Pelvic floor muscle training: mechanisms of action for the improvement of genitourinary syndrome of menopause.

Objective: This study aims to investigate the mechanism of action of pelvic floor muscle training (PFMT) for the improvement of the signs and symptoms of genitourinary syndrome of menopause (GSM) in postmenopausal women with GSM and urinary incontinence (UI).Methods: Twenty-nine women were included in the secondary analysis of a single-arm feasibility study. Using color Doppler ultrasound, the peak systolic velocity, time-averaged maximum velocity, and pulsatility index of the internal pudendal and dorsal clitoral arteries were measured at rest and after a pelvic floor muscle (PFM) contraction task. PFM function was assessed by dynamometry, and vulvovaginal tissue elasticity was measured using the Vaginal Atrophy Index.Results: PFMT significantly improved blood flow parameters in both arteries (p < 0.05) and significantly increased the speed of PFM relaxation after a contraction (p = 0.003). After the intervention, a marginally significant decrease in PFM tone was observed, as well as an increase in PFM strength (p = 0.060 and p = 0.051, respectively). Finally, improvements in skin elasticity and introitus width were observed as measured by the Vaginal Atrophy Index (p < 0.007).Conclusion: Our findings suggest that PFMT improves blood flow in vulvovaginal tissues, PFM relaxation capacity, and vulvovaginal tissue elasticity in postmenopausal women with GSM and UI.

Reliability of vulvar blood perfusion in women with provoked vestibulodynia using laser Doppler perfusion imaging and laser speckle imaging.

BACKGROUND: Microvascular assessment has become increasingly used in gynecology to better understand the pathophysiology of various vulvar conditions and to study sexual function. Alteration in blood perfusion of the vulvar area has been observed using laser technologies in women with provoked vestibulodynia (PVD), the leading cause of vulvar pain. However, no studies have thus far investigated the reliability of and agreement between lasers for evaluating vulvar blood perfusion. OBJECTIVES: The main objective was to investigate the between-session reliability of the laser Doppler perfusion imaging (LDPI) and laser speckle contrast imaging (LSCI) for assessing blood perfusion of the vulvar vestibule in women with PVD. Secondary aims were to evaluate the association and agreement between the two laser technologies. METHODS: Twenty-six women with PVD participated in the study. Blood perfusion of the vulvar vestibule was assessed with LDPI and LSCI during two sessions 2 to 4 weeks apart. Blood perfusion was analyzed in five specific areas of the vulvar vestibule: 1) 3 o'clock site, 2) 6 o'clock site, 3) 9 o'clock site, 4) central area (delimited by areas 1, 2 and 3), and 5) posterior fourchette. The reliability of the measurements of the two instruments was calculated with intraclass correlation coefficients (ICCs), standard errors of measurement (SEMs) and coefficients of variation (CVs). Paired t-tests were also computed to compare the CVs of each laser technology. The association and agreement between LDPI and LSCI measurements were evaluated by Pearson's correlation coefficients and Bland-Altman plots, respectively. RESULTS: Excellent reliability was found for LDPI (ICCs = 0.78-0.80, p < 0.001, SEMs = 16.1-47.9) and LSCI measurements (ICCs = 0.75-0.81, p ≤ 0.001, SEMs = 17.0-52.2) for all vulvar vestibule areas. However, CVs were significantly higher using LDPI (CVs = 15.1-19.8) when compared to LSCI (CVs = 7.0-11.6) for all areas (p ≤ 0.031), except for area 4 (p = 0.079). Significant correlations were found between LDPI and LSCI for all areas (r = 0.58-0.89, p ≤ 0.003). Bland-Altman plots revealed a systematic difference between LDPI and LSCI measurements. CONCLUSION: Findings show that both LDPI and LSCI measurements are reliable for assessing blood perfusion of the vulvar vestibule in women with PVD. The LSCI appears to be a more reliable measurement as it presents less variation than LDPI. Finally, although LDPI and LSCI measurements are related, the systematic difference observed between them makes it impossible to compare absolute units.

Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel.

Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.

Reduction of Hypertrophic Labia Minora by Posterior-Lateral Wedge Resection with Preservation of the Central Blood Vessels and Nerve Bundle.

OBJECTIVE: The aim of this study was to introduce a new method of labiaplasty. Here, we describe the surgical procedure, outcomes and the advantages of this method. METHOD: The medical records of 21 patients aged between 20 and 45 years who underwent reduction of the labia minora from February 2015 to June 2017 were reviewed. The procedures performed in these studies used posterior-lateral wedge resection with preservation of the central blood vessels and nerve bundle. RESULTS: All the surgeries were performed successfully, and 21 patients experienced an uneventful postoperative period. A minor dehiscence occurred in one patient, who recovered with no requirement for additional treatment. All of the patients were satisfied with the eventual esthetic appearance. CONCLUSION: The posterior-lateral wedge resection with preservation of the central blood vessels and nerve bundle is a simple and safe method that is associated with satisfactory outcomes. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Randomized crossover study investigating daily versus on-demand vulvar Visnadine spray in women affected by female sexual arousal disorder.

The aim of the study was to verify the efficacy of vulvar Visnadine spray in premenopausal women affected by female sexual arousal disorder (FSAD). Thirty-eight women aged 25-40 years affected by FSAD were enrolled in the randomized crossover study, by two possible sequences: on-demand, washout, daily (A sequence); and daily, washout, on-demand (B sequence). The Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) were used to assess sexual function and sexual distress, respectively. Color Doppler ultrasonography was used to measure clitoral blood flow. The study had two follow-ups at 30 (T1) and 60 days (T2). Thirty-one women completed the study. Mean (SD) sexual activity and vulvar Visnadine spray usage was 1 ± 0.9 weekly during on-demand administration for both the sequences (Vs T0, p = NS). The mean sexual activity during daily usage was 2 ± 0.9 (Vs T0, p < .004) and 2 ± 0.8 (Vs T0, p < .001) for A and B sequences, respectively. FSFI total score, particularly genital arousal, improved more during the daily than during on-demand phases of both sequences (p < .001). Finally, clitoral blood flow improved significantly during daily usage of both the sequences (p < .001). Our study suggests that vulvar Visnadine spray could improve sexual performance of women affected by FSAD, producing changes in subjective and objective sexual aspects.

Vulvar Varicosities: A Review.

BACKGROUND: Vulvar varicosities (VV) are dilated and tortuous veins occurring within the external female genitalia. Patients may seek treatment of these varices for both medical and cosmetic purposes. In some patients, VV may be associated with a chronic pelvic pain syndrome called pelvic congestion syndrome (PCS). OBJECTIVE: To review the English language literature on VV in both pregnant and nonpregnant women. MATERIALS AND METHODS: A literature search pertaining to vulvar varicosities and PCS was performed using PubMed and Google Scholar databases. RESULTS: There is an overall paucity of literature discussing VV, particularly in nonpregnant women without PCS. Management options for VV include compression, sclerotherapy, embolization, and surgical ligation. Treatment can be dependent on the coexistence of pelvic or leg varicosities and may require referral to a vein specialist for advanced imaging techniques and procedures. Direct sclerotherapy to VV may not provide adequate treatment if pelvic or leg varices are also present. CONCLUSION: In women with persistent VV, imaging studies should be obtained before treatment to evaluate the surrounding venous anatomy of the pelvis and leg, as the results often affect the treatment approach. Patients presenting with VV and chronic pelvic pain should be evaluated for PCS.

Short communication: Repeatability of ß-hydroxybutyrate measurements in capillary blood obtained from the external vulvar skin.

The primary objective of this study was to evaluate the repeatability of measurements of ß-hydroxybutyrate (BHB) concentrations in capillary blood obtained from minimal-invasive puncturing of different sites at the external vulva skin of dairy cows. A total of 240 multiparous cows sampled once within 21 d in milk were enrolled in the study. Capillary blood samples were obtained from the right and left labium of the external vulva skin and additionally from a site close to the first puncture. Samples were analyzed by using an electronic hand-held device [FreeStyle Precison Neo (FSP-Neo), Abbott GmbH & Co., Wiesbaden, Germany)]. Additionally, samples from a coccygeal vessel were analyzed as reference in a laboratory. Mean deviations (± standard deviation) between the 3 capillary sampling sites ranged from 0.01 ± 0.14 (left vs. right labium) to 0.02 ± 0.13 mmol/L (left or right labium vs. additional site). The BHB concentrations in capillary blood compared with the reference showed a mean deviation of 0.14 ± 0.18 mmol/L. The Spearman correlation coefficient between BHB concentrations in capillary blood and coccygeal blood was 85.4%. Mixed model analyses showed no significant effect of sampling site or squeezing the skin during sampling procedures on the differences toward the reference. Based on laboratory BHB concentrations of ≥1.2 and ≥1.4 mmol/L, respectively, the prevalence of hyperketonemia was 10.4 (n = 25) and 5.0% (n = 12). Thresholds to detect hyperketonemia with the FSP-Neo were optimized by receiver operating characteristic analyses. Based on a laboratory BHB concentration of ≥1.2 mmol/L thresholds were determined as 1.1 (left labium, 2nd puncture) and 1.0 mmol/L (right labium), with sensitivities between 94 and 99% and specificities between 89 and 97%. Based on a serum BHB concentration of 1.4 mmol/L, receiver operating characteristic analyses resulted in optimized cutoffs of 1.4 mmol/L for all sampling sites at the vulva, with sensitivities of 100% and specificities between 96 and 99%. In conclusion, vulvar capillary blood is suitable for accurate measuring of BHB concentrations by using the FSP-Neo. After adjusting the thresholds, the FSP-Neo provides very good test characteristics independent of the capillary sampling site or squeezing the skin and allows a practical and reliable screening tool for dairy cows.

Hair-thread tourniquet syndrome of the hypertrophic clitoris in a 6-year-old girl.

Hair-thread tourniquet syndrome is defined as the ischemic strangulation of hair resulting in edema and severe pain and may cause amputation of organs. Strangulation of the external genitalia (clitoris, labia minora) has rarely been described in girls. Here, we present a case of hypertrophic clitoris injury secondary to hair strangulation in a 6-year-old girl.

Staged endovascular and surgical treatment of slow-flow vulvar venous malformations.

OBJECTIVE: The objective of the study was to report our experience in a rare series of treated symptomatic slow-flow vulvar venous malformations (VVMs) using a staged, multidisciplinary approach. STUDY DESIGN: Consecutive patients with symptomatic lesions treated over a 7 year period (2005-2012) were followed up for technical success, resolution of symptoms, aesthetic outcomes, and complications. Direct endovenous sclerotherapy (DEVS) using sodium tetradecyl sulfate (STS) foam was performed in all patients under ultrasound and contrast-enhanced fluoroscopic guidance. Surgical excision and layered primary closure was performed within 24 hours after the last DEVS session. RESULTS: Eleven patients (mean age, 25 years; range, 4-43 years) were treated. Presenting symptoms included pain (n = 11), soft tissue swelling (n = 11), local heaviness (n = 11), dyspareunia (n = 2), and dysmenorrhea (n = 2). Most were isolated lesions (n = 8). There were 2 cases of Klippel-Trénaunay syndrome and 1 case of Maffucci syndrome. The latter required Nd:YAG laser photocoagulation prior to sclerotherapy. On average, approximately 3 DEVS sessions were required prior to surgical excision (range, 1-6). Mean estimated surgical blood loss was 130 mL (range, 20-400 mL). Mean follow-up was 23 months (range, 3-55 months). Elimination of pain and soft tissue redundancy was achieved in all patients with satisfactory aesthetic outcomes. All patients experienced minor pain and swelling after DEVS. Following surgical excision, there was 1 case of hematoma and wound dehiscence requiring surgical evacuation. No other reinterventions, endovascular or surgical, were required. CONCLUSION: VVMs require increased awareness and appropriate preoperative evaluation for proper identification and treatment. A multidisciplinary approach can provide improvement in clinical signs and symptoms with satisfactory cosmesis and minimal complications.

The pars intermedia: an anatomic basis for a coordinated vascular response to female genital arousal.

INTRODUCTION: The pars intermedia is an area of the vulva that has been inconsistently described in the literature. AIM: We conducted anatomic studies to better describe the tissues and vascular structures of the pars intermedia and proposed a functional rationale of the pars intermedia in the female sexual response. METHODS: Nine cadaveric vulvectomy specimens were used. Each was serially sectioned and stained with hematoxylin and eosin and Masson's trichrome. MAIN OUTCOME MEASURES: Histologic ultrastructural description of the pars intermedia. RESULTS: The pars intermedia contains veins traveling longitudinally in the angle of the clitoris, supported by collagen-rich stromal tissues. These veins drain the different vascular compartments of the vulva, including the clitoris, the bulbs, and labia minora; also, the interconnecting veins link the different vascular compartments. The pars intermedia is not composed of erectile tissue, distinguishing it from the erectile tissues of the corpora cavernosa of the clitoris as well as the corpus spongiosum of the clitoral (vestibular) bulbs. CONCLUSIONS: The venous communications of the pars intermedia, linking the erectile tissues with the other vascular compartments of the vulva, appear to provide the anatomic basis for a coordinated vascular response during female sexual arousal.

Sexual arousal in women with provoked vestibulodynia: the application of laser Doppler imaging to sexual pain.

Introduction. Women with provoked vestibulodynia (PVD) report lower sexual arousal than nonaffected women, however, laboratory studies of arousal have reported contradictory results about whether group differences exist in genital and subjective arousal. Aim. To examine genital and subjective sexual arousal in women with and without PVD. Methods. Eligible women with and without PVD (N = 42) attended a laboratory session that included an interview, questionnaire completion, and genital imaging. A direct measure of superficial blood flow-laser Doppler imaging-was used to assess vulvar blood flow levels while participants watched three films, including an erotic film. Participants answered questions about their level of sexual arousal before, during, and after the erotic film. Main Outcome Measures. Average vulvar blood flow levels during the baseline and erotic films, numerical ratings of subjective sexual arousal and anxiety, as well as questionnaire measures of arousal. Results. There was a significant group difference in genital arousal, whereby the PVD group showed a lower genital response to the erotic film, as well as a significant interaction between baseline blood flow and group membership. Separate group regression analyses demonstrated that baseline blood flow explained a substantial amount of the variance in erotic film blood flow in the control group (70%), while only 27% was explained by this variable in the PVD group. There were no differences in subjective sexual arousal or anxiety between the groups. Across questionnaire measures, women with PVD reported lower sexual arousal than the control group. Conclusions. The results suggest that women with PVD show lower genital responsiveness than nonaffected women to sexual stimuli in a laboratory setting and that their genital arousal is likely impacted by a number of biopsychosocial factors. Boyer SC, Pukall CF, and Chamberlain SM. Sexual arousal in women with provoked vestibulodynia: The application of laser Doppler imaging to sexual pain. J Sex Med **;**:**-**.

Hair tourniquet syndrome.

A 6-year-old girl presented with necrosis of the left labium minus. An encircled hair at the base of the lesion was seen, and the diagnosis genital hair tourniquet syndrome was made. Genital hair tourniquet syndrome in children is a rare but potentially severe syndrome that requires immediate medical attention to prevent resulting necrosis.

An unusual site for calciphylaxis: a case report.

BACKGROUND: Calciphylaxis is a rare condition characterized by calcification of the tunica media of small arteries with or without endovascular fibrosis, extravascular calcification and vascular thrombosis, leading to tissue ischemia and hence necrosis of tissues supplied by respective vessel. CASE REPORT: An 83-year-old lady presented with a 2-week history of rapidly progressing painful necrotic vulval lesion. This patient was being treated medically with bisphosphonates for mild hypercalcaemia secondary to a parathyroid adenoma. The diagnosis of calciphylaxis was made by biopsy of lesion, revealing extensive necrotic areas and multiple abscesses with numerous thrombosed and calcified blood vessels. CONCLUSIONS: This case shows an unusual presentation of calciphylaxis, in a patient with primary hyperparathyroidism, in the absence of end stage renal failure. The pathogenesis of the condition is still relatively unknown. Particularly of note in this case is the presentation of the lesion 9 months after the start of treatment with bisphosphonate after the relative decrease of serum parathyroid levels and serum calcium levels. This leads to the question of initiation of the pathology - did the bisphosphonate treatment have an input in initiation of the lesion? The case under review adds a new differential diagnosis to necrotic vulval lesions, other than malignancy.

Labial hair tourniquet: unusual complication of an unrepaired genital laceration.

Hair tourniquet syndrome has been recognized as a medical entity since the 1600 s. Appendages develop acute ischemia from tightening of hair strands circumferentially wrapped around them. Most commonly affected sites are fingers, toes, and penis, but limited reports have described involvement of the female genitalia. Although hair strangulation involving the labia minora or clitoris has been described, it typically occurs in young children. We present a case of an adolescent girl with a labial appendage hair tourniquet resulting from a previous unrepaired genital laceration. This is one of the oldest patients in whom a genital hair tourniquet has been reported, as well as description of a posttraumatic genital appendage. Genital hair tourniquets are medical emergencies that require prompt diagnosis and treatment to avoid tissue necrosis and possible amputation. Genital trauma in general requires surgical evaluation.

Pilot study of the suitability of dorsal vulval skin as a transposition flap: vascular anatomic study and clinical application.

OBJECTIVE: To identify the blood supply to the vulval fold and adjacent skin, and evaluate it as a transposition flap for closing perineal wounds in dogs. STUDY DESIGN: Prospective study. ANIMALS OR SAMPLE POPULATION: Five female canine cadavers and 2 cases referred for excision of mast cell tumors adjacent to the vulva. METHODS: Dissection was performed to identify the vascular supply to the vulval fold in two cadavers following arterial injection of red latex and methylene blue, respectively. In three cadavers, barium sulfate mixed 1:1 with water was injected into the terminal aorta. The vulval fold and surrounding perineal skin was excised and radiographed. Transposition flaps using the vulval fold and adjacent skin were used to close skin defects in two dogs presented for wide excision of mast cell tumors situated ventro-lateral and dorso-lateral to the vulva, respectively. RESULTS: The vulval fold and adjacent skin was perfused bilaterally by branches of the ventral perineal and external pudendal arteries, which entered dorsally and ventrally, respectively. As incisions used to create a transposition flaps from the skin surrounding the vulval fold transect these vessels, the flap is dependent on the sub-dermal plexus for survival. There was 100% survival of transposition flaps in the 2 clinical cases and healing proceeded uneventfully with acceptable cosmetic and functional results. CONCLUSIONS: The vulval fold and surrounding skin can be used as a subdermal plexus flap to close large perineal defects in dogs. CLINICAL RELEVANCE: Availability of a defined local skin flap will improve treatment of diseases resulting in large perineal skin defects in female dogs.

Characterization of the vasculature supplying the genital tissues in female rats.

INTRODUCTION: The internal pudendal arteries are the key resistance vessels controlling the peripheral circulatory component of sexual responses in both male and females. Previous studies in the male rat demonstrated that this vessel has markedly heightened susceptibility to vascular damage compared with other vessels in the body. Evidence suggests that the female may also be susceptible to vascular pathologies contributing to sexual dysfunction. AIM: The aim of this study is to characterize the anatomical, morphological, and functional properties of the pudendal artery in female rats. METHODS: The pelvic arteries in young Sprague-Dawley female rats were dissected to generate a composite representation of the vascular gross anatomy. Morphometry was performed on perfusion-fixed pudendal arteries whereas others were mounted in a wire myograph to assess responses to vasoactive drugs. These measures were contrasted with a previous study examining male rats. MAIN OUTCOME MEASURES: Outcome measures used are gross anatomy, lumen diameter, wall thickness, cross-sectional area, and contractile responses in the internal pudendal artery. RESULTS: The gross anatomy of the pudendal artery in female rats appears to parallel that found in male rats, acting as the primary feeder vessel of the clitoral, labial, and vaginal tissue. Compared with the male rat, the female pudendal artery has a smaller lumen diameter (169 ± 5.7 vs. 303 ± 13.8 µm), wall thickness (14 ± 0.7 vs. 47 ± 2.2 µm), and cross-sectional area (8 ± 0.4 vs. 52 ± 3.4 × 103 µm(2) ). These structural differences also translate into a decreased contractile capacity of the pudendal arteries from female rats vs. male rats (8.1 ± 2.7 vs. 20 ± 1.4 mN). CONCLUSIONS: Although the gross anatomical features of the vasculature tree supplying the genital tissue in male and female rats appear to have similarities, the tissue-specific properties of the vessel itself have a very different structure-function balance. We hypothesize that this discordance likely reflects the very different sex-specific roles of this vessel in regulating blood flow during arousal.

Management of a Klippel-Trenaunay syndrome in pregnant women with mega-cisterna magna and splenic and vulvar varices at birth: a case report.

Klippel-Trenaunay syndrome (KTS) is a rare, sporadic and complex malformation characterized by the clinical triad of: (i) capillary malformation (port-wine stain); (ii) soft tissue and bone hypertrophy or occasionally, hypertrophy of one lower limb; and (iii) atypical lateral varicosity. The maternal and fetal risks associated with pregnancy in women with KTS are proportional to disease severity, which can be exacerbated by pregnancy. Complications include bleeding, disseminated intravascular coagulation, thromboembolic events and pain. Here, we report the case of a pregnant woman with KTS who had an uneventful pregnancy, labor and postpartum course, but had splenic and large vulvar vein varices. The obstetrical course of women with KTS varies. Management is largely conservative and multidisciplinary approaches form the mainstay for managing these patients based on their symptoms.

Spontaneous vulvar hematoma during pregnancy: a case report.

BACKGROUND: Vulvar hematoma is a relatively uncommon occurrence. Most have been described resulting from traumatic injury in nonpregnant women or as an uncommon complication of childbirth. We describe a case of a spontaneous 6-cm vulvar hematoma that presented as unexplained vulvar edema in a 35-weeks-pregnant woman. CASE: A pregnant woman presented to the obstetrics triage unit with rapid onset unilateral vulvar swelling and no preceding traumatic event. A detailed physical examination and radiologic evaluation revealed a spontaneous vulvar hematoma as the cause. After incision and drainage of the hematoma, her edema resolved and the patient went on to have an uneventful vaginal delivery 4 weeks later. CONCLUSION: Spontaneous vulvar hematoma is a rare event. Rapid recognition and treatment in this case allowed for complete recovery and enabled this pregnant woman to continue a normal pregnancy with uncomplicated spontaneous vaginal delivery.

Cigarette smoking decreases the genital vascularization in young healthy, eumenorrheic women.

INTRODUCTION: Cigarette smoking is a major health hazard and may impair the normal sexual response. AIM: To evaluate (in the early follicular phase, and independently from sexual stimulation) in young, eumenorrheic, healthy, lean women the general and genital vascular effects of the smoking habit. METHODS: One hundred thirty-seven patients undertook, in the early follicular phase of the menstrual cycle (day 3-5): the administration of the two-factor Italian McCoy Female Sexuality Questionnaire (MFSQ); two-dimensional (2-D) color Doppler evaluation of the ophthalmic, carotid, uterine, clitoral, and labia minora arteries; three-dimensional (3-D) analysis of clitoral and labia minora vascularization; and blood pressure evaluation. Fasting blood samples were drawn to test plasma estradiol, androstenedione, and testosterone circulating levels. MAIN OUTCOME MEASURES: The two-factor Italian MFSQ; the pulsatility index (PI) of internal carotid, ophthalmic, uterine, clitoral, and labia minora arteries; the vascularization index (VI), the flow index (FI), and the vascularization flow index (VFI) of clitoral body and labia minora, blood pressure measurement, and hormonal assay. RESULTS: The subjects were divided in: nonsmokers (Group I; N=72); current (>2 years) light smokers-1 to 10 cigarettes/day-(Group II; N=35); and current heavy smokers->10 cigarettes/day-(Group III; N=30). The 2-D Doppler analysis of the ophthalmic and internal carotid arteries showed significant increased resistance in Group III compared with Group II and Group I. The genital vessels (uterine, clitoral, and labium minus arteries) showed the lowest PIs in the nonsmokers. The 3-D power Doppler histogram analysis of clitoral and labium minus blood flow showed the worst vascular indices (VI, FI, VFI) in the heavy smokers. CONCLUSIONS: Cigarette smoking may favor a reduced central and peripheral tissue perfusion with consequent increased risk of cerebrovascular and cardiovascular diseases and with genital vessels stiffness and impaired sexual performances.