Sildenafil improves sexual functioning in premenopausal women with type 1 diabetes who are affected by sexual arousal disorder: a double-blind, crossover, placebo-controlled pilot study

Sexual dysfunction in women living with HIV: an updated narrative review

INTRODUCTION

Female sexual dysfunction is a significant concern for many women worldwide, with chronic health conditions such as HIV infection contributing to its prevalence. However, there is a paucity of studies focusing this subject in the available literature.

OBJECTIVES

This narrative review aimed to provide a comprehensive and updated overview of the current state of knowledge regarding sexual dysfunction in women living with HIV (WLWH).

METHODS

References for this review were identified from MEDLINE, Embase, and Cochrane databases using the search terms "sexual dysfunction" AND "HIV" AND "female" OR "woman." The final reference list was generated based on the timeline, originality, and relevance to the scope of this narrative review.

RESULTS

In the general population, female sexual function is influenced by various factors, including biological, psychological, physiological, sociocultural, and relational ones. In WLWH, the role of antiretroviral therapy in female sexual dysfunction is controversial. Although current international guidelines recommend collecting a thorough sexual life anamnesis during routine outpatient visits, sexual difficulties are often inadequately addressed.

CONCLUSION

A tailored clinical approach that focuses on the multidimensional domains of sexual dysfunction may improve the sexual health and quality of life in WLWH.

A Review of Antidiabetic Medicinal Plants as a Novel Source of Phosphodiesterase Inhibitors: Future Perspective of New Challenges Against Diabetes Mellitus

Intracellular glucose concentration plays a crucial role in initiating the molecular secretory process of pancreatic β-cells through multiple messengers and signaling pathways. Cyclic nucleotides are key physiological regulators that modulate pathway interactions in β -cells. An increase of cyclic nucleotides is controled by hydrolysed phosphodiesterases (PDEs), which degrades cyclic nucleotides into inactive metabolites. Despite the undeniable therapeutic potential of PDE inhibitors, they are associated with several side effects. The treatment strategy for diabetes based on PDE inhibitors has been proposed for a long time. Hence, the world of natural antidiabetic medicinal plants represents an ideal source of phosphodiesterase inhibitors as a new strategy for developing novel agents to treat diabetes mellitus. This review highlights medicinal plants traditionally used in the treatment of diabetes mellitus that have been proven to have inhibitory effects on PDE activity. The contents of this review were sourced from electronic databases, including Science Direct, PubMed, Springer Link, Web of Science, Scopus, Wiley Online, Scifinder and Google Scholar. These databases were consulted to collect information without any limitation date. After comprehensive literature screening, this paper identified 27 medicinal plants that have been reported to exhibit anti-phosphodiesterase activities. The selection of these plants was based on their traditional uses in the treatment of diabetes mellitus. The review emphasizes the antiphosphodiesterase properties of 31 bioactive components derived from these plant extracts. Many phenolic compounds have been identified as PDE inhibitors: Brazilin, mesozygin, artonin I, chalcomaracin, norartocarpetin, moracin L, moracin M, moracin C, curcumin, gallic acid, caffeic acid, rutin, quercitrin, quercetin, catechin, kaempferol, chlorogenic acid, and ellagic acid. Moreover, smome lignans have reported as PDE inhibitors: (+)-Medioresinol di-O-β-d-glucopyranoside, (+)- Pinoresinol di-O-β-d-glucopyranoside, (+)-Pinoresinol-4-O-β-d-glucopyranosyl (1→6)-β-dglucopyranoside, Liriodendrin, (+)-Pinoresinol 4'-O-β-d-glucopyranoside, and forsythin. This review provides a promising starting point of medicinal plants, which could be further studied for the development of natural phosphodiesterase inhibitors to treat diabetes mellitus. Therefore, it is important to consider clinical studies for the identification of new targets for the treatment of diabetes.

Pharmaceutical and Energy-Based Management of Sexual Problems in Women

This article summarizes and critiques the evidence for use of available pharmacotherapies (vasoactive, psychoactive, and hormonal medications) and energy-based therapies (laser, radiofrequency, shockwave, and neurostimulation) for treatment of female sexual dysfunction. The enthusiasm with which energy-based treatments for sexual dysfunction have been adopted is disproportionate to the amount of data currently available to support their clinical use. Pharmacotherapy for female sexual dysfunction has considerably more research evidence to justify its use. Patients must be empowered to make an informed, autonomous determination as to whether the risk/reward ratio favors the use of pharmacotherapy, energy-based therapy, or some other treatment intervention.

Oncology Survivorship and Sexual Wellness for Women

Sexual dysfunction is extremely common in cancer survivors. Cancer survivors are living longer, and survivorship issues like sexual functioning are now a part of routine cancer care. Oncology providers need to be as comfortable assessing and addressing these issues as they would any other aspect relating to cancer care. Providers should know how to perform an evaluation for sexual dysfunction, understand basic treatment options, and have appropriate referrals available to ensure that the patient's needs are met. This review provides an overview of sexual dysfunction pertaining to women who are survivors of cancer and articulates areas needing further research.

Ultrastructural Study of Clitoral Cavernous Tissue and Clitoral Blood Flow From Type 1 Diabetic Premenopausal Women on Phosphodiesterase-5 Inhibitor

BACKGROUND

The effects of phosphodiesterase-type 5 (PDE5) inhibitors on the in vivo clitoral structure of women with diabetes have never been investigated.

AIM

To study the in vivo structural and hemodynamic changes of the clitoris in premenopausal women with type 1 diabetes on PDE5 inhibitors.

METHODS

38 premenopausal women with type 1 diabetes aged 36 -46 years. A randomized 1:1 study design was used: Study Group (group A) on Tadalafil 5 mg daily, and control group (group B). Blood samples were taken from each woman to measure HbA1c, testosterone, and Free Androgen Index. The women underwent microbiopsy of the clitoral body by means of semiautomatic gun during total anesthesia for surgery therapy of a benign gynecological pathology. The tissue removed was processed for electron microscopy. Translabial color Doppler ultrasound was used to measure the peak systolic velocity (PSV), the end diastolic velocity (EDV), and the pulsatility index (PI) of clitoral arteries.

MAIN OUTCOME MEASURES

Micro-ultrastructure observation of clitoral tissue and color Doppler sonography of clitoral blood flow.

RESULTS

Of the 38 women, 13 (68.4%) of group A and 15 (78.9%) of group B completed the study. Group A showed a mean PSV and EDV increase, and a mean PI decrease with respect to baseline (P < .001). Group B did not show any change in both the parameters (P = NS). By a quantitative study in both groups a variable degree of ultrastructural abnormalities of smooth muscle cells (SMCs) was observed, consisting in increased glycogen and lipoic deposits, cytoplasmic vacuoles, and focal increase of electron density of SMCs. Moreover, the mean SMC thickness of group A (1.83 ± 0.68 µm) was larger than that of group B (1.3 ± 0.41 µm) (P = .02).

CLINICAL IMPLICATIONS

PDE5 inhibitors could be used to treat diabetic women with genital arousal disorder.

STRENGTHS & LIMITATIONS

The study shows a clear effect of PDE5 inhibitors on clitoral SMCs. However, a limit was to not have investigated the sexual function/behavior of women of both groups, this was because of the short time of the study.

CONCLUSION

This study could help to understand in what way PDE5 inhibitors act on the ultrastructural pathophysiological clitoral cavernous tissue of women with diabetes. It could support PDE5 inhibitor usage in women with genital sexual arousal disorder due to metabolic diseases. Caruso S, Cianci A, Cianci S, et al. Ultrastructural Study of Clitoral Cavernous Tissue and Clitoral Blood Flow From Type 1 Diabetic Premenopausal Women on Phosphodiesterase-5 Inhibitor. J Sex Med 2019;16:375-382.

Efficacy and tolerability of a spray formulation containing Visnadine in women self-reporting sexual symptoms: a randomized double-blind placebo-controlled pilot study

PURPOSE

The aim of this pilot, double-blind, randomized, placebo-controlled study, was to evaluate both the efficacy and the tolerability of a formulation for vulvar application containing Visnadine, a natural extractive substance with vasoactive properties, (ReFeel^® spray, IDI Integratori Dietetici Italiani S.r.l., Italy) in women self-reporting sexual symptoms.

METHODS

Sixty women (age range 18-60 years) volunteered to test the product against placebo (PL): Two puffs in the vulvar area, 10 min before sexual stimulation, for 30 days and for a minimum of six times. The main outcome measure was the improvement of the Female Sexual Function Index (FSFI) score (cut-off ≤ 26.55 for female sexual dysfunction [FSD]). Secondary outcomes were sexual satisfaction and tolerability with the product.

RESULTS

PL group (n = 28) and Visnadine group (n = 30) were comparable for age, sexual function and rate of FSD at baseline (T0). After 1 month (T1), women in Visnadine group scored from 25.0 ± 3.8 to 27.9 ± 2.4 (p < 0.001), whereas no changes were evident in PL group (from 25.4 ± 5.0 to 25.6 ± 4.7). Statistically significant differences at T1 were reported in women with a positive (p < 0.001) or a negative FSD diagnosis (p < 0.01) using active treatment. Women with FSD reported significantly more improvement in satisfaction with their sexual function when treated with Visnadine spray compared to PL (p < 0.001), as well as more excitation (p < 0.001), pleasure (p < 0.001) and less time to reach orgasm (p < 0.003). No significant side effects were evident in both groups.

CONCLUSIONS

On demand, 1-month use of Visnadine spray displayed positive effects on sexual function in women with and without FSD and it was well tolerated. Topical Visnadine may not only be part of multimodal strategies to manage clinically relevant sexual symptoms but also simply to help women to enhance their subjective impaired perception of sexual response.

Sex Differences in the Treatment of Sexual Dysfunction

PURPOSE OF REVIEW

Sex differences in the treatment of sexual dysfunction are partly due to neurobiological differences, as well as, the central and peripheral physiological effects of hormones and neurotransmitter actions on reproductive systems in men and women. Differences in epidemiology of complaints and diagnostic considerations, variance in medical comorbidities, and interference from related medications also contribute to the need for different strategies for treatments of sexual dysfunction according to gender.

RECENT FINDINGS

Flibanserin and ospemifene are new medication treatment options that may help some women with symptoms of sexual dysfunction. Various therapies are available to address sexual dysfunction and sex differences are relevant to consider, in terms of diagnosis, effectiveness of treatments, and side effect profiles that may help determine indication, safety, and outcomes for specific treatments.

Female Sexual Dysfunction-Medical and Psychological Treatments, Committee 14

INTRODUCTION

Since the millennium we have witnessed significant strides in the science and treatment of female sexual dysfunction (FSD). This forward progress has included (i) the development of new theoretical models to describe healthy and dysfunctional sexual responses in women; (ii) alternative classification strategies of female sexual disorders; (iii) major advances in brain, hormonal, psychological, and interpersonal research focusing on etiologic factors and treatment approaches; (iv) strong and effective public advocacy for FSD; and (v) greater educational awareness of the impact of FSD on the woman and her partner.

AIMS

To review the literature and describe the best practices for assessing and treating women with hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders.

METHODS

The committee undertook a comprehensive review of the literature and discussion among themselves to determine the best assessment and treatment methods.

RESULTS

Using a biopsychosocial lens, the committee presents recommendations (with levels of evidence) for assessment and treatment of hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders.

CONCLUSION

The numerous significant strides in FSD that have occurred since the previous International Consultation of Sexual Medicine publications are reviewed in this article. Although evidence supports an integrated biopsychosocial approach to assessment and treatment of these disorders, the biological and psychological factors are artificially separated for review purposes. We recognize that best outcomes are achieved when all relevant factors are identified and addressed by the clinician and patient working together in concert (the sum is greater than the whole of its parts). Kingsberg SA, Althof S, Simon JA, et al. Female Sexual Dysfunction-Medical and Psychological Treatments, Committee 14. J Sex Med 2017;14:1463-1491.

Survivorship, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology

Many cancer survivors experience menopausal symptoms, including female survivors taking aromatase inhibitors or with a history of oophorectomy or chemotherapy, and male survivors who received or are receiving androgen-ablative therapies. Sexual dysfunction is also common in cancer survivors. Sexual dysfunction and menopause-related symptoms can increase distress and have a significant negative impact on quality of life. This portion of the NCCN Guidelines for Survivorship provide recommendations for screening, evaluation, and treatment of sexual dysfunction and menopausal symptoms to help healthcare professionals who work with survivors of adult-onset cancer in the posttreatment period.

Flavonoid glycosides isolated from Epimedium brevicornum and their estrogen biosynthesis-promoting effects

Epimedium brevicornum Maxim has a long history of use in the treatment of estrogen deficiency-related diseases. However, the chemical constituents and mechanism of action of this medicinal plant are not fully understood. In the present study, we isolated four new isoprenylated flavonoid glycosides, as well as 16 known flavonoids (13 isoprenylated flavonoids), from this plant. The chemical structures of the new flavonoid glycosides were elucidated by extensive spectroscopic analysis. The new compounds 1–4 were potent promoters of estrogen biosynthesis in human ovarian granulosa-like KGN cells. ZW1, an isoprenylated flavonoid analogue and a specific inhibitor of phosphodiesterase 5 (PDE5), was synthesized and used to explore the mechanism of the isoprenylated analogues on estrogen biosynthesis. ZW1 treatment increased estrogen production by upregulation of aromatase mRNA and protein expression. ZW1 increased the phosphorylation of cAMP response element-binding protein (CREB). Further study showed that the inhibition of PDE5 by ZW1 increased estrogen biosynthesis partly through suppression of phosphodiesterase 3 (PDE3). Our results suggested that the isoprenylated flavonoids from E. brevicornum may produce beneficial health effects through the promotion of estrogen biosynthesis. PDE5 warrants further investigation as a new therapeutic target for estrogen biosynthesis in the prevention and treatment of estrogen-deficiency related diseases.

The Physiology of Female Sexual Function and the Pathophysiology of Female Sexual Dysfunction (Committee 13A)

INTRODUCTION

The article consists of six sections written by separate authors that review female genital anatomy, the physiology of female sexual function, and the pathophysiology of female sexual dysfunction but excluding hormonal aspects.

AIM

To review the physiology of female sexual function and the pathophysiology of female sexual dysfunction especially since 2010 and to make specific recommendations according to the Oxford Centre for evidence based medicine (2009) "levels of evidence" wherever relevant.

CONCLUSION

Recommendations were made for particular studies to be undertaken especially in controversial aspects in all six sections of the reviewed topics. Despite numerous laboratory assessments of female sexual function, genital assessments alone appear insufficient to characterise fully the complete sexual response.

Sexual Dysfunction and Intimacy for Ostomates

Sex and intimacy presents special challenges for the ostomate. Since some colorectal surgery patients will require either temporary or permanent stomas, intimacy and sexuality is a common issue for ostomates. In addition to the stoma, nerve damage, radiotherapy, and chemotherapy are often used in conjunction with stoma creation for cancer patients, thereby adding physiological dysfunction to the personal psychological impact of the stoma, leading to sexual dysfunction. The purpose of this paper is to describe the prevalence, etiology, and the most common types of sexual dysfunction in men and women after colorectal surgery and particularly those patients with stomas. In addition, treatment strategies for sexual dysfunction will also be described.

The clinical relevance of sexual dysfunction in systemic sclerosis

Systemic sclerosis is a chronic multi-organ autoimmune disease, leading to important clinical and psychological implications. Among organ complications, sexual dysfunction is a major issue for both male and female gender, with high prevalence and great impact on quality of life, although frequently not addressed by both clinicians and patients. While erectile dysfunction is the most common cause of sexual problems in males, genital tract and general physical changes are major contributors to sexual impairment in females. This review presents current state of the art on this topic, discussing published data on presentation, evaluation and therapeutic options.

Comparison of the Effects of Elaeagnus angustifolia Flower Capsule and Sildenafil Citrate Tablet on Anxiety Resulting From Sexual Dysfunction in Women Referring to the Selected Clinics of Shiraz University of Medical Sciences

Dissatisfaction from sexual relationships can result in deprivation as well as problems, such as depression, anxiety, and destruction of family’s mental health. One hundred twenty-five women (18 to 40 years) who suffered from hypoactive sexual desire disorder were divided into Elaeagnus angustifolia flower (4.5 g g daily for 35 days), sildenafil citrate tablet (50 mg for 4 weeks), and control groups. The study data were collected using the Female Sexual Function Index and Spielberger’s questionnaire and measurement of thyroid-stimulating hormone and prolactin hormone. In the Elaeagnus angustifolia group, the mean score of state and trait anxiety decreased after the intervention. In the sildenafil citrate group also, the mean score of state anxiety decreased from 22.15 ± 4.98 to 20.1 ± 5.15 ( P = .001) and that of trait anxiety decreased from 23.07 ± 4.44 to 21.55 ± 4.82 ( P = .002) after the intervention. Consumption of sildenafil citrate tablet was effective in reduction of the mean score of anxiety resulting from sexual dysfunction.

Phosphodiesterase-5 inhibitors for erectile dysfunction in patients with diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Patients with diabetes mellitus frequently experience erectile dysfunction. This systematic review and meta-analysis were conducted to find efficacy and tolerability of phosphodiesterase 5 (PDE5) inhibitors in patients with diabetes mellitus experiencing erectile dysfunction.

METHODOLOGY

Electronic searches were carried out to identify English language peer-reviewed randomized controlled trials (RCTs), which reported clinical efficacy of any PDE5 inhibitor in patients with diabetes mellitus having erectile dysfunction. Effect sizes were computed using Cohen's d, and I(2) -test was used to assess heterogeneity. Pooled mean effect sizes were computed using random-effects model. Number needed to treat (NNT), and the adverse event rates were computed.

RESULTS

The systematic review included a total of 17 studies yielding 25 comparisons. Three studies were open RCTs while others were double-blind RCTs. The pooled mean effect size of any PDE5 inhibitor over placebo was 0.926 (95% confidence intervals [CI]: 0.864-0.987; I(2) =26.3). The pooled mean effect size for sildenafil was 1.198 (CI: 1.039-1.357; I(2) =0), for tadalafil was 0.910 (CI: 0.838-0.981; I(2) =33.6), and for vardenafil was 0.678 (CI: 0.627-0.729; I(2) =0). In pooled analysis, the NNT for sildenafil, tadalafil, vardenafil and any PDE5 inhibitor was 2.4, 2.6, 4.1 and 3.0 respectively. The most common side effects were headache, flushing, and nasal congestion.

CONCLUSIONS

PDE5 inhibitors are effective and safe medications for the treatment of sexual dysfunction in patients with diabetes mellitus experiencing erectile dysfunction.

Women taking the "blue pill" (sildenafil citrate): such a big deal?

For years, phosphodiesterase type 5 inhibitors have been used for the treatment of erectile dysfunctions. Due to the similarities between male and female sexual response, several studies have assessed the effects of sildenafil citrate (Viagra^®) in women affected by female sexual arousal disorder. The results are still conflicting and the drug is not devoid of adverse effects. Furthermore, female sexual arousal disorder is a heterogeneous condition whose underlying causes are difficult to diagnose and appropriate treatment requires a thorough sexual, psychological, and medical history along with specialist consultations. The clinician should pursue a global approach to the patient with sexual difficulties, while non-hormonal treatment such as phosphodiesterase type 5 inhibitors (ie, sildenafil citrate) should be kept as the last option.

Survivorship: sexual dysfunction (female), version 1.2013

Cancer treatment, especially hormonal therapy and therapy directed toward the pelvis, can contribute to sexual problems, as can depression and anxiety, which are common in cancer survivors. Thus, sexual dysfunction is common in survivors and can cause increased distress and have a significant negative impact on quality of life. This section of the NCCN Guidelines for Survivorship provides screening, evaluation, and treatment recommendations for female sexual problems, including those related to sexual desire, arousal, orgasm, and pain.

Pharmacologic therapy for female sexual dysfunction

Female sexual dysfunction (FSD) is a common health issue that can have significant negative effects on overall well-being and quality of life. The primary purpose of this article is to review commonly noted pharmacologic therapies for FSD. The pathophysiology, clinical evaluation, and selected nonpharmacologic therapies are also briefly addressed as well as recommendations for practice.

An update on the pharmacological management of female sexual dysfunction

INTRODUCTION

Female sexual dysfunction (FSD) is a global health issue, with as many as 12% of women over 18 years old reporting sexual difficulties associated with distress. It is a multifaceted problem with psychological and biological causes. Affected women tend to have an impaired quality of life, a decreased level of well-being and relationship issues. Hence there is a need for management options for affected women.

AREAS COVERED

This paper focuses on current pharmacological options for the treatment of FSD, particularly estrogens and androgens, which have been extensively studied. Some investigational drugs are also described, including the centrally acting agents such as flibanserin and bupropion, and intravaginal DHEA and testosterone, which may be useful as an alternative for women with specific conditions, such as breast cancer survivors.

EXPERT OPINION

Although approval for the use of testosterone for treatment of FSD is limited to some European countries and restricted to surgically menopausal women, there is extensive off-label use for this purpose. No other product has yet achieved regulatory approval for treatment of FSD. Completion of studies of nonhormonal FSD therapies and safety studies of testosterone may result in regulatory approval of such products for the treatment of FSD in the near future.

Female reproduction and type 1 diabetes: from mechanisms to clinical findings

BACKGROUND

The functional reproductive alterations seen in women with type 1 diabetes (T1D) have changed as therapy has improved. Historically, patients with T1D and insufficient metabolic control exhibited a high prevalence of amenorrhea, hypogonadism and infertility. This paper reviews the impact of diabetes on the reproductive axis of female T1D patients treated with modern insulin therapy, with special attention to the mechanisms by which diabetes disrupts hypothalamic-pituitary-ovarian function, as documented mainly by animal model studies.

METHODS

A comprehensive MEDLINE search of articles published from 1966 to 2012 was performed. Animal model studies on experimental diabetes and human studies on T1D were examined and cross-referenced with terms that referred to different aspects of the gonadotropic axis, gonadotrophins and gonadal steroids.

RESULTS

Recent studies have shown that women with T1D still display delayed puberty and menarche, menstrual irregularities (especially oligomenorrhoea), mild hyperandrogenism, polycystic ovarian syndrome, fewer live born children and possibly earlier menopause. Animal models have helped us to decipher the underlying basis of these conditions and have highlighted the variable contributions of defective leptin, insulin and kisspeptin signalling to the mechanisms of perturbed reproduction in T1D.

CONCLUSIONS

Despite improvements in insulin therapy, T1D patients still suffer many reproductive problems that warrant specific diagnoses and therapeutic management. Similar to other states of metabolic stress, T1D represents a challenge to the correct functioning of the reproductive axis.

Disorders in sexual desire and sexual arousal in women, a 2010 state of the art

In this contribution, female sexual desire and arousal disorders are viewed from the perspective of incentive motivation and information processing models of sexual response. The effects of hormones, somatic disease, and medication on sexual arousability are discussed, as well as the influence of psychological factors, such as stimulus meaning, mood and cognition, and relational context on female sexual desire and arousal. Specific topics to attend to during the anamnesis of sexual desire and arousal problems, and empirically evaluated psychological and pharmacological treatments for these problems are discussed.

UK-414,495, a selective inhibitor of neutral endopeptidase, potentiates pelvic nerve-stimulated increases in female genital blood flow in the anaesthetized rabbit

BACKGROUND AND PURPOSE

Female sexual arousal consists of a number of physiological responses resulting from increased genital blood. Vasoactive intestinal peptide (VIP), neuropeptide Y and to a lesser extent nitric oxide are neurotransmitters found in the vasculature of the genitalia. Neutral endopeptidase (NEP) modulates the activity of neuropeptides including VIP. The aim of this study was to investigate the control of genital blood flow by VIP and endogenous neuropeptides using a selective NEP inhibitor [UK-414,495, ((R)-2-({1-[(5-ethyl-1,3,4-thiadiazol-2-yl) carbamoyl]cyclopentyl}methyl) valeric acid)].

EXPERIMENTAL APPROACH

Vaginal and clitoral blood flow (VBF and CBF) were monitored using laser Doppler in terminally anaesthetized New Zealand rabbits. Increases in VBF and CBF were induced by either electrical stimulation of the pelvic nerve or by i.v. infusion of VIP.

KEY RESULTS

Stimulation of the pelvic nerve increased VBF and CBF, compared with basal flow. Increases were mimicked by infusion of exogenous VIP. UK-414,495 dose-dependently potentiated pelvic nerve-stimulated increases in VBF (EC(50)= 37 +/- 9 nM; 3.6 x IC(50) rabbit NEP). Nerve-stimulated increases in VBF and CBF were both enhanced after UK-414,495. UK-414,495 increased the amplitude and duration of VIP-induced increases in VBF. UK-414,495 had no effect on basal VBF or cardiovascular parameters.

CONCLUSIONS AND IMPLICATIONS

Inhibition of NEP potentiates pelvic nerve-stimulated increases in genital blood flow. This suggests that the endogenous neurotransmitter mediating genital blood flow is a substrate for NEP (most likely VIP). NEP inhibitors may restore sexual arousal in women adversely affected by female sexual arousal disorder.

Sexual Function of Women with Chronic Illness and Cancer

Addressing the sexual sequelae of chronic disease and its treatment is now accepted as a fundamental part of healthcare. Most of the sexual effects of chronic disease are negative, and ongoing illness continues to modulate a woman's sexual self-image, energy and interest in sexual activity, as well as her ability to respond to sexual stimuli with pleasurable sensations, excitement, orgasm and freedom from pain with genital stimulation or intercourse. Nevertheless, for many women with chronic illness, sexuality remains extremely important despite the commonly associated fatigue and acquired sexual dysfunctions; sexual resilience can be substantial. Following recovery from cancer surgery, chemotherapy and radiation, prognosis can be excellent and a return to full health can often be expected, and yet, there may have been devastating changes to sexual function owing to the cancer treatment. Women with metastatic disease may still treasure sexual intimacy. Assessment and management of sexual dysfunction is therefore necessary in all women with chronic illness or past or present cancer.

Quality of life and sexual changes after double transobturator tension-free approach to treat severe cystocele

OBJECTIVES

To study the quality of life and sexual function changes of women affected by severe cystocele and treated with the double transobturator tension-free approach.

STUDY DESIGN

23 women (mean age 60.6) with third and fourth degree cystocele (according to Baden and Walker classification) were monitored by Short Form-36 (SF-36) and Pelvic Organ Prolapse/Urinary Incontinenece Sexual Questionnaire (PISQ-12) before and 12 months after surgical treatment. Each woman also underwent translabial color Doppler ultrasonography to measure the Resistance Index (RI), Pulsatility Index (PI), Peak Systolic Velocity (PSV), and End-Diastolic Velocity (EDV) of the clitoral arteries, before surgery and 12 months postoperatively.

RESULTS

SF-36 showed a considerable increase in all of the categories (physical functioning, physical role functioning, bodily pain, general health, vitality, social functioning, emotional role functioning, and mental health) compared to those obtained at baseline (P<0.05). PISQ-12 also showed a considerable increase in the behavioural emotive factor score, in the physical factor score, in the partner-related factor score and, consequently, in the total score compared to that obtained at baseline (P<0.05). Color Doppler measurement showed that the mean Pulsatility Index, Peak Systolic Velocity, Resistance Index and End-Diastolic Velocity were not significantly lower to those obtained at baseline (P=NS).

CONCLUSIONS

Double transobturator tension-free approach to treat severe cystocele considerably improves quality of life and sexual function, and does not significantly influence clitoral blood flow. Our data could add new information about sexual behaviour after prolapse treatment, particularly about the impact on clitoral blood flow changes.

Standards for clinical trials in sexual dysfunction in women: research designs and outcomes assessment

INTRODUCTION

Clinical trial design in female sexual dysfunction (FSD) is an evolving science, with some areas of controversy.

AIM

To develop an evidence-based, expert consensus-report on design of FSD clinical research.

METHODS

Literature review including the Food and Drug Administration (FDA) clinical trial guidelines with critique by six experts from three countries, modified after public presentation and debate.

MAIN OUTCOME MEASURE

Expert opinion and recommendations were based on grading of evidence based literature, internal committee dialogue, open presentation, and debate.

RESULTS

Design of clinical research for regulatory approval is driven by FDA guidelines. Diagnostic and Statistical Manual-IV definitions and consideration of comorbidity of sexual disorders may complicate patient selection and outcomes. Measures for study end points include satisfying sexual events utilizing a daily diary, sexual distress, and patient-reported outcomes measures of the construct under study. Currently, trial duration is recommended to be 6 months for efficacy trials to allow for modification of behavioral adaptations to changes in desire. Important issues include safety assessments, generalizability, having a representative study population, stratification by reproductive status, partner assessment, contextual and interpersonal factors, symptom duration and severity, management of placebo response, and drug dosing. Statistical analysis should include assessment of change from baseline to end point between study drug and placebo, determination of statistically significant change vs. clinically meaningful effects, linear mapping of all measures of the same construct, and determination of responders and remitters.

CONCLUSIONS

Future trials should include clear population definitions, direct and indirect measures of the specific FSD construct, and procedures to allow generalizability of diagnosis and treatment to the target population.

Sildenafil citrate for female sexual arousal disorder: a future possibility?

Female sexual arousal disorder (FSAD) is a common disorder encountered in clinical practice, with self-reported arousal difficulties reported in up to 26% of American women. Various oral therapies for FSAD have been studied, including sildenafil citrate, a phosphodiesterase inhibitor that is currently used to treat male erectile dysfunction. In vitro studies of sildenafil citrate have demonstrated smooth-muscle relaxation in clitoral tissue, and phosphodiesterase type-5 has been shown to be present in vaginal, clitoral and labial smooth muscle; these findings have led to theories that sildenafil citrate might be successful for treating FSAD. This Review discusses the data from clinical trials that have assessed sildenafil citrate for the treatment of FSAD; the trials show that sildenafil citrate is moderately effective. Sildenafil citrate may also be effective in women with FSAD secondary to multiple sclerosis, diabetes or antidepressant use; however, more trials in these patient populations are required to confirm these findings.

Phosphodiesterase type 5 inhibitors and female sexual response: faulty protocols or paradigms?

INTRODUCTION

Phosphodiesterase type 5 inhibitors (PDE5), such as sildenafil, tadalafil, and vardenafil, have revolutionized the treatment of erectile dysfunction. Few successes, in contrast, have been reported for the use of these agents in treatment of sexual arousal problems in women.

AIM

To review research examining efficacy of PDE5 in women, critique the methods and models employed, and integrate the findings within a broader, gender-specific understanding of female sexual response.

METHODS

A conceptual and methodological review of all published studies examining PDE5 efficacy in female samples.

MAIN OUTCOME MEASURES

Study methods, populations, outcome measures, study results.

RESULTS

A total of 16 studies were reviewed. Studies using self-reported measures of sexual functioning showed mixed results whereas studies examining physiological effects of PDE5 on genital vasocongestion consistently report significant effects on genital sexual response.

CONCLUSIONS

The lack of efficacy of PDE5 treatment in women is likely attributable to gender differences in the concordance between physiological and psychological components of sexual response. Discordance between genital and subjective measures of sexual response in women may be augmented by PDE5 effects on genital vasocongestion in some populations, rendering successful treatment unlikely via pharmacological treatment alone.

Assessing the clinical efficacy of sildenafil for the treatment of female sexual dysfunction

OBJECTIVE

To review the clinical data regarding the efficacy and safety of sildenafil for the treatment of female sexual dysfunction (FSD).

DATA SOURCES

A MEDLINE search from 1950 to February 2009 was conducted using the key words sildenafil and female sexual dysfunction. Human studies and publication in English were used as primary limits. A combination of several publication-type limits was used to locate the clinical trials (eg, clinical trial, controlled clinical trial, randomized clinical trial). A bibliographic search was also performed of all located articles.

STUDY SELECTION AND DATA EXTRACTION

Clinical trials involving sildenafil treatment of premenopausal and postmenopausal women with FSD and women with FSD due to concomitant medications and/or disease states were reviewed.

DATA SYNTHESIS

An increasing number of clinical trials have been published regarding the treatment of FSD with sildenafil. Eight studies demonstrated a possible benefit from treatment for FSD in patients receiving sildenafil, regardless of dose, while 4 trials did not show any significant differences with treatment. It appears that sildenafil might be beneficial for women with FSD caused by diseases such as multiple sclerosis, type 1 diabetes, spinal cord injury, and use of antidepressant medications.

CONCLUSIONS

Although data suggest a possible role of sildenafil for the treatment of FSD, the information should be interpreted cautiously, as many of the studies included small sample sizes, used inappropriate statistical tests, and used nonvalidated assessment tools. A better FSD classification system and consistent use of validated assessment tools might help alleviate differences among clinical trials and provide a more cohesive foundation for assessing the safety and efficacy of sildenafil for the treatment of FSD.

A literature review and case reports series on the use of phosphodiesterase inhibitors in the treatment of female sexual dysfunction

Summary

The term ‘female sexual dysfunction’ (FSD) encompasses a number of different disorders, and while their aetiologies are not fully understood, the sub-classifications of this broad umbrella term are increasingly becoming more established and accepted. However, there is less consensus regarding the optimal treatment of these conditions. While it is known that phosphodiesterase (PDE5) is involved in the female sexual response, the clinical and research evidence supporting the unlicensed use of PDE5 inhibitors (PDE5i) in women is inconclusive and at times contradictory. In this article we explore this further by means of a comprehensive literature review on the use of PDE5i in the treatment of FSD and we also present our clinical experience of using these drugs in this context.

Erectile dysfunction and lower urinary tract

During the last decades it turned out that the NO/cGMP signaling cascade is one of the most prominent regulators of a variety of physiological and pathophysiological processes in a broad range of mammalian tissues. Thus cGMP is a key second messenger and targeting this pathway by increasing intracellular cGMP levels is a very successful approach in pharmacology as shown for nitrates, PDE5 inhibitors and more recently for stimulators of the guanylate cyclase. Besides the beneficial effects of cGMP elevation in cardiac, vascular, pulmonary, renal or liver disorders the launch of PDE5 inhibitors for the treatment of erectile dysfunction 10 years ago, has directed a lot of attention to the NO/cGMP signaling in the lower urinary tract. Triggered by the use of PDE5 inhibitors in ED it turned out that cGMP is a common regulatory mechanism for lower urinary tract function also beyond ED. In recent years intense research and development efforts were undertaken to elucidate the role of the NO/cGMP and to fully exploit the therapeutic implications of cGMP elevation in urological disorders in ED and beyond. Therefore we have summarized the effects of cGMP elevation for treatment of erectile dysfunction in males and in females. We have also reviewed the recent pre-clinical and clinical lines of evidence for treatment options of benign prostatic hyperplasia and lower urinary tract symptoms in male patients and overactive bladder and urinary incontinence in female patients. In addition we also touch more speculative concepts using cGMP elevating drugs for the treatment of premature ejaculation, peyornies disease and stone disease.

Physiologic measures of sexual function in women: a review

OBJECTIVE

To review and describe physiologic measures of assessing sexual function in women.

DESIGN

Literature review.

SETTING

Studies that use instruments designed to measure female sexual function.

PATIENT(S)

Women participating in studies of female sexual function.

INTERVENTION(S)

Various instruments that measure physiologic features of female sexual function.

MAIN OUTCOME MEASURE(S)

Appraisal of the various instruments, including their advantages and disadvantages.

RESULT(S)

Many unique physiologic methods of evaluating female sexual function have been developed during the past four decades. Each method has its benefits and limitations.

CONCLUSION(S)

Many physiologic methods exist, but most are not well-validated. In addition there has been an inability to correlate most physiologic measures with subjective measures of sexual arousal. Furthermore, given the complex nature of the sexual response in women, physiologic measures should be considered in context of other data, including the history, physical examination, and validated questionnaires. Nonetheless, the existence of appropriate physiologic measures is vital to our understanding of female sexual function and dysfunction.

Oral phosphodiesterase type 5 inhibitors: nonerectogenic beneficial uses

INTRODUCTION

Phosphodiesterase type 5 (PDE5) hydrolyses cyclic guanylate monophosphate (cGMP) specifically to 5' GMP. PDE5 inhibitors were a breakthrough medication that addressed a previously unfulfilled medical need. They promoted vascular relaxation in the corpora cavernosa and penile erection during sexual stimulation. Sildenafil, vardenafil, and tadalafil were approved then introduced as effective treatments for male erectile dysfunction. This impact has stimulated academic, clinical, and industrial research.

AIM

To highlight the nonerectogenic beneficial uses of oral PDE5 inhibitors.

METHOD

A systematic review of published studies in this affair based on a Pubmed and medical subject heading databases search of all concerned articles.

MAIN OUTCOME MEASURES

Demonstrated beneficial as well as applicable uses of oral PDE5 inhibitors.

RESULTS

As chemical molecules, these drugs were shown to exert potential nonerectogenic beneficial effects. They showed efficacy as a useful adjunct in the management of pulmonary hypertension. Additional uses were extended to different utilities: essential hypertension, benign prostatic hyperplasia, gastrointestinal disorders, endothelial dysfunction, female sexual dysfunction, genital blood flow, exercise capacity, Raynaud's phenomenon, sperm motility, etc.

CONCLUSION

Exploring PDE5 inhibitors for their possible medical applications in diverse specialties seems to be beneficial in making use of these molecules for the welfare of humanity.