Understanding the sexual health perceptions, concerns, and needs of female partners of prostate cancer survivors.

BACKGROUND: Prostate cancer (PCa) and its treatments can have a significant negative impact on the sexual health of survivors and couples, but few studies have specifically examined the impact of PCa-related sexual dysfunction on female partners of survivors. AIM: Our objective was to perform a qualitative study to comprehensively characterize female partners' perceptions of the implications of PCa on their sex lives, as well as partners' sexual health concerns and unmet needs. METHODS: We conducted semi-structured telephone interviews about sexual health and unmet needs with female partners of PCa survivors recruited from multiple clinical locations and support groups for PCa caregivers from September 2021 to March 2022. Interviews were audio-recorded, transcribed verbatim, and independently coded. Participants were recruited until thematic saturation was achieved. OUTCOMES: Outcomes of this study were female partner sexual health concerns and unmet needs. RESULTS: Among 12 participants, the median age was 65 (range 53 to 81) years, 9 were White, the median time since their partner's PCa diagnosis was 2.25 years (range 11 months to 20 years), and a majority reported that their partner had undergone radical prostatectomy, radiation, and/or hormonal therapy. Major emergent themes pertained to the significant impact of age- and PCa-related sexual dysfunction on female sexual quality of life, the dyadic nature of sexual dysfunction and recovery, the role of the partner in coping with and adjusting to sexual dysfunction, difficulties communicating about sexual dysfunction in an intimate relationship, a lack of physician-led sexual health counseling and support, and the benefit of peer interactions and proactive information seeking in addressing unmet sexual health needs. CLINICAL IMPLICATIONS: Future efforts should continue to explore the impact of PCa on partner sexual health and address unmet needs through sexual health education and support. STRENGTHS AND LIMITATIONS: In this study, we identified female partners' sexual health concerns both related to and independent of PCa survivor sexual health. Limitations include exclusion of male partners of survivors and potential responder bias, as partners who agreed to participate may have experienced more sexual health concerns. CONCLUSION: We found that female partners experience PCa-related sexual dysfunction as a couple's disease, grief due to age- and PCa-related sexual losses, and a lack of physician-led sexual health counseling and information. Our results highlight the importance of including partners of PCa survivors in the sexual recovery process and of developing sexual care programs to address partners' unmet sexual health needs.

Predictors of Worsening Erectile Function in Men with Functional Erections Early After Radical Prostatectomy.

BACKGROUND: Prior studies suggest that men with good erectile function shortly after radical prostatectomy (RP) can subsequently have worsened erectile function. AIM: To determine the prevalence and predictors of early erectile function recovery post-RP and of worsening erectile function after initial erectile function recovery. METHODS: We retrospectively queried our institutional database. Men who underwent RP during 2008-2017 and who completed the International Index of Erectile Function erectile function domain both pre-RP and serially post-RP, constituted the population. Functional erections were defined as International Index of Erectile Function (IIEF)-6 erectile function domain scores ≥24. We analyzed factors predicting functional erections at 3 months post-RP as well as factors predicting a decrease in functional erections between 3 and 6 months, defined as ≥2-point drop in the erectile function domain. Multivariable logistic regression models were used to identify predictors of early erectile function recovery and also of subsequent decline. OUTCOMES: Erectile function recovery rates at 3 months post-RP and predictive factors; rates of erectile function decline between 3-6 months and associated predictors. RESULTS: Eligible patients comprised 1,655 men with median age of 62 (IQR 57, 67) years. Bilateral nerve-sparing (NS) surgery was performed in 71% of men, unilateral NS in 19%, and no NS in 10%. Of this population, 224 men (14%; 95% CI 12%, 15%) had functional erections at 3 months post-RP. On multivariable analysis, significant predictors of early erectile function recovery included: younger age (OR 0.93, P < .001), higher baseline erectile function domain score (OR 1.14, P < .001) and bilateral NS (OR 3.81, P = .002). The presence of diabetes (OR 0.43, P = .028) and a former smoking history (OR 0.63, P = .008; reference group: never smoker) was associated with the erectile dysfunction at 3 months post-RP. Of the men with early functional erections, 41% (95% CI 33%, 48%) had a ≥ 2-point decline in erectile function between 3 and 6 months. No factors were identified as predictors for this decline. CLINICAL IMPLICATIONS: Only a small proportion of men have functional erections at 3 months post-RP and a notable number of them will experience a decline in erectile function between 3 and 6 months. STRENGTHS AND LIMITATIONS: Strengths: large patient population and the use of validated questionnaire. LIMITATIONS: single-center retrospective study. CONCLUSION: A minority of men had functional erections 3 months post-RP, about half of whom had a decline in erectile function by month 6. We recommend appropriately counseling post-RP patients on the risk of such a decline in erectile function. Salter CA, Tin AL, Bernie HL, et al. Predictors of Worsening Erectile Function in Men with Functional Erections Early After Radical Prostatectomy. J Sex Med 2022;19:1790-1796.

Unmet Sexual Health Needs of Patients and Female Partners Following Diagnosis and Treatment for Prostate Cancer.

BACKGROUND: Prostate cancer (PCa) and its treatment can have significant and pervasive sexual side effects for patients and their partners; however, partner needs are not well understood, and most resources do not incorporate partner priorities. AIM: Our objective was to perform a qualitative study to identify unmet sexual needs of patients and female partners after PCa diagnosis. METHODS: We conducted a qualitative study of posts to the Inspire Us TOO Prostate Cancer Online Support and Discussion Community. Overall, 6,193 posts were identified in the Sexual Health & Intimacy forum of the community, of which 661 posts were from female authors. A random sample of 10% (n = 66) of posts from female partners and an equal number of randomly selected posts from male patients were analyzed. OUTCOMES: We assessed sexual health themes among patients and female partners. RESULTS: Multiple themes emerged that were unique to female partners of PCa survivors. These included expanding the sexual repertoire, feeling invisible, contextualizing sexual intimacy within the broader picture of survival, and addressing relationship concerns. Patients and their partners also shared common sexual health themes, including coming to terms with changes in sexual function and frustration with clinicians. Both patients and their partners use online health communities to get support and share their experiences with sexual recovery and use of sexual aids. Psychosocial treatments were infrequently mentioned, and may be particularly helpful to address partner concerns. CLINICAL IMPLICATIONS: A common concern for couples was not receiving sufficient information from healthcare providers regarding sexual side effects from PCa and its treatment. STRENGTHS AND LIMITATIONS: Strengths of the study include leveraging a unique data source to address an understudied topic of sexual health concerns among partners after PCa diagnosis. However, members of an online community may not be representative of all couples facing PCa. Also, this analysis is limited to female partners of patients with PCa, and further study is underway to examine the sexual health needs among gay and bisexual couples. CONCLUSION: Both patients and female partners have many unmet sexual health needs during PCa survivorship, and designing interventions to incorporate partner perspectives may improve the management of sexual side effects of PCa for couples. Li R, Wittmann D, Nelson CJ, et al. Unmet Sexual Health Needs of Patients and Female Partners Following Diagnosis and Treatment for Prostate Cancer. J Sex Med 2022;19:1797-1803.

Predictors of Curvature Improvement in Men With Peyronie's Disease Treated With Intralesional Collagenase Clostridium Histolyticum.

INTRODUCTION: Penile curvature is the most common abnormality that is observed by men with Peyronie's disease (PD). Collagenase Clostridium histolyticum (CCH) has become a standard treatment for PD patients. AIM: To identify predictor factors associated with improvements of penile curvature outcomes in men with PD treated with CCH. METHODS: We retrospectively collected the data of patients with PD treated with CCH up to 8 injections divided into 4 cycles between January 2014 and July 2020. Per protocol, penile curvature was assessed at baseline, and after the second and ford CCH cycle. If after cycle 2, curvature demonstrated no improvement, or penile curvature was significantly improved and the patient was happy, no further treatment was recommended. However, if penile curvature was significantly improved and the patient remained dissatisfied, 4 cycles were completed. Three categories of response were evaluated: improvement (≥10 degrees or ≥20%, either 1 happens), unchanged (±10 degrees or ±20%) or worsened (≥10 degrees or ≥20%, either 1 happens). Logistic regression analyses were performed to evaluate predictive factors associated with penile curvature improvements. OUTCOMES: Degrees of the curvature changes between the baseline and after the cycles of CCH. RESULTS: A total of 114 patients underwent CCH treatment. Median age was 57 years. Median PD duration was 11 months. At baseline, mean curvature was 47 degrees, 65% had dorsal curvature, 53% mid-shaft location, and 15% calcification. After CCH treatment, the mean final curvature was 40 degrees. A total of 44% improved the curvature, 39% had no change while 17% worsened after CCH treatment. Of men who had penile curvature improvement with CCH treatment, the mean curvature decreasing in degrees and percentage were 22 degrees and 41%, respectively. Men with baseline curvature ≤ 30, 31-59, and ≥ 60 degrees, the percentage curvature improvement were 29%, 43%, and 60%, respectively. Baseline curvature was the only significant predictor of penile curvature improvement after CCH (OR 1.33, 95% CI = 1.1, 1.7). CLINICAL IMPLICATIONS: We confirmed baseline penile curvature is the most important predictive factor, and this is the first report describing proportions of penile curvature improvement with CCH treatment. STRENGTHS AND LIMITATIONS: This study has several strengths, including the use of validated instruments. Nonetheless, there are limitations: the retrospective nature of the study, a single institution; and modelling device was not controlled. CONCLUSION: Penile curvature improvement was significantly more common in patients with greater baseline curvature, reaching up to 60% for patients with ≥ 60 degrees. Flores JM, Nascimento B, Punjani N, et al. Predictors of Curvature Improvement in Men With Peyronie's Disease Treated With Intralesional Collagenase Clostridium Histolyticum. J Sex Med 2022;19:1680-1686.

Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel.

BACKGROUND: Patients with prostate cancer suffer significant sexual dysfunction after treatment which negatively affects them and their partners psychologically, and strain their relationships. AIM: We convened an international panel with the aim of developing guidelines that will inform clinicians, patients and partners about the impact of prostate cancer therapies (PCT) on patients' and partners' sexual health, their relationships, and about biopsychosocial rehabilitation in prostate cancer (PC) survivorship. METHODS: The guidelines panel included international expert researchers and clinicians, and a guideline methodologist. A systematic review of the literature, using the Ovid MEDLINE, Scopus, CINAHL, PsychINFO, LGBT Life, and Embase databases was conducted (1995-2022) according to the Cochrane Handbook for Systematic Reviews of Interventions. Study selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each statement was assigned an evidence strength (A-C) and a recommendation level (strong, moderate, conditional) based on benefit/risk assessment, according to the nomenclature of the American Urological Association (AUA). Data synthesis included meta-analyses of studies deemed of sufficient quality (3), using A Measurement Tool to Assess Systematic Reviews (AMSTAR). OUTCOMES: Guidelines for sexual health care for patients with prostate cancer were developed, based on available evidence and the expertise of the international panel. RESULTS: The guidelines account for patients' cultural, ethnic, and racial diversity. They attend to the unique needs of individuals with diverse sexual orientations and gender identities. The guidelines are based on literature review, a theoretical model of sexual recovery after PCT, and 6 principles that promote clinician-initiated discussion of realistic expectations of sexual outcomes and mitigation of sexual side-effects through biopsychosocial rehabilitation. Forty-seven statements address the psychosexual, relationship, and functional domains in addition to statements on lifestyle modification, assessment, provider education, and systemic challenges to providing sexual health care in PC survivorship. CLINICAL IMPLICATIONS: The guidelines provide clinicians with a comprehensive approach to sexual health care for patients with prostate cancer. STRENGTHS & LIMITATIONS: The strength of the study is the comprehensive evaluation of existing evidence on sexual dysfunction and rehabilitation in prostate cancer that can, along with available expert knowledge, best undergird clinical practice. Limitation is the variation in the evidence supporting interventions and the lack of research on issues facing patients with prostate cancer in low and middle-income countries. CONCLUSION: The guidelines document the distressing sexual sequelae of PCT, provide evidence-based recommendations for sexual rehabilitation and outline areas for future research. Wittmann D, Mehta A, McCaughan E, et al. Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel. J Sex Med 2022;19:1655-1669.

Predictors of Pursuing Intralesional Xiaflex in Peyronie's Disease Patients.

BACKGROUND: Intralesional collagenase such as Xiaflex (ILX) has become a standard treatment for Peyronie's disease (PD). Many robust studies have demonstrated its clear efficacy in the treatment algorithm. AIM: To examine predictors of the patient decision to pursue ILX in PD patients. METHODS: The study included PD patients (i) with stable disease (ii) who had doppler duplex ultrasonography (DUS) at least 6 months prior to analysis date and (iii) did not choose an operation. All patients received a standard discussion regarding treatment options, specifically, observation, ILX and penile reconstructive surgery (plication, plaque incision and grafting, implant surgery). Patients who opted to use ILX were compared to those who opted against it. Comorbidity, demographic and PD characteristics were recorded at the initial PD visit. All patients completed three validated questionnaires including the PD questionnaire (PDQ), Self-Esteem and Relationship (SEAR) questionnaire and a depression questionnaire (CES-D). Logistic regression was used to determine predictors of ILX use. OUTCOMES: Predictors of ILX utilization. RESULTS: Four hundred and fifty stable PD men had DUS completed 6 months before to allow sufficient time for treatment decision. Of these, 111 (24.7%) patients had ILX treatment and 339 (75.3%) did not. Mean age, relationship status and pain occurrence were similar between groups, but ILX patients had less bother defined as PDQ ≥ 9 (46.8% vs 53.7%, P = .02). ILX patients had more complex curves (79.3% vs 47.8%, P < .01) and more severe instability (32.4% vs 15.3%, P = .01). ILX patients also had higher PDQ domain scores (Psychological 11.5 ± 6.4 vs 7.5 ± 6.2, P < .01; Pain 6.2 ± 6.0 vs 4.3 ± 5.6, P = .02; and Bother 9.8 ± 4.7 vs 6.6 ± 4.8, P < .01). On univariable statistics, significant bother (OR 2.41, 95% CI 1.36-4.28, P<0.01), complex curvature (OR 4.18, 95%CI 2.52-6.93, P < .01), moderate and/or severe instability (OR 1.98, 95%CI 1.18-3.30, P < .01) and PDQ-Bother scores (OR 1.15, 95%CI 1.08-1.22 P < .01) predicted ILX use. On multivariable analysis, instability (OR 2.58, 95%CI 1.02-6.57, P = .05) and significant bother (OR 1.23, 95%CI 1.04-1.45, P = .01) predicted ILX use. CLINICAL IMPLICATIONS: Educates providers as to which patients are more likely to choose ILX. STRENGTHS & LIMITATIONS: Our study has a large sample size and all patients received the same standardized treatment discussion. Our study is limited by the absence of insurance data on all patients, and its retrospective single center design. CONCLUSION: ILX was chosen by the minority of stable PD patients. While moderate to severe instability and significant bother is predictive of ILX use, other demographic factors including relationship status, sexual orientation or pain were not. Punjani N, Nascimento B, Salter C, et al. Predictors of Pursuing Intralesional Xiaflex in Peyronie's Disease Patients. J Sex Med 2021;18:1258-1264.

Predictors of Depression in Men With Peyronie's Disease Seeking Evaluation.

BACKGROUND: Peyronie's disease (PD) has negative impacts on the psychosocial status of men including depression warranting clinical evaluation in up to 50% of men. AIM: To examine predictors of depression in patients with early PD seeking evaluation. METHODS: All PD patients at a high-volume PD practice underwent screening and curvature assessment after intracavernosal injection. Complex deformity was defined as any degree of multiplanar curvature, curvature >60 degrees, or presence of hourglass deformity. Men completed the PD questionnaire (PDQ), a validated depression questionnaire (CES-D) as well as the Self-Esteem and Relationship (SEAR) questionnaire. Scores of ≥16 on CES-D were considered indicative of moderate/severe depression. Predictors of the presence of depression were defined using univariable and multivariable logistic regression. OUTCOMES: Demographic, bother and curve related predictors of depression in men with PD. RESULTS: 408 men completed all questionnaires. Mean age was similar between depressed and nondepressed groups (57 ± 10 years overall, P = .60 between groups). Proportions of erectile dysfunction were similar between groups (P = .96). Mean PD duration was similar between groups (19 ± 35 months overall, P = .46 between groups). Mean degree of curvature was 38 ± 2 degrees in the depressed vs 33 ± 1 degrees in the nondepressed groups (P = .03). A complex deformity was seen in 64.5% in the depressed vs 61.5% in the nondepressed (P = .56). A total of 110 (27%) patients had CESD scores ≥16. 74% depressed men were in relationships compared to 84% nondepressed men (P < .01). Other characteristics including bother, pain, duration of disease, curve complexity and instability were similar between the two groups. On univariable analysis, factors protective against depression included being partnered (OR 0.42, 95%CI 0.24-0.75, P < .01) and higher total SEAR scores (OR 0.95, 95%CI 0.94-0.97, P < .01). Elevated PDQ domain scores were associated with depression (Psychologic Symptoms 1.05, 95%CI 1.02-1.10, P < .01; Pain 1.08, 95%CI 1.03-1.12, P < .01; Bother 1.11, 95% CI 1.05-1.68, P < .01) as well as baseline history of depression (OR 2.93, 95%CI 1.67-5.14, P < .001). On multivariable analysis, only total SEAR score remained protective against depression (OR 0.96, 95%CI 0.94-0.97, P < .001). CLINICAL IMPLICATIONS: Providers must recognize that men with PD seeking evaluation have meaningful rates of depression for which early recognition is necessary. STRENGTHS AND LIMITATIONS: Retrospective review of a large prospectively collected dataset from a single center of men with PD utilizing a validated screening tool for depression. CONCLUSION: While no significant demographic, bother or curve related factors predicted depression in early PD men seeking evaluation, it remains a significant problem warranting further prospective evaluation. P. Nahid, N. Bruno, S. Carolyn, et al. Predictors of Depression in Men With Peyronie's Disease Seeking Evaluation. J Sex Med 2021;18:783-788.

Development and Validation of the Satisfaction Survey for Inflatable Penile Implant (SSIPI).

BACKGROUND: No validated English language patient-reported outcome (PRO) currently exists that assesses satisfaction with inflatable penile prosthesis (IPP). Satisfaction data have been largely based primarily on surgeon assessment of patients or using questionnaires that have not been designed for this purpose. AIM: To develop an English-language validated PRO that assesses patient satisfaction after IPP surgery. METHODS: Initially, a literature review and discussions with experts defined domains important to IPP satisfaction (pain, appearance, function, overall satisfaction). The initial 35-item Satisfaction Survey for Inflatable Penile Implant (SSIPI) was developed. Cognitive interviews were then performed with IPP patients (n = 12) to gain feedback on the SSIPI domains and items. These data were used to modify SSIPI with the addition of 2 questions for a final item number of 37. Patients from 4 centers, who were between 6 months and 5 years after IPP, were administered the questionnaire through RedCap. Reliability statistics and content analysis were used to winnow questions to yield the final 16-item version of the SSIPI. Internal consistency was assessed via Cronbach's alpha and item-total correlation. Test-retest reliability was assessed via intraclass correlation coefficients using baseline and 2-week data. For convergent validity, the Erectile Dysfunction Inventory of Treatment Satisfaction and the Self-Esteem and Relationship (SEAR) questionnaire were used. For discriminant validity, the International Prostate Symptom Score (IPSS) was used. Confirmatory factor analysis was used to assess the factor structure of the SSIPI. OUTCOMES: Internal consistency, test-retest reliability, convergent and discriminant validity, and confirmatory factor analysis were assessed. RESULTS: 118 men were surveyed. Mean age was 66.8 ± 9.5 years. The 16-item SSIPI showed high internal consistency with an overall Cronbach's Alpha of 0.97 (domains 0.85-0.89). Item-total correlations for individual items to subscales ranged from 0.60 to 0.91. The overall test-retest reliability was 0.94 (domains 0.87-0.93). Erectile Dysfunction Inventory of Treatment Satisfaction and Self-Esteem and Relationship had correlations of 0.84 overall (domains 0.57-0.79) and 0.47 overall (domains 0.34-0.44), respectively. International Prostate Symptom Score (discriminant validity) had correlations of -0.29 overall (domains -0.17 to -0.31). CLINICAL IMPLICATIONS: SSIPI is the first English-language validated IPP satisfaction PRO. This will enable clinicians to collect satisfaction data in a standardized way. STRENGTHS AND LIMITATIONS: As strengths we have used a rigorous psychometric process and have no industry sponsorship. Limitations include small numbers of specific subpopulations. CONCLUSION: The SSIPI has demonstrated robust psychometric properties. Salter CA, Bach PV, Jenkins L, et al. Development and Validation of the Satisfaction Survey for Inflatable Penile Implant (SSIPI). J Sex Med 2021;18:1641-1651.

The Relationship and Psychosocial Impact of Arousal Incontinence After Radical Prostatectomy.

INTRODUCTION: Arousal incontinence (AI) is a lesser known complication of radical prostatectomy (RP), and few data are available on its impact on self-esteem and sexual relationships. AIM: The goal of this study was to assess the impact of AI on patient self-esteem, confidence, and sexual relationships. METHODS: This was a retrospective study. The validated Self-Esteem and Relationship (SEAR) questionnaire, as well as questions regarding AI, stress urinary incontinence (SUI), climacturia, International Prostate Symptom Score, and the International Index of Erectile Function erectile function domain, were sent to men who had undergone an RP within the past 24 months at a single institution. The data were de-identified and analyzed using descriptive statistics. OUTCOMES: The outcomes of this study include prevalence of AI, SEAR domain scores, patient and partner bother, management strategies employed by the patients, and the presence of concurrent climacturia or SUI. RESULTS: Fifty-three percent of men experienced post-operative AI; of these, 41% were currently experiencing AI, and 12% reported having prior AI that had resolved. Bother of any severity was reported by 87% of men, and perceived partner bother was reported by 64% of men. Forty-one percent of men with current AI avoided sexual activity due to the presence of AI, and 14% of men with prior AI still avoided intercourse. There was no difference in total SEAR score or in the subdomains of self-esteem, sexual relationship, or confidence between men with current AI compared to those with no AI. CLINICAL IMPLICATIONS: AI leads to patient bother and avoidance of sexual situations. STRENGTHS & LIMITATIONS: This is the largest study specifically evaluating AI and the only study assessing its impact on self-esteem, sexual relationships, and self-confidence. Limitations include lack of a validated AI questionnaire, poor survey response rate, being a single-center study, and the potential for recall bias. CONCLUSION: Although AI is a common occurrence post-RP and is associated with patient bother in the majority of men, it does not impact overall self-esteem, confidence, or sexual relationships compared to post-RP men who have not experienced AI. Salter CA, Bach PV, Katz D, et al. The Relationship and Psychosocial Impact of Arousal Incontinence After Radical Prostatectomy. J Sex Med 2020;17:94-98.

Evaluating the Impact of Penile Girth Discrepancy on Patient Bother in Men With Peyronie's Disease: An Observational Study.

BACKGROUND: Men with Peyronie's disease (PD) may experience penile narrowing. Little data on penile girth changes and their psychosocial impact exist. AIM: To assess girth discrepancy in men with PD and its association with patient bother. METHODS: This was a retrospective observational study. All patients with PD at our institution who were seen in the sexual medicine clinic and who completed 3 validated instruments the PD questionnaire (PDQ), Self-Esteem and Relationship (SEAR) questionnaire, and a depression questionnaire, the Center for Epidemiologic Studies Depression Scale (CES-D), and a curvature assessment were included. Patient and PD characteristics are described. Associations of instability and bother to girth differences are assessed. 2 outcomes for girth differences are classified as (i) girth difference of ≥ 1 cm vs less and (ii) girth differences of ≥10% vs less. Unadjusted and adjusted effects of PD and patient characteristics are assessed on the outcome of high bother using logistic regression models. OUTCOMES: The main outcomes of this study were penile girth changes, instability, and questionnaire scores. High bother was defined as a PDQ bother score of ≥9. RESULTS: A total of131 men had midshaft curvature and were the focus of the study. Their mean age was 59 ± 9 (range 31-78) years. PD duration was 16 ± 25 (range 1-180) months, with a mean degree of primary curvature of 37 ± 20o. Mean girth difference between base and point of maximum curvature was 0.78 ± 0.53 cm equating to a mean girth difference at point of maximum curvature of 6 ± 4%. Instability was present in 53% of men. There were 54 men with a girth difference of ≥ 1 cm and 23 men with a ≥10% change in girth. There was no difference in CES-D, SEAR, or PDQ domain scores or high bother in men with significant girth changes. Univariable analysis of predictors of high bother included the degree of curvature (odds ratio [OR]: 1.06; P < .001), instability (OR 6.62; P < .001), CES-D sum (OR 1.09; P = .002), and SEAR score (OR 0.96; P = .001). On multivariate analysis, only the degree of primary curvature was predictive of high bother (OR 1.06; P < .001). CLINICAL IMPLICATIONS: Penile girth changes have little impact on overall psychosocial well-being. The degree of penile curvature is the primary predictor of patient bother. STRENGTHS AND LIMITATIONS: Strengths include a large patient population and use of validated questionnaires. Limitations include single-center, retrospective study and subjective instability grading. CONCLUSIONS: Penile girth discrepancy in men with PD has limited psychosocial impact. Clinically significant bother was associated with the degree of primary curvature. Salter CA, Nascimento B, Terrier, JE, et al. Evaluating the Impact of Penile Girth Discrepancy on Patient Bother in Men With Peyronie's Disease: An Observational Study. J Sex Med 2020;17:1560-1565.

Bother Associated With Climacturia After Radical Prostatectomy: Prevalence and Predictors.

INTRODUCTION: Orgasm-associated incontinence, climacturia, is one of the lesser studied radical prostatectomy (RP) complications. Little is known about patient bother related to this condition, specifically, its prevalence and predictors. AIM: To ascertain the prevalence and predictors of patient bother associated with climacturia. METHODS: Patients presenting for the evaluation of sexual dysfunction after RP at a single center were queried on various domains of sexual dysfunction. This included orgasmic dysfunction and sexual incontinence (including climacturia and arousal incontinence). Patients were specifically asked about the frequency and amount of climacturia. In addition, questions addressed patient bother and the perceived bother of their partners. Descriptive statistics were used for patient characteristics. A t-test was used for comparing the frequency of patient and partner bother, and the Pearson correlation test compared relationships between bother and predictors. Multivariable analysis was conducted to define predictors of climacturia-associated bother. MAIN OUTCOME MEASURE: The main outcome measures was the prevalence and predictors of climacturia-associated patient bother and perceived partner bother. RESULTS: Climacturia was reported by 23% of 3,207 consecutive men analyzed. Bother of any degree was experienced by 45% of these patients, and 14% reported partner bother related to this condition. Patient bother was associated with perceived partner bother (P < .001) and inversely correlated with relationship duration (P < .001). The overall frequency and quantity of climacturia were also predictive (P < .001 for both). In the adjusted model, all of these factors remained significant. CLINICAL IMPLICATIONS: Given the prevalence of this condition and the bother associated with it, this complication should be discussed with patients preoperatively. STRENGTH & LIMITATIONS: Strengths include a large study population and specific questions on climacturia-associated bother. Limitations include the fact that it is a single-center study and no direct partner questioning occurred. CONCLUSION: Climacturia and its associated bother are common after RP. The predictors of patient bother include perceived partner bother, shorter relationship duration, and increasing frequency and quantity of climacturia. Salter CA, Bach PV, Miranda E, et al. Bother Associated With Climacturia After Radical Prostatectomy: Prevalence and Predictors. J Sex Med 2020;17:731-736.

Guideline of guidelines: testosterone therapy for testosterone deficiency.

We analysed the guidelines for testosterone therapy (TTh) produced by major international medical societies including: the American Urological Association, European Association of Urology, American Association of Clinical Endocrinologists, British Society for Sexual Medicine, Endocrine Society, International Society for Sexual Medicine, and the International Society for the Study of the Aging Male, and compared their recommendations. All the organisations were in general agreement concerning the following key points: Only men meeting the criteria for testosterone deficiency (TD) should be treated. Consider screening asymptomatic men with certain conditions that increase the risk of TD. Exogenous TTh causes impairment of spermatogenesis. There is no evidence that TTh causes prostate cancer. Men on TTh require careful laboratory monitoring.

Arousal Incontinence in Men Following Radical Prostatectomy: Prevalence, Impact and Predictors.

BACKGROUND: Arousal incontinence (AI) occurs during physical or psychological sexual stimulation in men and has been described after radical prostatectomy (RP). AIM: The goals of this study are to describe the characteristics of men experiencing AI, outline the nature of their symptoms, and assess for predictors of this condition. METHODS: A survey with questions on AI, stress urinary incontinence (SUI), the International Index of Erectile Function and International Prostate Symptom Score were sent out to men who had undergone an RP within the past 24 months at a single institution. The data were deidentified and analyzed using descriptive statistics. Comparisons between men with and without AI were made using t-tests and χ2 and Fisher exact tests. Logistic regression in univariable and multivariable analyses were used to define predictors of AI. MAIN OUTCOME MEASURES: The outcomes of this study included prevalence of AI, symptom severity and timing, patient and patient-perceived partner bother, management strategies used by the patients, and concurrent SUI. RESULTS: 226 (32%) men completed the survey. Of these men, almost half (49%) experienced AI at some point during their recovery. Improvement over time was endorsed by 62% of men. 57% of men reported AI in less than half of the sexual encounters, with the amount of urine leakage being equivalent to a tablespoon or less in 88% of men. On univariate analysis, increasing degree of SUI, as measured by pads per day, was associated with AI (P = .01). A lower International Prostate Symptom Score was also associated (P = .05). On multivariate analysis, the absence of hypertension and pads per day were associated with AI (P = .01 for both). CLINICAL IMPLICATIONS: AI occurred in almost half of the respondents in our series. Thus, AI should be discussed with patients before surgery to allow for realistic expectations. STRENGTHS & LIMITATIONS: Strengths of this study include the largest patient population analyzed to date regarding AI and that it is the only one to address timing and patient experiences with the use of validated instruments for erectile and urinary function. Limitations include single-center data, non-validated AI patient-reported outcomes, and poor survey response rate. CONCLUSION: Based on the available data, AI is reported by almost half of men after RP and is associated with SUI. Bach PV, Salter CA, Katz D, et al. Arousal Incontinence in Men Following Radical Prostatectomy: Prevalence, Impact and Predictors. J Sex Med 2020;16:1947-1952.

Unmet Sexual Health Resource Needs and Preferences for Interventions to Address These Needs Among Female Partners of Patients With Prostate Cancer.

OBJECTIVE: To characterize unmet sexual health resource needs and preferences for interventions to address unmet needs among female partners of patients with prostate cancer (PCa), given the significant negative impact of PCa on the sexual health of partners. METHODS: We conducted an exploratory sequential mixed methods study of female partners recruited from multiple U.S. clinical locations, websites, and support groups for caregivers. We first conducted semistructured in-depth interviews. Qualitative results informed development of a cross-sectional survey, which was administered to a larger sample of partners. RESULTS: Overall, 12 and 200 female partners participated in the qualitative and quantitative portions of the study. Major emergent themes from interviews were the benefits and drawbacks of technology-based interventions, the importance of sexual health resources throughout the PCa journey, and a desire for sexual health support groups that include partners. In the survey, the most common sexual health topics that partners wanted more information about were male libido problems (30.0%), erectile dysfunction (26.5%), and female libido and arousal problems (24.5%). Additionally, 41.5% wanted more information about sexual health websites, 35.0% about partners-only support groups, 29.5% about support groups for couples, and 23.5% about sexual medicine specialists. CONCLUSIONS: To our knowledge, this is the largest study to date on female partners' unmet sexual health resource needs and preferences for sexual health interventions. Partners prefer technology-based interventions, desire sexual health-focused support groups, and want more information about a variety of sexual issues and specialists who treat them.

Development and Validation of a Survey to Assess Sexual Health in Female Partners of Patients with Prostate Cancer.

BACKGROUND: Prostate cancer (PCa) diagnosis and treatment can have a significant negative impact on sexual health, affecting patients and their partners; however, the impact on partners is insufficiently addressed in current practice. OBJECTIVE: We describe the development and validation of an instrument to measure sexual health in female partners of patients with PCa. DESIGN, SETTING, AND PARTICIPANTS: Questions assessing sexual health were developed through a literature review, two qualitative studies, and an expert consensus process. Candidate survey items were tested through cognitive interviews and used to iteratively refine the questionnaire. INTERVENTION: The final questionnaire was tested in a validation study among 200 female partners. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We performed an exploratory factor analysis, followed by an analysis for internal validity, test-retest reliability, and convergent and discriminant validity. RESULTS AND LIMITATIONS: An initial set of 32 items was developed and refined through cognitive interviews. The resulting 27-item questionnaire was tested among 200 female partners of patients with PCa from across the USA. The exploratory factor analysis eliminated eight items and revealed seven key factors: (1) distress/satisfaction, (2) loss of connection as a couple, (3) active communication, (4) discomfort with communication, (5) frustration with sexual counseling, (6) expansion of sexual repertoire, and (7) nonpenetrative sexual activity. The overall scale demonstrated strong internal consistency (ordinal alpha 0.94) and test-retest reliability (0.89). Strengths of the study include development and evaluation of the first questionnaire to evaluate sexual quality of life among female partners of patients with PCa. However, additional work is needed to assess sexual health and quality of life among male and nonbinary partners. CONCLUSIONS: We developed a new instrument, the Sexual Concerns In Partners of Patients with Prostate cancer (SCIPPP-F), and found it to be valid in a diverse sample of female partners across the USA. PATIENT SUMMARY: Our new instrument can be used to characterize sexual health among female partners of patients with prostate cancer.

Combined Multidisciplinary Gender-Affirming Surgery During the Covid-19 Pandemic: A Model to Optimize Access to Care, Resource Utilization and Medical Readiness for Military Patients.

INTRODUCTION: Access to surgical care for gender-affirming surgery (GAS) has been a persistent challenge within the DoD due to long waiting lists, strict insurance requirements, and surgeon/subspecialty scarcity. These issues were magnified during the COVID-19 pandemic response, as limited resources led to postponement of "elective" surgeries. To remedy this, our center organized a multidisciplinary collaboration to perform simultaneous GAS. This model is necessary to optimize the quality-of-life and medical readiness for a particularly marginalized population within the U.S. Military who now constitute roughly 1% of all active duty personnel. In addition, one-stage surgery provides a feasible solution to streamlining care and decreasing DoD personnel health care costs. MATERIALS AND METHODS: We present a case describing successful multidisciplinary surgical management of a transgender woman desiring multiple GASs. We include a comparative, cost-benefit analysis to emphasize the advantages of single-stage over multistage surgeries. RESULTS: Our patient is a 24-year-old active duty transgender female who underwent breast augmentation and fat harvesting with plastic surgery, which was immediately followed by simultaneous simple orchiectomy by urology and facial feminizing surgery with otolaryngology. Total operative time was 8.3 hours. Our patient was discharged on post-operative day 1 and had an uneventful recovery without complications. Keys to successful implementation included the judicious, coordinated use of local analgesia as well as the organization of separate operating room bedside tables and scrub techs for each team. Total convalescent leave time and temporary profile duration were reduced by 50% relative to the staged approach: 4 weeks and 3 months versus 8 weeks and 6 months, respectively. Of note, anesthesia provider fees total ∼$8,213 when surgeries are performed as three separate events. For one-stage surgery, anesthesia fees amount to only $1,063 (assuming ∼10 hour anesthesia time with a CRNA provider). CONCLUSIONS: Our case study demonstrates that one-stage multidisciplinary surgery can be accomplished without added risk to the patient. Judicious surgical planning, including having surgeons operating at the same time, reduces operative time and provides for efficient operating room utilization. Simultaneous GAS is an effective approach to improve access to surgical care for transgender patients. A single anesthetic enables patients to achieve their surgical goals sooner and to lessen their overall recovery time. This allows service members to return to duty sooner, supporting the Defense Health Agency mission to ensure a medically-ready force. This model should become the standard within MTFs across the DoD, as it promotes improved quality-of-life for patients, decreases personnel costs, and ensures medical readiness.