)-androstenedione and dehydroepiandrosterone sulphate. Despite the careful selection of participants that yielded an homogeneous group of women without sexual disorders, we observed a wide range of distribution for each of the circulating androgens measured in this study.

CONCLUSIONS

This report provides clinically applicable ranges for androgens throughout the menstrual cycle in reproductive-aged, regularly cycling, young healthy Caucasian European women with self-reported normal sexual function.

Use of the Italian translation of the Female Sexual Function Index (FSFI) in routine gynecological practice

AIMS

To investigate domains of sexual function in healthy women attending a gynecological office for routine annual check-up using the Italian translation of the Female Sexual Function Index (FSFI) according to age, reproductive status and hormonal treatments; and to confirm the usefulness of the FSFI in detecting relevant clinical entities.

METHODS

Of 720 women (age range 18-65 years), 564 (78%) filled in a short anamnestic questionnaire and the FSFI assessing desire, arousal, lubrication, orgasm, satisfaction and pain. A semi-structured DSM-IV-TR clinical interview was administered to a convenience sample of women selected according to the quartile distribution of the median full scale FSFI score. Analysis of data was performed by frequency tables and non-parametric statistics.

RESULTS

The median full scale score of FSFI in our study population was 27.6 (lower quartile: 18.7, upper quartile: 30.9) and the percentage of women under the lower quartile of the distribution was 24.4%. Sexual function decreased progressively with age, being significantly lower after 30 years and after 60 years (chi(2) = 52.6; p = 0.0001). Menopausal women had significantly lower median FSFI full scale score compared with fertile women and women who used oral contraception (OC) (p < 0.0001 for both), while users of hormone replacement therapy (HRT) displayed better overall sexual function than untreated postmenopausal women (p < 0.005). A positive diagnosis of female sexual dysfunction (FSD) was evident only in young women scoring under the lower quartile of the distribution (cut-off score: 23.4 for women not taking OC and 20.8 for OC users), while older women were dysfunctional also above the lower quartile of the distribution (cut-off score: 14.1 for menopause, 18.5 for HRT) of the FSFI full scale score.

CONCLUSIONS

The FSFI is a powerful screening tool for FSD, especially in young fertile women, and may be used effectively in routine gynecological practice.

A psychoeducational intervention for sexual dysfunction in women with gynecologic cancer

Treatment of early-stage cervical and endometrial cancer has been associated with significant sexual difficulties in at least half of women following hysterectomy. Despite the fact that women report such sexual side effects to be the most distressing aspect of their cancer treatment, evidence-based treatments for Female Sexual Arousal Disorder (FSAD), the most common sexual symptom in this group, do not exist. We developed and pilot tested a brief, three session psychoeducational intervention (PED) targeting FSAD in 22 women with early-stage gynecologic cancer. The PED consisted of three, 1-h sessions that combined elements of cognitive and behavioral therapy with education and mindfulness training. Women completed questionnaires and had a physiological measurement of genital arousal at pre- and post-PED (sessions 1 and 4) and participated in a semi-structured interview (session 4) during which their feedback on the PED was elicited. There was a significant positive effect of the PED on sexual desire, arousal, orgasm, satisfaction, sexual distress, depression, and overall well-being, and a trend towards significantly improved physiological genital arousal and perceived genital arousal. Qualitative feedback indicated that the PED materials were very user-friendly, clear, and helpful. In particular, women reported the mindfulness component to be most helpful. These findings suggest that a brief 3-session PED can significantly improve aspects of sexual response, mood, and quality of life in gynecologic cancer patients, and has implications for establishing the components of a psychological treatment program for FSAD.

Appetitive and aversive classical conditioning of female sexual response

INTRODUCTION

There is only limited evidence for appetitive classical conditioning of female sexual response, and to date modulation of female sexual response by aversive conditioning has not been studied.

AIM

The aim of this article is to study appetitive and aversive classical conditioning of sexual responses in women.

MAIN OUTCOME MEASURES

Vaginal pulse amplitude was assessed by vaginal photoplethysmography and ratings of affective value were obtained.

METHOD

Two differential conditioning experiments were conducted. In Experiment 1, on appetitive conditioning, neutral pictures served as conditional stimuli (CSs) and genital vibrotactile stimulation as the unconditional stimulus (US). In Experiment 2, on aversive conditioning, erotic pictures served as CSs and a pain stimulus as US. In both experiments, only one CS (the CS+) was followed by the US during the acquisition phase. Conditioned responses were assessed during the extinction phase.

RESULTS

In Experiment 1, during the extinction phase, as expected vaginal pulse amplitude was higher in response to the CS+ than during the CS-. Also, the CS+ was rated as marginally more positive than the CS-. In Experiment 2, during the extinction phase, as expected vaginal pulse amplitude was lower in response to the CS+ than during the CS-, and the CS+ was rated as more negative than the CS-.

CONCLUSIONS

The results provide evidence for appetitive classical conditioning of sexual response in women, and are the first to show attenuation of sexual response in women by aversive conditioning.

OM, Souza CD. Adaptação transcultural do Female Sexual Function Index

Ainda hoje pouco se conhece sobre a epidemiologia das disfunções sexuais femininas. O Female Sexual Function Index (FSFI) [Índice de Função Sexual Feminina] é um questionário breve, que pode ser auto-aplicado, e que se propõe avaliar a resposta sexual feminina. Este estudo teve por objetivo avaliar a adaptação transcultural da versão em português do FSFI. O processo envolveu cinco etapas: tradução, versão, apreciação formal de equivalência, revisão crítica por especialistas em sexualidade e pré-teste do instrumento. Após a identificação de problemas semânticos, concordâncias e discordâncias, foi possível propor uma versão sintética, escolhendo e incorporando itens de uma das duas versões em português. Algumas mudanças foram realizadas após o pré-teste do questionário, para tornar a versão em português mais coloquial e aceitável para a população-alvo ao utilizar termos mais corriqueiros, como opção ou complemento à linguagem científica. Ao se comparar mais de uma versão do instrumento, no processo de equivalência transcultural, foi possível detectar problemas e dificuldades na adaptação da linguagem que poderiam ter passado despercebidos, caso não se observassem todas as fases do processo.

The roles of testosterone and alpha-amylase in exercise-induced sexual arousal in women

INTRODUCTION

Several studies have demonstrated that moderate exercise increases genital response to erotic stimuli in women. The increase in genital arousal could be the result of various changes that can occur in response to exercise including changes in hormone levels, neurotransmitter levels, mood, and autonomic nervous system activity.

AIM

The present study was an attempt to shed light on two such mechanisms through which exercise enhances sexual arousal.

METHOD

Sixteen participants came into the lab on two separate occasions: during one visit, they filled out questionnaires for 20 minutes, and during the other visit, they exercised on a treadmill for 20 minutes. The questionnaires and exercise were both followed by the presentation of a neutral then erotic film during which the women's physiological sexual arousal was measured. Saliva samples were taken at baseline, prefilm, and postfilm. Main Outcome Measures. Subjective arousal was measured using a self-report questionnaire, and genital arousal was measured by a vaginal photoplethysmograph. Testosterone and alpha-amylase (a marker of sympathetic nervous system [SNS] activity) were measured via saliva assays.

RESULTS

Findings replicated previous studies showing a significant increase in physiological sexual arousal with exercise. There was a significant increase in alpha-amylase across the study in the exercise condition, but not in the no-exercise condition. There were no differences in testosterone levels between the exercise and no-exercise conditions.

CONCLUSIONS

SNS activity is one mechanism through which exercise increases genital sexual arousal. Testosterone does not mediate the relationship between exercise and genital sexual arousal.

Sexual function and quality of life in the male partner of infertile couples: prevalence and correlates of dysfunction

PURPOSE

We prospectively collected data on mental and physical health related quality of life as well as sexual and relationship function in couples presenting for the treatment of infertility.

MATERIALS AND METHODS

Infertile couples were invited to complete a demographic survey, the Short Form 36 and the Center for Epidemiological Studies Depression Inventory. Male partners completed the International Index of Erectile Function and the Self-Esteem and Relationship Quality scale. Female partners completed the Female Sexual Function Index and a version of the Self-Esteem and Relationship Quality Scale modified for women. Multiple regression analysis was conducted to assess for associations between partner responses.

RESULTS

A total of 121 couples were enrolled at 2 sites. Male partners reported significantly lower standardized scores on the Mental Health subscale of the Short Form 36 (mean 47.6, p <0.05) compared to normative values. Of the men surveyed 11% and 12% reported moderate or severe depression, respectively. There were 18% who had mild erectile dysfunction and 4% had moderate erectile dysfunction. The mean transformed score for the Self-Esteem and Relationship Quality Scale in our subjects was 29.44 (range 0 to 100). In multivariate analysis white race and partner Female Sexual Function Index score were significant predictors of International Index of Erectile Function Erectile Function Domain scores (p <0.01). Relationship duration and partner Self-Esteem and Relationship Quality Scale scores were significantly associated with male Self-Esteem and Relationship Quality Scale score on multivariate analysis.

CONCLUSIONS

Depression, erectile dysfunction and sexual relationship problems are prevalent among male partners of infertile couples. Partner sexual function is a significant predictor of male partner sexual function. Relationship duration and female partner assessment of relationship health are predictive of men's assessment of their relationship status.

The sexual lives of medical students: a single institution survey

INTRODUCTION

Little is known about the personal sexual lives of medical students.

AIM

To assess sexual habits and determine the presence of sexual dysfunction among medical students.

MAIN OUTCOME MEASURES

Demographic and sexual experience data and domain scores on validated sexuality surveys. Instruments selected included the International Index of Erectile Function, the Index of Premature Ejaculation, and the Self Esteem and Relationship Quality Survey for male medical students and the Female Sexual Function Index (FSFI), and the Index of Sex Life for female medical students.

METHODS

Medical students at our institution were invited to complete a demographic questionnaire and gender- appropriate sexuality surveys. Results were compared with established normative data and validated cut-off scores when available. Linear regression and Pearson coefficient were used to assess relationships between variables.

RESULTS

There were 132 responses (78 female mean age 24 years, 54 male, mean age 25 years). Condoms and oral contraceptives were the most popular form of contraception. Among men, 81.5%, 37%, and 93% were in a relationship, married, and heterosexual, respectively. Among women, 64%, 18%, and 95% were in a relationship, married, and heterosexual. Erectile dysfunction was reported by 30% of men. Proxy measures of other sexual problems in men revealed a 28% prevalence of dissatisfaction with sex life, a 28% prevalence of problems controlling ejaculation, an 11% prevalence of orgasmic dysfunction, and a 6% prevalence of low sexual desire. Based on validated FSFI scoring, 63% of women were at high risk of sexual dysfunction. Proxy measures of other problems in women indicated disorders of pain, orgasms, desire, sex satisfaction, lubrication, and arousal in 39%, 37%, 32%, 28%, 26%, and 24% of female respondents, respectively.

CONCLUSIONS

These data provide insight into the sexual lives of medical students. Rates of sexual dysfunction are higher than expected based on normative data. Further research is required.

Multilevel local anesthetic nerve blockade for the treatment of vulvar vestibulitis syndrome

OBJECTIVE

Vulvar vestibulitis syndrome is a major cause of dyspareunia. This pilot study was designed to evaluate a novel treatment approach.

STUDY DESIGN

This is a prospective study of 27 women with vulvar vestibulitis. The protocol included 5 treatment sessions with caudal epidural, pudendal nerve block, and vestibular infiltration of local anesthetic agents.

RESULTS

There were significant improvements in vestibular pain as determined by the vulvalgesiometer, McGill pain questionnaire, self-report, and the Female Sexual Functioning Inventory.

CONCLUSION

Serial multilevel nerve blocks administered for the treatment of vulvar vestibulitis is a conceptually neurophysiologically based modality that may be effective and merits a placebo-controlled study.

Sexual function following anal sphincteroplasty for fecal incontinence

OBJECTIVE

The objective of the study was to assess sexual function following anal sphincteroplasty and determine associations between sexual function and fecal incontinence.

STUDY DESIGN

Women 1 year or longer following anal sphincteroplasty with or without other reconstructive surgery were matched to controls. Subjects were mailed the Female Sexual Function Index (FSFI), Fecal Incontinence Quality of Life (FIQOL), Fecal Incontinence Severity Index (FISI), and a general questionnaire.

RESULTS

Twenty-six cases and 26 controls responded; 73% were sexually active. Sexual function scores were similar between the groups. Seventeen sphincteroplasty patients and 8 controls complained of fecal incontinence at follow up. Significant correlations were found between FSFI domains and the FIQOL depression/self-perception scale, FISI fecal incontinence of solid stool, and total FISI.

CONCLUSION

Sexual activity and function was similar following anal sphincteroplasty, compared with controls, despite worse symptoms of fecal incontinence. Fecal incontinence of solid stool and depression related to fecal incontinence were correlated with poorer sexual function.

Predictors of genital pain in young women

Despite the high prevalence of genital pain in healthy young adult women, limited research has addressed genital pain during intercourse using contemporary models of multidimensional sexual function. The objectives of this study were threefold: (1) to identify differences in sexual functioning in women who experience genital pain compared to pain free women; (2) to identify predictors of sexual functioning in women with and without genital pain; and (3) to identify predictors of sexual satisfaction in women with and without genital pain. Sexually active female undergraduates (n = 651) were administered the Female Sexual Function Index and the Derogatis Sexual Functioning Inventory. We evaluated the sexual factors that impact the sexual function of women with any pain (including high and low pain groups) versus women with no history of pain. Women with genital pain reported greater rates of sexual dysfunction as compared to pain-free women; however, sexual functioning in the high versus low pain groups was distinguished primarily by vaginal lubrication. Women in the high pain group showed negative correlations between domains of sexual satisfaction and genital pain frequency and intensity that were not found in the low pain group. For pain-free women, intercourse played a strong role in sexual satisfaction, whereas non-intercourse sexual behavior was central to sexual satisfaction in women who reported pain. The evaluation of levels of genital pain may provide insight into the mechanisms underlying the impairment of sexual function, sexual behavior, and sexual satisfaction.

Sexual function after vaginal surgery for pelvic organ prolapse and urinary incontinence

OBJECTIVE

The objective of the study was to assess sexual function following vaginal surgery and to determine the impact on postoperative sexual function in women who undergo concurrent antiincontinence procedures, compared with those who do not.

STUDY DESIGN

Sexually active women undergoing vaginal repairs for prolapse or urinary incontinence were prospectively enrolled. Subjects completed the Female Sexual Function Index (FSFI), Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and a standardized questionnaire. Follow-up occurred at 6 months.

RESULTS

Forty-nine subjects (96%) returned their postoperative surveys; 48 were sexually active. Improvements were noted in postoperative prolapse stage, UDI-6, and IIQ-7. However, sexual function and frequency were similar. The most bothersome barrier to sexual activity before repair was vaginal bulging; postoperatively it was vaginal pain. Twelve subjects (25%) commented on the negative impact of vaginal pain postoperatively. Finally, FSFI scores were not different based on performance of antiincontinence surgery.

CONCLUSION

Sexual function was unchanged following vaginal reconstructive surgery despite anatomic and functional improvements; lack of benefit may be attributable to postoperative dyspareunia.

An examination of the association of abuse (physical, sexual, or emotional) and female sexual dysfunction: results from the Boston Area Community Health Survey

OBJECTIVE

To examine associations between abuse (physical, sexual, and emotional) in childhood and adolescence/adulthood and sexual activity and dysfunction in women.

DESIGN

We analyzed data from the Boston Area Community Health Survey, a community-based epidemiologic study of urologic and sexual symptoms and risk factors in a racially and ethnically diverse random sample of women aged 30-79 years (N = 3,205 women).

SETTING

Boston area community.

PATIENT(S)

Participants were community residents.

INTERVENTION(S)

Data were observational; no interventions were made.

MAIN OUTCOME MEASURE(S)

Sexual activity and dysfunction rates were assessed by means of a validated questionnaire (the Female Sexual Function Index).

RESULT(S)

Abuse history was not significantly associated with likelihood of sexual activity. Among those who were sexually active with a partner, a history of each of three types of abuse approximately doubles the odds of female sexual dysfunction. Specifically, childhood emotional (odds ratio [OR] 2.13, 95% confidence interval [CI] 1.28-3.56), adult sexual (OR 1.94, 95% CI 1.23-3.08), and adult emotional abuse (OR 1.86, 95% CI 1.15-3.01) were all significantly and positively associated with sexual dysfunction after adjusting for covariates (including depression). Analyses of the six female sexual dysfunction domains showed that the relationships were strongest for pain and satisfaction.

CONCLUSION(S)

These findings extend those from previous studies by identifying an association between female sexual dysfunction and multiple types of abuse, even after adjusting for depression.

The Female Sexual Function Index (FSFI): Validation of the Malay Version

INTRODUCTION

Female sexual dysfunction (FSD) is a prevalent sexual health problem that has been inadequately investigated in Malaysia, a nation with a conservative multiethnic society.

AIM

To validate the Malay version of the Female Sexual Function Index (MVFSFI) for the study of FSD.

MAIN OUTCOME MEASURE

To measure the validity and reliability of the MVFSFI and its domains.

METHODS

Validation was carried out on aspects of face, content, discriminant, and criterion (concurrent) validity. Reliability studies on test-retest and on internal consistency were conducted with Cronbach's alpha and Pearson correlation, respectively. The values with the highest sensitivity and specificity generated from the receiver operating characteristic curves were taken as the cutoff scores to differentiate cases and noncases.

RESULTS

A total of 230 married women aged 18-70 years participated in this study. There was a high test-retest correlation by respondents (r at least >0.7). The MVFSFI was found to have good discriminant validity as a whole and for each domain. A total score of 55 was taken as the cutoff point for the MVFSFI to distinguish between women with sexual dysfunction and those without (sensitivity = 99%, specificity = 97%). Scores lower than 55 indicate sexual dysfunction. The cutoff score for each domain was also established for the MVFSFI: </=5 for sexual desire disorder (sensitivity = 95%, specificity = 89%); </=9 for sexual arousal disorder (sensitivity = 77%, specificity = 95%); </=10 for disorder of lubrication (sensitivity = 79%, specificity = 87%); </=4 for orgasmic disorder (sensitivity = 83%, specificity = 85%); </=11 for sexual dissatisfaction (sensitivity = 83%, specificity = 85%); and </=7 for sexual pain disorder (sensitivity = 86%, specificity = 95%).

CONCLUSION

The MVFSFI is a validated and locally accepted questionnaire for use in the assessment of FSD in the Malaysian population.

Presence of a sexual problem may not affect women's satisfaction from their sexual function

INTRODUCTION

It has been proposed that women's sexual problems/dysfunctions, in the absence of personal and interpersonal distress, may have little clinical importance, as they may not necessarily affect women's sexual satisfaction. However, data are missing to support such interpretation.

AIM

The objective of the present study was to examine whether the presence of a sexual problem necessary affects women's satisfaction with sexual function.

METHOD

The study included 164 women who visited a general hospital because of symptoms not related to their sexual function and were asked to complete voluntarily and anonymously demographic data and two questionnaires.

MAIN OUTCOME MEASURES

Women completed the Female Sexual Function Index (FSFI)--an instrument which evaluates women sexual function--and the Symptom Checklist of Sexual Function-women version (SCSF-w), a screening tool of women's self-perception of sexual function.

RESULTS

Mean patients' age was 43 +/- 12.6 (18-72) years. According to the FSFI, 48.8% of the participants had a sexual dysfunction. However, based on their self-perception of sexual function (SCSF), 80.5% of the sample declared to be satisfied with their sexual function, despite the fact that 69.5% of them reported at least one sexual problem. Of all women, only 26.2% would like to talk about their sexual problem(s) with a doctor (57.4% of those who are "bothered" by their sexual symptoms). Logistic regression analysis revealed no association between any sexual dysfunction and women's satisfaction from their sexual function.

CONCLUSION

Despite the presence of sexual problem(s), women may be satisfied with their sexual function, but half of those who are bothered would like to talk about it with their doctor. The presence of a sexual problem or its severity is not a determinant of women's help-seeking behavior. Such data strongly support current definitions of women's sexual dysfunction, where the presence of personal distress has been included as a crucial dimension.

The Treatment Satisfaction Scale (TSS) is a sensitive measure of treatment effectiveness for both patients and partners: results of a randomized controlled trial with vardenafil

INTRODUCTION

Erectile dysfunction (ED) treatment studies do not routinely measure "treatment effectiveness," a function of treatment response (based on efficacy and tolerability) and treatment satisfaction (both patient and partner satisfaction). The ED Treatment Satisfaction Scale (TSS) is a brief, comprehensive self-report measure of patient and partner satisfaction.

AIM

To measure, for the first time in an ED treatment study, pre- and post-treatment patient and partner satisfaction with the TSS.

METHODS

A randomized, double-blind, placebo-controlled, parallel-group, multi-institutional comparison of the efficacy and safety of flexible-dose vardenafil was performed in 229 couples (treated man with ED >6 months and untreated woman partner aged > or =18 years without sexual dysfunction [defined as a total Female Sexual Function Index score >26.55]).

MAIN OUTCOME MEASURES

Couples completed the TSS throughout the trial. Couples also completed the modified Sexual Life Quality Questionnaire-Quality of Life domain (mSLQQ-QoL) and men completed the International Index of Erectile Function-erectile function domain (IIEF-EF). Analysis of covariance produced least squares (LS) mean domain scores. Post hoc Pearson correlation coefficients were calculated for patient and partner TSS scores, and for TSS scores with other outcomes.

RESULTS

TSS domain scores increased from baseline to last observation carried forward (LOCF) in the vardenafil-treated men and untreated women partners, but exhibited little change for the placebo group (P < 0.0001 vs. placebo). For both patients and partners in the vardenafil group, correlations between TSS domains, the IIEF-EF and the mSLQQ-QoL scores at LOCF were moderate to strong.

CONCLUSIONS

The TSS detected that vardenafil was superior to placebo on treatment satisfaction from both patient and partner perspectives. The TSS holds promise for evaluating "treatment effectiveness" by measuring more general treatment satisfaction.

The impact of body awareness on sexual arousal in women with sexual dysfunction

INTRODUCTION

The impact of self-awareness during sexual activity has been widely discussed. However, research has been largely focused on the effects of performance anxiety in male erectile functioning. It has been suggested that physical appearance concerns may have a similar influence on sexual function in women as does men's self-awareness about erectile function. However, the role that physical appearance or awareness of one's body may play in female sexual response has received little empiric attention.

AIM

To examine the effects of body awareness and self-report levels of body esteem on sexual response in 21 sexually dysfunctional women.

METHODS

Body awareness was induced in one of two counterbalanced sessions. A full-length mirror was placed in front of participants throughout the experimental session, and participants were instructed to use the mirror to place 10 electrodes on each side of their bodies to prepare for a possible electrocardiogram. This methodology was used to ensure that women looked at themselves in the mirror and became more aware of their bodies during the experimental session.

MAIN OUTCOME MEASURES

Self-reported mental arousal, perceptions of physical arousal, physiological sexual arousal, affect, anxiety, and cognitive distraction responses to erotica.

RESULTS

Results showed that subjective mental sexual arousal and perceptions of physical sexual arousal increased in response to erotica in the Body Awareness condition compared to in the No Body Awareness condition. These results were not accounted for by level of body esteem. There were no changes in physiological sexual arousal, affect, anxiety, or level of cognitive distraction across the two conditions.

CONCLUSIONS

Findings suggest that awareness of one's body is related to increased subjective sexual response in conditions where cognitive distraction does not occur. It is particularly noteworthy that the current sample was made up of sexually dysfunctional women, all of whom had relatively low body image.

Pelvic floor muscle training improves sexual function of women with stress urinary incontinence

The aim of this study was to assess the effect of a program of supervised pelvic floor muscle training (PFMT) on sexual function, in a group of women with urodynamically diagnosed stress urinary incontinence (SUI), using a validated questionnaire. Incontinence episodes frequency and continence pads used per week were measured before and after treatment using a 7-day bladder diary. Improvements in sexual function were assessed using the Female Sexual Function Index (FSFI). Seventy women completed the 12-month program of supervised PFMT successfully. At the end of the study, incontinence episode frequency decreased by 38.1%, and patients required 39% less pads per week. All domains of the FSFI were also significantly improved with median total FSFI scores increasing from 20.3 to 26.8. This is one of the few studies to quantify, using a validated questionnaire, the improvement in sexual function of women with SUI, undergoing successfully a 12-month supervised PFMT program.

Sex differences in memory for sexually-relevant information

The present study was conducted in an attempt to examine potential differences between men and women in memory for sexually relevant information. A total of 77 undergraduate students (31 men, 46 women) read a sexual story and completed memory tasks in response to the story. Based on previous research, we hypothesized that differences would exist between men and women for different types of sexual information and we hoped to understand whether specific variables (sexual experiences, sexual functioning, and reactions to the sexual story) could explain such differences. Men were more likely to remember erotic or explicit details of the story, whereas women were more likely to remember love and emotional bonding details of the story. Additionally, women were more likely to recall information referencing the characters in the story. Results from regression analyses indicated that sexual desire and satisfaction were related to differences in recall and recognition of the love and emotional bonding aspects of the story, and that frequency of sexual intercourse was related to differences in the recall of erotic or explicit details of the story. The significant results obtained in this study correspond to previously established sex differences in memory for sexual information.

The effects of false positive and false negative physiological feedback on sexual arousal: a comparison of women with or without sexual arousal disorder

The effects of false positive and false negative physiological feedback (vaginal photoplethymograph response print-out) on women's sexual arousal were examined. Participants included women without sexual dysfunction (n=16) and women with Sexual Arousal Disorder (SAD; n=15). Measures of subjective sexual arousal, physiological sexual arousal (vaginal pulse amplitude), expectancies, affect, and anxiety were obtained in response to viewing an erotic film. Results indicated that false positive feedback significantly increased subjective levels of sexual arousal, whereas false negative feedback significantly decreased subjective levels of sexual arousal in both groups. Sexually functional women had overall higher expectancies for sexual arousal than women with SAD. Unexpectedly, false positive feedback did not significantly impact physiological sexual arousal in sexually functional women; however, it resulted in significantly decreased responses in physiological sexual arousal in women with SAD. False negative feedback had no significant effect on physiological sexual response in sexually functional women or women with SAD.

Correlates of placebo response in the treatment of sexual dysfunction in women: a preliminary report

INTRODUCTION

Placebo responses have been large across a number of clinical trials for treatment of women's sexual dysfunction. Studying placebo responses may elucidate predictors of symptom reduction and responsiveness to intervention.

AIM

To determine the correlates of placebo response in participants enrolled in a clinical trial for female sexual dysfunction.

METHODS

We analyzed data from 16 women with sexual arousal and orgasmic dysfunction who were randomized to receive 8 weeks of placebo treatment within a larger randomized controlled trial. Using nonparametric correlations, we tested whether age, length of relationship, psychological symptoms, and scores on self-report measures predicted change in sexual function with placebo treatment.

MAIN OUTCOME MEASURE

Female Sexual Function Index.

RESULTS

Consistent with findings from other studies, we found a significant improvement in sexual function scores after 8 weeks of treatment with placebo. We also found that age and length of relationship predicted the magnitude of change in sexual function across treatment. Changes in relationship adjustment, but not relationship adjustment at baseline, predicted the magnitude of improvement in sexual function scores. We observed no relationship between psychological symptom severity and change in sexual function.

CONCLUSIONS

Participant age and length of relationship predicted subsequent magnitude of change in sexual function scores during treatment with placebo. In addition, relationship adjustment covaried with changes in sexual function. Our findings suggest that "placebo effects" may represent underlying factors that influence the way in which women respond to the process of treatment.

Night sweats, sleep disturbance, and depression associated with diminished libido in late menopausal transition and early postmenopause: baseline data from the Herbal Alternatives for Menopause Trial (HALT)

OBJECTIVE

The objective of the study was to evaluate the association of depression, sleep disturbance, and menopausal symptoms with diminished libido.

STUDY DESIGN

Data from a 2001-2002 baseline survey of 341 peri- and postmenopausal women, aged 45-55 years, participating in a randomized trial, was analyzed. Eligibility included at least 2 hot flashes and/or night sweats per day and no hormone therapy for at least the prior 3 months. The survey evaluated sexual function, depression, sleep, and vasomotor symptoms. We examined the association between these factors, using multivariate regression models.

RESULTS

Of 341 women, 64% had diminished libido, 18% had moderate to severe depression, and 43% had poor sleep quality. Women averaged 4.6 hot flashes and 1.9 night sweats per day. Depressive symptoms (P = .003), poor sleep (P = .02), and night sweats (P = .04) were significantly associated with diminished libido.

CONCLUSION

Factors associated with diminished libido in midlife are complex but include depression, disturbed sleep, and night sweats, all common symptoms of the menopausal transition and early menopause.

ORIGINAL RESEARCH—WOMEN'S SEXUAL HEALTH: Persistent Genital Arousal: Disordered or Normative Aspect of Female Sexual Response?

INTRODUCTION

Persistent genital arousal disorder (PGAD), previously known as persistent sexual arousal syndrome, is a serious and extremely distressing condition. Clinical experience suggests that there may be a subset of women who experience persistent genital arousal as a normative and not especially distressing part of their sexuality.

AIM

To determine whether there are women who report unprovoked genital arousal and view it as normative, and to identify differences between women who endorse all five features of PGAD vs. those who endorse only some of features.

MAIN OUTCOME MEASURES

Respondents were asked about the nature, onset, duration, and severity of their arousal, and their feelings about PGAD. Overall sexual and relationship satisfaction was assessed, as were scores on the Female Sexual Function Index (FSFI).

METHODS

An on-line, anonymous survey on persistent genital arousal was conducted. Of the 388 respondents, 206 women endorsed all five features of PGAD (PGAD group) and 176 endorsed some, but not all, criteria (non-PGAD group).

RESULTS

The two groups were similar in age, relationship status, and duration. More PGAD than non-PGAD women reported current symptoms and greater symptom severity. Distress ratings were significantly greater for PGAD than non-PGAD women (7.9 vs. 4.7 on a 10-point scale). Forty-eight percent of PGAD vs. 27% of non-PGAD women reported continuous feelings of arousal. Significantly more PGAD women than non-PGAD women endorsed negative feelings about their genital arousal. Women with PGAD reported lower desire, less sexual satisfaction, greater pain, and lower overall scores on the FSFI.

CONCLUSIONS

There is a cohort of women who regularly, if intermittently, experience unprovoked and persistent genital arousal and find it mildly pleasurable. Their genital arousal differs from that of women who meet all five criteria for a diagnosis of PGAD. Possible explanations and etiologies for these differing reactions are discussed.

Simultaneous Measurement of Pelvic Floor Muscle Activity and Vaginal Blood Flow: A Pilot Study

INTRODUCTION

Dyspareunia, defined as persistent or recurrent genital pain associated with sexual intercourse, is hypothesized to be related to pelvic floor hyperactivity and to diminished sexual arousal. Empirical research to support these hypotheses is scarce and concentrates mostly on the role of either pelvic floor activity or genital arousal in female dyspareunia. Currently, however, there is no measurement device to assess pelvic floor activity and genital response simultaneously.

AIM

The aim of this study was to investigate the validity of a new device that enables simultaneous measurement of pelvic floor activity and genital response in women.

MAIN OUTCOME MEASURES

Genital arousal measured as vaginal pulse amplitude, and vaginal surface electromyogram (EMG).

METHOD

Thirty sexually functional women participated. To investigate the accuracy of genital response measurement with the adapted photoplethysmograph, and the sensitivity of the device for involuntary changes in pelvic floor activity, vaginal pulse amplitude and vaginal surface EMG were monitored during exposure to emotional, including erotic, films. In addition, vaginal surface EMG was monitored during instructed pelvic floor contractions.

RESULTS

The genital data obtained during emotional films proved accurate measurement of genital response. EMG values during the emotional films indicated limited sensitivity of the device for small, involuntary changes in pelvic floor activity due to emotional state. The EMG measurements during the instructed pelvic floor contractions proved sensitivity of the new probe to voluntary pelvic floor activity.

CONCLUSION

It is concluded that following improvement of the sensitivity of the EMG measurement for small, involuntary changes in pelvic floor activity, the device will be a valuable tool in research on superficial dyspareunia.

Women's Endorsement of Models of Female Sexual Response: The Nurses' Sexuality Study

INTRODUCTION

The current Summary of Recommendations on Sexual Dysfunction in Women is conceptually grounded on a model of women's sexual function that has not been empirically tested in samples of women with and without sexual dysfunction.

AIM

The current research represents an initial effort to assess the extent to which women in a community sample endorse current theoretical models of female sexual function based upon work by Masters and Johnson, Kaplan, and Basson as accurately reflecting their own sexual experience.

MAIN OUTCOME MEASURES

Women's endorsement of brief descriptions of current models of female sexual function (Masters and Johnson, Kaplan, and Basson) as accurately reflecting their own sexual experience and their own levels of sexual function or dysfunction as assessed by the Female Sexual Function Index (FSFI).

METHODS

A random sample of 580 Registered Nurses was mailed a 58-item questionnaire which assessed women's perception of the fit of their sexual experience with current models of female sexual response and included the FSFI.

RESULTS

In total, 133 women, of whom 111 had a current man partner, returned responses. Approximately equal proportions of women endorsed the Masters and Johnson, Kaplan, and Basson models of female sexual response as representing their own sexual experience. Women endorsing the Basson model had significantly lower FSFI domain scores than women who endorsed either the Masters and Johnson or Kaplan models.

CONCLUSION

These are the first data to assess the proportion of a community sample of women who endorse widely accepted models of female sexual response as representing their own sexual experience. Women in this sample were equally likely to endorse each of these different models, emphasizing the heterogeneity of women's sexual response, and highlighting the need for additional research to guide the field's acceptance and application of particular models of female sexuality in particular situations. Women's endorsement of models of female sexual response was correlated with their FSFI scores, and findings suggest that the Basson model, currently advanced by the Second International Consultation on Sexual Medicine, may best reflect women with sexual concerns (e.g., FSFI < 26.55), rather than a single normative sexual response pattern.

The female sexual function index: a methodological critique and suggestions for improvement

The Female Sexual Function Index (FSFI) is a very well-worded sexual function screen with excellent psychometric qualities. However, some aspects of the scoring procedures pose conceptual and statistical problems, which we illustrate in part by way of an empirical example. The recommended solutions should further strengthen the utility and validity of this instrument.

Hormones and sexuality during transition to menopause

OBJECTIVE

To examine the relationship between reproductive hormonal dynamics and sexual dysfunction assessed in a cohort of women approaching menopause.

METHODS

Women in the Penn Ovarian Aging Study were assessed at yearly intervals for 3 years with early follicular hormone measurements (estradiol, follicle-stimulating hormone, luteinizing hormone [LH], sex hormone binding globulin, dehyroepiandrosterone sulfate [DHEAS], total testosterone), anthropometric measures, and extensive questionnaires including the Female Sexual Function Index. Univariable analyses were performed to determine the association between hormones, menopausal status, and sexual dysfunction. Multivariable linear and logistic regression models were created to examine the influence of hormones on sexual function adjusting for the effect of potential confounders.

RESULTS

The final multivariable model indicated that sexual dysfunction increased with advanced menopausal status, with postmenopausal women being 2.3 times as likely to experience sexual dysfunction compared with premenopausal women (odds ratio 2.3, 95% confidence interval [CI] 1.3-4.1). Low DHEAS serum concentrations were associated with decreased sexual function (odds ratio 1.59, 95% CI 1.19-2.14). Additional risk factors associated with sexual dysfunction included absence of a sexual partner (11.2, 95% CI 6.9-18.1), high anxiety (3.8, 95% CI 1.6-9.2), and children under the age of 18 living at home (1.6, 95% CI 1.1-5.5). Lubrication, orgasm, and pain were specific aspects of sexuality negatively affected by menopause.

CONCLUSION

This study confirms the observation that sexual dysfunction increases over the menopausal transition. Several factors associated with sexual dysfunction include low DHEAS, absence of a sexual partner, anxiety, and children under the age of 18 living at home.

LEVEL OF EVIDENCE

II.

Predictors of sexual and relationship functioning in couples with Chronic Prostatitis/Chronic Pelvic Pain Syndrome

INTRODUCTION

Both partners in a relationship are typically affected when one experiences sexual dysfunction and/or pain. However, couple functioning has rarely been investigated in Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS), a common condition in men involving pelvic pain and sexual dysfunction.

AIM

To identify potential predictors of sexual and relationship function among couples with CP/CPPS, and to examine associations among pain, sexual, and relationship variables in patients and their women partners.

METHODS

Thirty-eight patients with CP/CPPS and their women partners completed questionnaires assessing sexual and relationship function via mail.

MAIN OUTCOME MEASURES

Patients completed a subscale from the Multidimensional Pain Inventory and the International Index of Erectile Function. Partners completed the Female Sexual Function Index. All participants completed the Golombok-Rust Inventory of Sexual Satisfaction and the Dyadic Adjustment Scale.

RESULTS

Couples' sexual function, sexual satisfaction, and relationship adjustment were all significantly associated. Pain severity significantly predicted sexual and relationship functioning among couples. However, multiple regression models revealed that sexual and relationship variables were the strongest predictors of patient and partner functioning, over and above pain severity. Patient sexual function was predicted by patient sexual satisfaction and female sexual function, whereas female sexual function was predicted by female sexual satisfaction and patient relationship adjustment. With regard to sexual satisfaction, patient sexual function and relationship adjustment and female relationship adjustment predicted patient sexual satisfaction. Female sexual function predicted female sexual satisfaction. Among both patients and partners, relationship adjustment was significantly predicted by that of one's partner. The only partner variable that was significantly predicted by patient pain severity was female sexual function.

CONCLUSIONS

Significant links exist among the sexual and relationship functioning of patients with CP/CPPS and their partners. These results emphasize the importance of the interpersonal context on couples' functioning, and highlight the need to adopt a biopsychosocial approach when investigating CP/CPPS.

Sexual and relationship functioning in men with chronic prostatitis/chronic pelvic pain syndrome and their partners

This study compared the sexual and relationship functioning of 38 male patients with Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) to that of their female partners, and of both the men and women in these couples to those in 37 control couples. Male sexual function was also examined as a predictor of partner sexual function. In comparison to control males, the men with CP/CPPS reported significantly more sexual dysfunction and symptoms of depression. Furthermore, symptoms of depression mediated the relationship between some aspects of sexual function and male participant status as a patient or control. However, men with CP/CPPS did not report significantly decreased sexual satisfaction or relationship functioning compared to controls. Partners of men with CP/CPPS reported significantly more pain upon intercourse, vaginismus, and depressive symptoms when compared to control females. In addition, patients with CP/CPPS and their partners did not differ significantly from each other with regard to sexual functioning and satisfaction, relationship functioning, and symptoms of depression. Patient sexual functioning significantly predicted female partner sexual functioning. This study was the first to evaluate partners of men with CP/CPPS. Patients and partners in this study reported lower levels of sexual functioning in some domains, yet were comparable to control couples on measures of satisfaction and relationship functioning. Furthermore, the sexual and relationship functioning of patients and partners was significantly associated. The results of this study have implications for the assessment and management of CP/CPPS and for future research in this area.

Interstitial Cystitis and Female Sexual Dysfunction

OBJECTIVES

To use the Female Sexual Function Index (FSFI) to compare female sexual dysfunction in patients with interstitial cystitis/painful bladder syndrome (IC) with that in controls.

METHODS

Consecutive patients with IC and asymptomatic controls were tested for voiding diary voided volumes, Pelvic Pain and Urgency/Frequency Questionnaire scores, and FSFI scores.

RESULTS

Of the 97 subjects, 75 had IC and 22 were controls. The mean age was 38 and 43 years (P = 0.09), the voided volume was 165 mL and 294 mL (P <0.0001), and the Pelvic Pain and Urgency/Frequency Questionnaire score was 18 versus 3 (P <0.0001) for the IC and control groups, respectively. The total adjusted FSFI scores differed between patients with IC and the controls (20.2 +/- 9.6 versus 29.0 +/- 6.8, respectively, P <0.001). Using 26.55 as the cutpoint, 51 patients with IC (68%) had an abnormal FSFI score versus 3 controls (14%; P <0.001). Patients with IC scored worse on all domains of female sexual dysfunction than did the controls (P <0.01).

CONCLUSIONS

The results of our study have shown that female patients with IC have sexual dysfunction, including pain, more commonly than do controls.

Beyond the lower urinary tract: the association of urologic and sexual symptoms with common illnesses

OBJECTIVE

In addition to being prevalent and bothersome, urologic and sexual symptoms may be related to chronic medical illnesses. We investigate the relationship between ten urologic and sexual symptoms and four major illnesses (type II diabetes, cardiac disease, hypertension, and depression).

METHODS

We analyzed data from the Boston Area Community Health (BACH) survey, a community-based epidemiologic study of urologic symptoms and risk factors. BACH used a two-stage stratified cluster sampling design to recruit 5,506 adults aged 30-79 (2301 men, 3205 women; 1770 black, 1877 Hispanic, and 1859 white).

RESULTS

In bivariate analyses, most urologic and sexual symptoms were associated with type II diabetes, cardiac disease, hypertension, and depression. However, in multivariate models adjusting for all four illnesses, gender, race/ethnicity, age, alcohol intake, smoking, physical activity, and body mass index there were fewer significant associations. We found that all urologic symptoms were significantly related to at least one illness, with depression increasing the odds of all urologic and sexual symptoms studied.

CONCLUSIONS

Urinary tract specialists should consider factors outside the urinary tract that may be contributing to urologic symptoms. It remains unknown whether treatment of medical and psychological illnesses can result in meaningful improvement in urologic symptoms, or conversely, whether urinary tract symptoms can provide valuable insight into an individual's overall health status.

ORIGINAL RESEARCH—PSYCHOLOGY: Differences between Pre- and Postmenopausal Women in Cues for Sexual Desire

INTRODUCTION

Recently, McCall and Meston presented an assessment tool for empirically categorizing stimuli associated with sexual desire in women. Significant differences in cues resulting in sexual desire were found between women with and without hypoactive sexual desire disorder (HSDD).

AIM

The present study examined differences in cues resulting in sexual desire between pre- and postmenopausal women with and without sexual desire concerns using the Cues for Sexual Desire Scale (CSDS) which assesses four distinct aspects of desire motivators: (i) Love/Emotional Bonding Cues; (ii) Erotic/Explicit Cues; (iii) Visual/Proximity Cues; and (iv) Implicit/Romantic Cues.

MAIN OUTCOME MEASURES

The Female Sexual Function Index and the CSDS.

METHODS

Women included premenopausal women with no sexual concerns (N = 35), premenopausal women with low sexual desire (N = 30), postmenopausal women with no sexual concerns (N = 21), and postmenopausal women with low sexual desire (N = 39).

RESULTS

Consistent with prior findings, women with low sexual desire reported significantly less Love/Emotional Bonding Cues, Erotic/Explicit Cues, Implicit/Romantic Cues, and had significantly lower CSDS total scores as compared with women with no sexual difficulties. Postmenopausal women were more likely to report cues associated with Love/Emotional Bonding as compared with premenopausal women.

CONCLUSIONS

There were significant differences between women with and without sexual desire concerns in Love/Emotional Bonding Cues, Erotic/Explicit Cues, Implicit/Romantic Cues, and CSDS total scores. There were no significant differences between pre- and postmenopausal women in Erotic/Explicit Cues, Visual/Proximity Cues, or Implicit/Romantic Cues. Interestingly, postmenopausal women with and without HSDD endorsed more Love/Emotional Bonding Cues resulting in feelings of sexual desire as compared with premenopausal women.

Sexual desire and linguistic analysis: a comparison of sexually-abused and non-abused women

Although studies have identified a relationship between a history of child sexual abuse (CSA) and problems with hypoactive sexual desire, little is known about the potential cognitive and affective mechanisms involved in the sexual desire of women with a history of CSA. In this study, 27 women with a history of CSA and 22 women with no history of abuse were asked to write about sexual and non sexual topics. The Linguistic Inquiry Word Count software program was used to compute the percentage of words that fell into positive emotions, negative emotions, body, and sex categories. As expected, women with a history of CSA used more negative emotions words when writing about sexual topics, but not non-sexual topics, compared to non-abused women. Women with a history of CSA also used more sex words when writing about the non-sexual topics compared to non-abused women. Frequencies of body and sex words used in the sexual texts were positively linked to levels of sexual desire function. This association was not different between women with and without a history of CSA. A history of CSA remained an independent predictor of levels of sexual desire dysfunction even when taking into consideration the language used in the sexual texts, indicating that there may be aspects of the sexual desire experienced by women with a history of CSA that differ from non-abused women that remain unexplored.

Effect of breast augmentation mammoplasty on self-esteem and sexuality: a quantitative analysis

Although not extensively researched, psychologic factors have attributed to the growing number of performed breast augmentation procedures. The reported a 293% increase in the cases of cosmetic surgery since 1997. The percent increase in breast augmentation procedures performed in 2003 was up 12 (280 procedures up to 401). As the number of women seeking breast augmentation surgery continues to rise, an increasing number of healthcare professionals are likely to be confronted with questions, concerns, and complications that often accompany the procedure. Consequently, it is important that healthcare providers comprehend the degree to which self-esteem and/or sexuality may affect their patients' outcomes. Healthcare professionals must ascertain specific nursing skills and attitudes while caring for the cosmetic surgical patient. Therefore, the purpose of this research is to gain an understanding of the changes that occur in the levels of self-esteem and sexuality following the breast augmentation. Test of the study hypotheses 1 through 4 failed to be rejected, thereby supporting significant positive relationships between the variables. Statistical analysis of Hypothesis 5 found positive significance between breast augmentation, self-esteem, and the demographic variables-educational level and history of previous cosmetic surgery.

Influence of self-perceived incontinence severity on quality of life and sexual function in women with urinary incontinence

AIMS

We examined the impact of patient-perceived incontinence severity (PPIS) on health-related quality of life (QoL) and sexual function in women with urinary incontinence (UI).

METHODS

Patients were recruited from clinic practices at one hospital. Between May 2004 and June 2006, 353 women 27-79 years old (mean 55.7) underwent detailed evaluations. To obtain health-related QoL and sexual function assessments, the patients were asked to fill the questionnaires including the incontinence quality of life (I-QoL) and female sexual function index (FSFI). Patients were categorized into the three groups according to the PPIS; 'mild,' 'moderate,' and 'severe.'

RESULTS

Among groups, the duration of symptoms, rate of mixed UI, mean number of treatment visits over the past year, rate of UI associated without any activity, and Valsalva leak point pressure (VLPP) was significantly different (P < 0.05). The I-QoL total score and subscale scores deteriorated significantly as the PPIS increased (P < 0.001). Of the six domains in the FSFI questionnaire, four domains, namely, 'arousal' (P = 0.026), 'lubrication' (P = 0.012), 'orgasm' (P = 0.017), and 'pain' (P = 0.037) as well as the FSFI total score (P = 0.004) were significantly different among the groups.

CONCLUSIONS

Our findings suggest that PPIS significantly influences health-related QoL and sexual function, and that strategies for assessing PPIS should be incorporated for assessing patients with UI.

Female sexual dysfunction in essential hypertension: a common problem being uncovered

OBJECTIVES

Female sexual dysfunction (FSD) is increasingly attracting more scientific and public interest, and represents a poorly investigated issue in patients with essential hypertension. We evaluated the prevalence of sexual dysfunction in hypertensive women compared with normotensive women according to age, hypertension severity, hypertension duration, and antihypertensive treatment.

METHODS

The study population consisted of consecutive, sexually active women attending an outpatient hypertension clinic. The Female Sexual Function Index (FSFI questionnaire) was used to evaluate FSD. Univariate and multivariate analyses were used to evaluate predictors of FSD.

RESULTS

Four hundred and seventeen women were studied. From them, 216 women had arterial hypertension (136 treated, 80 untreated) and 201 were normotensive. Sexual dysfunction was found in 42.1% of hypertensive women compared with 19.4% of normotensive women (odds ratio, 3.2; 95% confidence interval, 1.9-4.7; P < 0.001). Systolic blood pressure levels were significantly related to FSFI score (r = -0.67, P < 0.001). Successful control of hypertension was related to lower prevalence of FSD. Increasing age (beta = -0.187, P = 0.001), increasing systolic blood pressure (beta = -0.687, P < 0.001), and beta-blocker administration (beta = -0.162, P = 0.001) were significant predictors of sexual dysfunction in this patient population.

CONCLUSIONS

FSD is more prevalent in women with essential hypertension compared with women with normal blood pressure, and its prevalence declines with adequate blood pressure control. Adequate control of hypertension with medication not affecting sexual function can have a great impact on the quality of life of hypertensive patients. Physicians should recognize and properly manage FSD in hypertensive women.

ORIGINAL RESEARCH—BASIC SCIENCE: A Prospective Study Examining the Anatomic Distribution of Nerve Density in the Human Vagina

INTRODUCTION

Women possess sufficient vaginal innervation such that tactile stimulation of the vagina can lead to orgasm. However, there are few anatomic studies that have characterized the distribution of nerves throughout the human vagina.

AIM

The aim of this prospective study was to better characterize the anatomic distribution of nerves in the adult human vagina. A secondary aim was to assess whether vaginal innervation correlates with the subject's demographic information and sexual function.

METHODS

Full-thickness biopsies of anterior and posterior vagina (proximal and distal), cuff, and cervix were taken during surgery in a standardized manner. Specimens were prepared with hematoxylin and eosin, and S100 protein immunoperoxidase. The total number of nerves in each specimen was quantified. Enrolled patients completed a validated sexual function questionnaire (Female Sexual Function Index, FSFI) preoperatively.

MAIN OUTCOME MEASURES

A description of vaginal innervation by location and an assessment of vaginal innervation in association with the subject's demographic information and sexual function.

RESULTS

Twenty-one patients completed this study, yielding 110 biopsy specimens. Vaginal innervation was somewhat regular, with no site consistently demonstrating the highest nerve density. Nerves were located throughout the vagina, including apex and cervix. No significant differences were noted in vaginal innervation based on various demographic factors, including age, vaginal maturation index, stage of prolapse, number of vaginal deliveries, or previous hysterectomy. There were no correlations between vaginal nerve quantity and FSFI domain and overall scores. Fifty-seven percent of the subjects had female sexual dysfunction; when compared to those without dysfunction, there were no significant differences in total or site-specific nerves.

CONCLUSIONS

In a prospective study, vaginal nerves were located regularly throughout the anterior and posterior vagina, proximally and distally, including apex and cervix. There was no vaginal location with increased nerve density. Vaginal innervation was not associated with demographic information or sexual function.

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.

REVIEW: Female Sexual Satisfaction and Pharmaceutical Intervention: A Critical Review of the Drug Intervention Studies in Female Sexual Dysfunction

INTRODUCTION

A considerable number of double-blind randomized controlled studies investigating the effects of pharmaceutical intervention on female sexual functioning have been published in recent years. However, a comparison between outcomes of various studies is difficult as no generally accepted/correct approach to research has been established yet. To be able to translate trial results to daily clinical practice, current limitations and issues in drug intervention studies in female sexual dysfunction (FSD) need to be clarified.

AIM

To evaluate the needs in research into intervention in FSD by reviewing published studies.

METHODS

A systematic review of double-blind randomized controlled intervention trials on FSD.

MAIN OUTCOME MEASURES

Definitions of study populations, inclusion and exclusion criteria, use of power calculations, outcome measures and treatment duration.

RESULTS

A total of 25 double-blind randomized controlled trials investigating the effects of pharmaceutical intervention on female sexual functioning have been published. Of these, 11 studies required the diagnosis of FSD as an inclusion criterion. A standard methodology for research in this field is lacking. Significant differences in population inclusion requirements and tools for the measurement of change in sexual functioning were identified as major limiting factors.

CONCLUSIONS

The investigation of FSD is an evolving area in that new definitions and a new model for female sexual functioning have been recently proposed. There is a need for experts in the field and regulating authorities to reach a consensus regarding appropriate inclusion and exclusion criteria for FSD trials and main outcome measures appropriate for the evaluation of drug interventions. This consensus should also determine which treatment effect is considered to be clinically relevant. Treatment efficacy and clinical relevance should be related to outcomes which are meaningful for affected women.

Cues resulting in desire for sexual activity in women

INTRODUCTION

A number of questionnaires have been created to assess levels of sexual desire in women, but to our knowledge, there are currently no validated measures for assessing cues that result in sexual desire. A questionnaire of this nature could be useful for both clinicians and researchers, because it considers the contextual nature of sexual desire and it draws attention to individual differences in factors that can contribute to sexual desire.

AIM

The aim of the present study was to create a multidimensional assessment tool of cues for sexual desire in women that is validated in women with and without hypoactive sexual desire disorder (HSDD).

METHODS

Factor analyses conducted on both an initial sample (N = 874) and a community sample (N = 138) resulted in the Cues for Sexual Desire Scale (CSDS) which included four factors: (i) Emotional Bonding Cues; (ii) Erotic/Explicit Cues; (iii) Visual/Proximity Cues; and (iv) Implicit/Romantic Cues.

MAIN OUTCOME MEASURES

Scale construction of cues associated with sexual desire and differences between women with and without sexual dysfunction.

RESULTS

The CSDS demonstrated good reliability and validity and was able to detect significant differences between women with and without HSDD. Results from regression analyses indicated that both marital status and level of sexual functioning predicted scores on the CSDS. The CSDS provided predictive validity for the Female Sexual Function Index desire and arousal domain scores, and increased cues were related to a higher reported frequency of sexual activity in women.

CONCLUSIONS

The findings from the present study provide valuable information regarding both internal and external triggers that can result in sexual desire for women. We believe that the CSDS could be beneficial in therapeutic settings to help identify cues that do and do not facilitate sexual desire in women with clinically diagnosed desire difficulties.

The Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS): psychometric properties within a Dutch population

The aim of the present study was to investigate the psychometric properties of the Female Sexual Function Index (FSFI; Rosen et al., 2000) and the Female Sexual Distress Scale (FSDS; Derogatis, Rosen, Leiblum, Burnett, & Heiman, 2002) within a Dutch population of approximately 350 women with and without sexual complaints. The main conclusions of this study are that the multidimensional structure of the FSFI and the unidimensional structure of the FSDS are fairly well replicated in a Dutch sample. The amount of variance explained by confirmatory and exploratory factor analyses was good. Internal consistency and stability of the FSFI and its subscales and the FSDS are satisfactory to good, and the subscales are reasonably stable across demographic variables. The discriminant validity and the ability of the scales to predict the presence or absence of sexual complaints was excellent. The convergent and divergent construct validity of the FSFI and the FSDS was good. These results support the reliability and psychometric validity of the FSFI and the FSDS in the assessment of dimensions of female sexual functioning and sexual distress in clinical and nonclinical samples.

Sexual function in patients presenting to a urogynecology practice

The purpose of this study was to evaluate sexual function in women referred to a urogynecology practice. All new patients were mailed an optional female sexual function index (FSFI) in conjunction with their history forms; other sexual function information was obtained during the physician interview. Over 6 months, four hundred fifty new patients were enrolled. Of these, 243 (54%) were not sexually active. Reasons listed for sexual inactivity included partner problems/no partner (32%), low desire (14%), prolapse (10%), and pain (10%). There were several differences between sexually active and non-sexually active participants; however, after a multivariate analysis, only age, marital status, and stage/grade 1-2 of prolapse remained significant. One hundred nine sexually active patients completed the FSFI; the majority was sexually active two to four times per month. Female sexual dysfunction was noted in 70 (64%) patients. Lowest scores were noted for the domain of desire, followed by arousal, orgasm, lubrication, satisfaction, and pain. Reduced frequency of intercourse was the only factor significantly associated with dysfunction. Ninety-four percent were not embarrassed by the survey. Overall, sexual inactivity is common in patients presenting for urogynecologic care. Those that are sexually active report low rates of sexual activity and high rates of sexual dysfunction. Most sexually active patients will accept a sexual function questionnaire as part of their routine assessment.

Urethral and Bladder Neck Injury Associated With Pelvic Fracture in 25 Female Patients

PURPOSE

We describe the presentation, diagnostic evaluation, management and outcome of female urethral trauma.

MATERIALS AND METHODS

All female patients treated at Harborview Medical Center between 1985 and 2001 with urethral injury were identified by International Classification of Diseases 9th revision code. Approval of the Human Subject Division was obtained and patient charts were reviewed. The Urogenital Distress Inventory Short Form, the Incontinence Impact Questionnaire Short Form and the Female Sexual Function Index were sent to the patients.

RESULTS

A total of 25 patients (13 adults, 12 children) with a mean age of 22 years (range 4 to 67) met inclusion criteria. All had pelvic fracture related to blunt trauma. They represented 6% of all female patients treated in the same review period with pelvic fracture. Blood was seen at the introitus in 15 patients and 19 had gross hematuria. Of the injuries 9 were avulsions, 15 were longitudinal lacerations and 1 was not further specified. Primary repair was performed in 21 patients and 4 were treated nonoperatively. There were 5 patients who required secondary procedures including fistula repair in 4 and continent urinary diversion in 1. At a mean followup of 7.3 years (range 1.6 to 14.4) 9 of 21 patients (43%) had moderate or severe lower urinary tract symptoms and 8 of 13 (38%) had sexual dysfunction (FSFI score less than 26.55).

CONCLUSIONS

Female urethral and bladder neck injury occurs with pelvic fracture, presents with gross hematuria and/or blood at the introitus, and requires operative repair for avulsions and longitudinal lacerations. These patients are at risk for significant sexual and lower urinary tract dysfunction.

The sensitivity of event logs, self-administered questionnaires and photoplethysmography to detect treatment-induced changes in female sexual arousal disorder (FSAD) diagnosis

INTRODUCTION

The literature provides little evidence on what type of endpoints should be used to assess treatment-induced improvement in female sexual function.

AIM

The main goal of this study was to provide empiric evidence on the sensitivity of different types of measures for detecting treatment-induced changes in female sexual dysfunction diagnosis.

METHODS

The measures investigated in this study included event logs, self-administered questionnaires (Female Sexual Functioning Index; FSFI), vaginal photoplethysmography, and continuous subjective sexual arousal measured during exposure to erotic videos. Participants were 24 women with female sexual arousal disorder (FSAD) who received sex therapy, placebo, or gingko biloba in a four-arm double-blind placebo-controlled clinical trial. FSAD was diagnosed utilizing a semistructured interview administered at pre- and post-treatment. Those women who did not meet FSAD criteria at post-treatment (N = 10) were labeled as "improved," while women who still met FSAD criteria (N = 14) were categorized as "not improved" even if they showed signs of improvements.

MAIN OUTCOME MEASURE

Change scores from pre- to post-treatment on the FSFI, event logs, vaginal photoplethysmography, and continuous subjective levels of sexual arousal were used to predict whether women improved at post-treatment. Results were checked with exact logistic regression to control for the small sample size.

RESULTS

The FSFI was the only measure to significantly predict whether women improved at post-treatment. The findings from this study lend support for the use of validated questionnaires as endpoint criteria in detecting treatment-induced changes in women's sexual dysfunction.

The prevalence of sexual dysfunction and associated risk factors in women with chronic pelvic pain: a cross-sectional study

The aims of the study were to determine the prevalence of sexual dysfunction, its subtypes and associated risk factors in women with chronic pelvic pain (CPP) as compared to a general female population. We evaluated 112 women (mean age 34.73 +/- 8.07; age range 18-50) complaining of CPP with a comprehensive history including female sexual function index (FSFI) and several general assessment questions (GAQs), a complete physical examination and routine laboratory tests. A group of 108 healthy women (mean age 33.28 +/- 7.95; age range 19-52) without CPP were enrolled as cross-sectional controls. According to the general population, the incidence of female sexual dysfunction (FSD) was 67.8% in women with CPP and 32.2% in women without CPP (P < 0.0001). Among 112 CPP patients, 78 (69.6%) of them had FSD and 34 (30.4%) patients did not have FSD in the study (P < 0.0001). In that 78 patients, 42 patients (53.8%) had hypoactive sexual desire disorder, 26 patients (33.3%) had sexual arousal disorder, 17 patients (21.7%) had orgasmic disorder and finally 58 patients (74.3%) had sexual pain disorder. The FSFI scores in both groups were as follows: (patients vs. controls; median value; P value, respectively): desire: 3.31 versus 3.98 (P < 0.0001); arousal: 3.58 versus 4.35 (P < 0.0001); lubrication: 4.20 versus 4.88 (P < 0.0001); orgasm: 3.70 versus 4.48 (P < 0.0001); sexual satisfaction: 3.80 versus 4.64 (P < 0.0001); sexual pain: 2.75 versus 4.98 (P < 0.0001) and total FSFI score: 21.35 versus 27.29 (P < 0.0001). The prevalence of FSD was higher in women with CPP than in a general healthy population not complaining of CPP. Investigation of female sexuality was essential for these patients.