Genitourinary syndrome of lactation: a new perspective on postpartum and lactation-related genitourinary symptoms.

BACKGROUND: The genitourinary syndrome of menopause (GSM) is a well-documented condition characterized by a range of genitourinary symptoms in peri- and postmenopausal women. As with GSM, postpartum lactating women experience reduced estrogen and androgen levels. However, there is limited research on the impact of symptoms during the postpartum breastfeeding period. OBJECTIVES: The aim was to review the literature for genitourinary health in the postpartum breastfeeding population and summarize key findings and potential treatments. METHODS: We performed a comprehensive literature review in PubMed, Google Scholar, and Scopus from inception of database to November 2023 using the following keywords individually and in combination: "physiology of postpartum" or "physiology of lactogenesis" or "vulvovaginal health" or "vaginal atrophy" or "vaginal dryness" or "dyspareunia" or "urinary incontinence" or "lactation" or "breastfeeding" or "vaginal estrogen." All identified articles published in English were considered. Relevant studies were extracted, evaluated, and analyzed. The work presented in this article represents a summative review of the identified literature. RESULTS: During lactation, high levels of prolactin inhibit estrogen and androgen secretion via negative feedback, which leads to an increased prevalence of vulvovaginal atrophy, vaginal dryness, dyspareunia, and urinary incontinence in lactating postpartum women. Despite these highly prevalent and potentially devastating symptoms, there is a lack of consistent screening at postpartum visits and no treatment guidelines available to health care providers. CONCLUSION: Postpartum breastfeeding women experience similar physiology and symptoms to the postmenopausal phase, as seen in GSM. We propose the introduction of a novel term to describe the genitourinary changes seen in postpartum breastfeeding individuals: genitourinary syndrome of lactation. The diagnostic use of genitourinary syndrome of lactation will equip health care providers with an all-encompassing term to bring awareness to the symptoms experienced by postpartum breastfeeding individuals and lead to improved screening and treatment for the high numbers of individuals experiencing these genitourinary changes.

Impact of neoadjuvant relugolix on patient-reported sexual function and bother.

Introduction: Sexual function following local treatment for prostate cancer is an important quality of life concern. Relugolix is a novel oral GnRH receptor antagonist used in combination with radiation therapy in the treatment of unfavorable prostate cancer. It has been shown to achieve rapid and profound testosterone suppression. As a result, these very low testosterone levels may impact both sexual functioning and perceptions. This prospective study sought to assess neoadjuvant relugolix-induced sexual dysfunction prior to stereotactic body radiation therapy (SBRT). Methods: Between March 2021 and September 2023, 87 patients with localized prostate cancer were treated with neoadjuvant relugolix followed by SBRT per an institutional protocol. Sexual function and bother were assessed via the sexual domain of the validated Expanded Prostate Index Composite (EPIC-26) survey. Responses were collected for each patient at pre-treatment baseline and after several months of relugolix. A Utilization of Sexual Medications/Devices questionnaire was administered at the same time points to assess erectile aid usage. Results: The median age was 72 years and 43% of patients were non-white. The median baseline Sexual Health Inventory for Men (SHIM) score was 13 and 41.7% of patients utilized sexual aids prior to relugolix. Patients initiated relugolix at a median of 4.5 months (2-14 months) prior to SBRT. 95% and 87% of patients achieved effective castration (≤ 50 ng/dL) and profound castration (< 20 ng/dl) at SBRT initiation, respectively. Ability to have an erection, ability to reach orgasm, quality of erections, frequency of erections, and overall sexual function significantly declined following relugolix. There was a non- significant increase in sexual bother. Discussion: In concordance with known side effects of androgen deprivation therapy (ADT), neoadjuvant relugolix was associated with a significant decline in self-reported sexual function. However, patients indicated only a minimal and non-significant increase in bother. Future investigations should compare outcomes while on relugolix directly to GnRH agonist-induced sexual dysfunction.

Sexual Medicine Society of North America (SMSNA)/American Urological Association (AUA) telemedicine and men's health white paper.

PURPOSE: The purpose of this white paper is to educate health care professionals about the evolution of telemedicine (TM) and to propose a hybrid model that leverages the strengths of traditional in-person medicine as well as virtual medicine while maximizing the safety and quality of men's sexual health care. LITERATURE SEARCH STRATEGY: A literature search focused on the use of TM in urology and men's health was performed through PubMed/MEDLINE, Embase, and Web of Science (January 1, 2012-April 26, 2022). Keywords included all known permutations of the terminology used to refer to virtual health, care as well as the terminology used to refer to urologic diseases, issues specific to men's health, and men's sexual health concerns. Publications that emerged after the literature search that met this criterion also were incorporated. Opinion pieces, letters to the editor, meeting abstracts, and conference proceedings were excluded. Additional resources were retrieved, such as governmental technical reports, legislative updates and reviews, and blogs. This search strategy yielded 1684 records across databases after removal of duplicates. Abstracts from the retrieved records were reviewed for relevance. Relevant publications were defined as those that reported data on any aspect of TM use specific to urology, men's health, and/or men's sexual health. If relevance was unclear from the abstract, then the full text of the article was retrieved for a more detailed review. In addition, the published evidence-based practice guidelines relevant to care for erectile dysfunction, Peyronie's disease, ejaculatory dysfunction, and hypogonadism were retrieved. The most common reasons for article exclusions were a focus on TM use in disciplines other than urology and the absence of data (ie, opinion pieces). After exclusions, a total of 91 publications remained and constituted the evidence base for this paper.

A Cost Savings Analysis of Topical Estrogen Therapy in Urinary Tract Infection Prevention Among Postmenopausal Women.

INTRODUCTION: UTIs are some of the most common infections in geriatric patients, with many women experiencing recurrent infections after menopause. In the US, annual UTI-related costs are $2 billion, with recurrent infections creating a significant economic burden. Given the data published on topical estrogen in reducing the number of infections for postmenopausal women with recurrent UTI, we sought to evaluate how this would translate to cost savings. METHODS: We performed a systematic literature review of UTI reduction secondary to topical estrogen utilization in postmenopausal female patients. The cost per UTI was determined based on published Medicare spending on UTI per beneficiary, weighted on reported likelihood of complicated and resistant infections. For a patient with recurrent infections, topical estrogen therapy reported on average can reduce infections from 5 to 0.5 to 2 times per person per year. RESULTS: At a calculated cost per UTI of $1222, the reduction in UTI spending can range between $3670 and $5499 per beneficiary per year. Per-beneficiary spending on topical estrogen therapies was $1013 on average ($578-$1445) in 2020. After including the cost of the therapy, overall cost savings for topical estrogen therapies were $1226 to $4888 annually per patient. CONCLUSIONS: Topical estrogens are a cost-conscious way to improve the burden of UTI on postmenopausal women with the potential for billions of dollars in Medicare savings. System-wide efforts should be made to have these therapies available as prophylaxis for postmenopausal patients and to ensure they are affordable for patients.

"O" no: a Reddit analysis of orgasmic dysfunction.

Background: Female Reddit users frequently discussed potential causes of orgasm difficulties and its implications on mental health and relationships. Aim: This study aimed to evaluate the experiences of women discussing orgasms on the Internet site Reddit. We sought to qualitatively analyze the topics that arose in users' discussions to better understand the potential causes of orgasm difficulties and its implications on quality of life. Methods: Posts on the subreddit r/TwoXChromosomes containing the keywords "orgasm" and "climax" were included in the dataset. Posts and their associated comments were qualitatively analyzed using the grounded theory approach. Two independent researchers coded each thread to identify dominant themes and emergent concepts. Outcomes: The most frequently coded primary topics included: (1) orgasm (32.2% [n = 337]), (2) psychological (17.8% [n = 186]), (3) relationships (15.4% [n = 161]), and (4) treatment (10.7% [n = 112]). Results: Qualitative analysis of 107 threads and approximately 6300 comments resulted in 5 major categories: psychological aspect of orgasms, difficulty orgasming with partners, partners' responses to orgasmic dysfunction, types of orgasms, and treatments for orgasmic dysfunction. Preliminary themes included (1) the presence of an emotional component or history of trauma related to orgasmic difficulty, (2) difficulty orgasming with a partner regardless of ability to orgasm during masturbation and a variety of stimulation required to orgasm, (3) mixed partner responses to orgasmic dysfunction, (4) the definition of a normal orgasm, and (5) self-motivated treatment for orgasmic dysfunction, including clitoral stimulation devices and masturbation techniques. Notably, few posters discussed their orgasmic dysfunction with healthcare providers. Clinical Translation: The study reveals insights into the possible causes, psychosocial implications, and treatment of orgasm difficulties from a patient perspective, and can guide future research on female orgasms in a more precise, patient-oriented direction. Strengths and Limitations: The anonymous nature of the forum allowed for insight into sensitive topics related to female orgasms and sexual trauma. Limitations include the demographic distribution of Reddit users, which was primarily younger women in their 20s and 30s, which restricts generalizability. Conclusion: Reddit provides a medium for individuals with orgasm difficulties to discuss their experiences. Posts addressed users' inability to orgasm, their mental health and relationships, the stimulation required for orgasm, and treatments for orgasmic dysfunction. Interestingly, very few posts discussed healthcare, potentially suggesting that women do not classify their orgasmic dysfunction as a health issue.

Menopause in Plastic Surgery Patients: an Underrecognized and Undertreated Comorbidity.

SUMMARY: Nearly half of all plastic surgery patients are middle-aged cis-gender women, all of whom will experience menopause. While plastic surgeons do not treat menopause directly, it can be a concern-and even a motivating factor-for patients seeking plastic surgery. Additionally, the changes associated with menopause underlie problems that many plastic surgeons seek to address, including in facelifts, breast surgery, and vaginal rejuvenation. Hormone therapy has the potential to improve quality of life for women by treating bothersome symptoms and delaying the physical changes brought on by loss of estrogen. However, recent reports in the media highlight that women face significant barriers to accessing menopause care due to a lack of trained providers willing to manage hormone therapy, as well as historical fears regarding increased cancer risk, which recent evidence suggests were overestimated. Plastic surgeons may be the first, or only, providers with whom women discuss how their bodies change with age. As a result, plastic surgeons should consider menopause as an underlying risk factor or comorbidity for any woman presenting with ageing-related complaints, and to ensure that these patients have access to appropriate menopause care in their communities. This is especially important for surgeons offering vaginal rejuvenation therapies, given that locally-acting topical estrogen is a safe and highly-effective treatment. Here we present guidance and recommendations for how plastic surgeons should take menopause into account when evaluating and advising patients. Additionally, we present a treatment algorithm for safe prescribing of locally-acting hormone therapy for vaginal rejuvenation.

Female sexual medicine: an assessment of medical school curricula in a major United States city.

Background: Although approximately 41% of women experience sexual dysfunction, limited education on female sexual medicine (FSM) in medical school results in underpreparedness among physicians when addressing these bothersome conditions. Aim: This study aims to evaluate the extent to which FSM is represented in medical education by examining current preclinical and clinical curricula. Methods: Preclinical curriculum materials on female sexual anatomy, physiology, and pathology, as well as obstetrics and gynecology clinical materials (syllabi, lecture materials, and supplemental resources), were collected from medical schools in the Chicago area. We utilized previous literature to identify specific components of medical school content to evaluate. Outcomes: Upon reviewing each institution's curricula, we evaluated materials for topic saturation and assessed goals of each syllabus in terms of required content. Results: Curriculum materials were collected from 7 medical schools. In the preclinical assessment, 1 institution identified all anatomic components of the clitoris in our review, 4 discussed the physiology of the female orgasm, 3 highlighted the prevalence and epidemiology of female sexual dysfunction (FSD), 3 addressed treatments for FSD, and 1 instructed a genitourinary physical exam specific to assessing FSD. When assessing obstetrics and gynecology clinical materials, 5 institutions included topics related to FSM. Of these, only 1 institution had corresponding required synchronous clerkship time dedicated to these topics as a 1-hour lecture, in addition to an optional online training to third-year clinical students in comprehensive sexual history-taking practices, including screening for FSD. One other institution offered supplemental case-based gynecology modules including vulvovaginal diseases and chronic pelvic pain, though sexual pleasure, arousal, and libido were not included. Clinical Implications: The results of this study highlight the need for the inclusion of standardized curricula related to FSM in medical education to equip future physicians to treat patients with sexual dysfunction. Strengths and Limitations: The strengths of this study include that it is the first of its kind to complete a comprehensive review of FSM curricula at a cohort of undergraduate medical institutions. Its limitations include a small sample size of 7 medical schools limited to 1 geographical area. Conclusion: Our focused needs assessment of medical schools in the Chicago area reveals inconsistencies in outlined institution-specific course goals related to FSM and thus highlights the need for restructuring the curricula to prepare future physicians to recognize and treat patients with sexual dysfunction.

Recognition and practice patterns of sexual medicine experts towards postorgasmic illness syndrome.

Post-orgasmic illness syndrome (POIS) is a rare, but debilitating cluster of symptoms, occurring after ejaculation with unknown mechanism and uncertain treatment. To the best of our knowledge, this study, which is thought to be the first in the literature, is aimed to investigate the practice patterns of sexual medicine experts towards POIS. Worldwide sexual medicine experts were invited to participate anonymously in an online, open survey using SurveyMonkey between November 14, 2022, and January 15, 2023. In total 211 sexual medicine experts filled the survey. The majority of the participants were urologists (83.9%). Most participants stated that the available information about POIS was inadequate for both patients and physicians. 47.9% of the participants stated psychological disorder, 46.4% stated bio-psycho-social reasons for the responsibility for the pathophysiology of POIS. 56.4% of the participants stated that they would refer the patient for psychotherapy/sexual therapy to a sexologist, 41.7% would prefer antihistamine drugs to manage symptoms. Only 18% of participants reported symptom improvement in more than 30% of the patients. This survey study among sexual medicine experts from different parts of the world has developed representative estimates of knowledge, attitudes and practice patterns regarding POIS worldwide.

Clitoral adhesions: a review of the literature.

INTRODUCTION: Clitoral adhesions occur when the prepuce adheres to the glans. These adhesions have been found in up to 22% of women seeking evaluation for sexual dysfunction. The etiology of clitoral adhesions remains largely unclear. Studies published to date on the presentation and management of clitoral adhesions are relatively recent and raise questions for future research. OBJECTIVES: We sought to provide a background of existing knowledge on the prevalence, presentation, etiology, associated conditions, and management of clitoral adhesions and to identify areas for future research. METHODS: A review of literature was performed for studies that investigate clitoral adhesions. RESULTS: Conditions associated with chronic clitoral scarring appear to have a role in the development of clitoral adhesions. Symptoms include clitoral pain (clitorodynia), discomfort, hypersensitivity, hyposensitivity, difficulty with arousal, and muted or absent orgasm. Complications include inflammation, infection, and the development of keratin pearls and smegmatic pseudocysts. There are surgical and nonsurgical interventions to manage clitoral adhesions. Additionally, topical agents can be included in conservative and/or postprocedural management. Although many studies on clitoral adhesions are limited to patients with lichen sclerosus (LS), clitoral adhesions are not confined to this population. CONCLUSION: Areas for future research include etiologies of clitoral adhesion; such knowledge is imperative to improve prevention and management. Also, in previous studies, patients were instructed to apply various topical agents and manually retract the prepuce for conservative management or postlysis care. However, the efficacy of these interventions has not been investigated. Surgical and nonsurgical lysis procedures have been described for the management of pain and difficulties with arousal and orgasm that are causes of the sexual dysfunction associated with clitoral adhesion. Although previous studies have assessed efficacy and patient satisfaction, many of these studies were limited to small sample sizes and focused solely on patients with LS. Future studies are needed to inform a standard of care for the management of clitoral adhesions.

A qualitative analysis of female Reddit users' experiences with low libido: how do women perceive their changes in sexual desire?

BACKGROUND: The true prevalence of low sexual desire among women is disputed among researchers due to the complex nature and presentation of women's sexual problems. AIM: To qualitatively analyze the aspects of libido/sexual desire frequently discussed by Reddit users and compare them with the current understanding of female sexual well-being and sexual desire disorders. METHODS: By using the Reddit application programming interface, the TwoXChromosomes subreddit was queried for posts with the keywords libido and sex drive. Posts that were deleted or unrelated to themes of libido/sex drive were excluded. A total of 85 threads-63 queried from the keyword libido and 22 from sex drive-and approximately 2900 comments were qualitatively analyzed per the grounded theory approach. Five independent researchers read and coded each thread to identify dominant themes and emergent concepts. OUTCOMES: Outcomes of interest included codes related to sexual dysfunction, libido, orgasm, masturbation, types of sex, psychology, relationships, intimacy, treatment, medications, and health care. RESULTS: Posters were primarily heterosexual women in their 20s and 30s. The code categories with the highest frequency were relationships (22.7%, n = 272), libido (22.2%, n = 210), psychological (20.2%, n = 191), medications (7.29%, n = 69), and intimacy (6.0%, n = 57). Users frequently described a decrease in libido secondary to medications, particularly antidepressants and hormonal birth control. Many users discussed the challenges of navigating a relationship with low sexual desire and the resulting sexual distress. Posters described feelings of sadness, anxiety, and guilt due to their low desire. Additionally, users discussed the role that sex plays in relationships, whether as a way to develop intimacy between partners or to achieve orgasm. Finally, posters expressed dissatisfaction with health care addressing their concerns surrounding sexual desire. CLINICAL IMPLICATIONS: The study findings-namely, the impact of medications on sexual health, the interaction of sexual desire and mental health, and cited examples of inadequate sexual health care-can help guide sexual well-being research, diagnosis, and public policy. STRENGTHS AND LIMITATIONS: Using Reddit as a data source allowed for the analysis of women's experiences outside the preestablished concepts of female sexual desire. Limitations to the study include the potential for posts to be deleted by moderator guidelines, the young demographic distribution of Reddit users, and the popularity-based structure of subreddit threads. CONCLUSION: Our results emphasize the psychosocial aspects of sexual desire and the need to redefine sexual problems to encompass the complex nature of female sexual well-being.

Genitourinary Syndrome of Menopause.

Introduced in 2014, genitourinary syndrome of menopause (GSM) describes a variety of unpleasant genital, sexual and urinary symptoms that can either be isolated or coexisting and are not related to other medical conditions. GSM is a chronic and progressive condition that requires early recognition and appropriate management to preserve urogenital health. Despite the importance of early detection and treatment, the condition is consistently underdiagnosed and undertreated. Herein, we emphasize how to diagnose GSM in postmenopausal, hypoestrogenic, and hypoandrogenic women and summarize evidence-based treatments focusing on prescription treatments and adjunctive therapies.

The clinical management of testosterone replacement therapy in postmenopausal women with hypoactive sexual desire disorder: a review.

As women age, there is an overall decrease in androgen production due to decline of ovarian and adrenal function during menopause. Androgens have been demonstrated to play an important role in sexual motivation in women. As a result, many postmenopausal women experience Female Sexual Dysfunction (FSD) which are a group of disorders that pertain to sexual arousal, desire, orgasm, and pain. A prevalent manifestation of FSD is Hypoactive Sexual Desire Disorder (HSDD) or the absence of sexual fantasies, thoughts, and/or desire for or receptivity to sexual activity. There is gaining interest in the use of Testosterone Replacement Therapy (TRT) for the treatment of HSDD in postmenopausal women. This article reviews the literature on the relationship of androgen decline and HSDD, describes our methodology for evaluation, diagnosis of HSDD, and the use of TRT in treating postmenopausal women with HSDD. Our results conclude that testosterone is a vital hormone in women in maintaining sexual health and function. TRT is an effective treatment option for postmenopausal people with HSDD. There is still limited data on the effectiveness in premenopausal people with HSDD. Further research in the strengths and weaknesses for the long-term effect of TRT in women of all ages is needed.

Ethnic Minority Representation in Female Sexual Dysfunction Questionnaire Validation: A Scoping Review.

BACKGROUND: Female sexual dysfunction (FSD) is a significant cause of distress for an estimated 12-24% of women, and over the past 5 decades several questionnaires have been developed for clinical practice. AIM: The purpose of this scoping review is to evaluate the ethnic representation of sample populations used in the studies to validate FSD questionnaires. METHODS: A scoping review was performed using electronic databases, including PubMed and Scopus, to identify FSD questionnaires validated between 1976 and 2021. Weighted averages from the combined ethnicity data were compared to population data from 2019 US census data and 2018 healthcare workforce reports to evaluate epidemiologic diversity. Ethnicity data from each questionnaire were also investigated longitudinally to evaluate trends in representation over the past 50 years. OUTCOMES: Our outcome of interest was comparison of the weighted averages for ethnicity categories from validation populations to the US female general population, US female health care workforce, and US census data. RESULTS: 48 validation studies were reviewed and showed that the average ethnic representation of the study populations relative to the US general population and US female health care workforce, respectively, was: Caucasian (83.7% vs 62.7% and 68.5%), Black (7.8% vs 13.3% and 8.3%), Hispanic (3.6% vs 16.0% and 9.6%), Native American (0.1% vs 0.8% and 0.3%), Asian (0.6% vs 6.4% and 6.2%), and Other (3.1% vs 0.7% and 1.4%). CLINICAL IMPLICATIONS: FSD questionnaires are relied upon in research and clinical settings, so lack of diversity in validation populations could lead to under recognition and undertreatment in ethnic minority women. STRENGTHS & LIMITATIONS: Our results are dependent on the quality of data available from previously published validation studies. We attempted to account for biases in lack of data and size of validation populations by using weighted averages for making comparisons. We chose the US general population and female healthcare workforce for comparison and analyzed validation populations across multiple decades and geographic locations. Many of the validation studies were performed at least 10 years ago and may not reflect the current state of FSD and potential of questionnaire responses of ethnic minority women. This manuscript raises critical awareness regarding the lack of validated instruments for FSD in ethnically diverse women. CONCLUSION: Study populations used to validate FSD questionnaires demonstrate a trend of ethnic minority underrepresentation relative to the US female general and healthcare workforce populations. Battle CR, Rubin RS, Kingsberg SA, et al. Ethnic Minority Representation in Female Sexual Dysfunction Questionnaire Validation: A Scoping Review. J Sex Med 2022;19:1824-1838.

A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions.

BACKGROUND: Clitoral adhesions are characterized by adherence of preputial tissue to the glans clitoris and can be managed using a non-surgical approach in order to relieve symptoms of sexual dysfunction. AIM: To evaluate efficacy and patient satisfaction associated with the non-surgical lysis procedure in order to determine if it is an appropriate treatment for symptomatic clitoral adhesions. METHODS: The non-surgical lysis procedure is performed by using a fine Jacobsen mosquito forceps to separate the plane between the prepuce and the glans of the clitoris, removing smegma and/or keratin pearls from underneath the adhesions and allowing for visualization of the entire glans. A chart review of 61 women that were treated for clitoral adhesions using the non-surgical lysis procedure at 1 sexual medicine practice was performed and an online survey was sent to these patients. MAIN OUTCOME MEASURES: Encrypted survey responses were used to evaluate patient satisfaction as well as self-reported improvement in sexual functioning and pain before and after the procedure. RESULTS: 41 survey responses were received out of 61 eligible (67% response rate). A large majority reported improvement in pain (76%), sexual arousal (63%), and ability to achieve orgasm (64%) and no participants reported worsening in these symptoms. Of the 16 women that reported the inability to orgasm from external clitoral stimulation prior to the procedure, 6 (38%) were able to do so afterwards. Seventy-one percent of respondents reported improvement in their satisfaction with sex and 83% reported being satisfied with their decision to have the procedure. Ninety-three percent of participants reported that they would recommend this procedure to a friend with clitoral adhesions. CLINICAL IMPLICATIONS: The results of this study will help clinicians to recognize the non-surgical lysis procedure as a treatment option for clitoral adhesions. STRENGTHS & LIMITATIONS: This study is the first of its kind assessing a cohort of patients undergoing the non-surgical lysis procedure for clitoral adhesions. Its limitations include a small sample size from 1 clinic and lack of validated instrument to evaluate sexual function and pain before and after the procedure. CONCLUSION: Providers should regularly examine the clitoris of patients with symptoms of sexual dysfunction in order to determine if they have clitoral adhesions. The non-surgical lysis procedure may be a viable therapeutic option for these patients that has demonstrated both satisfaction and symptom relief. Myers MC, Romanello JP, Nico E, et al. A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions. J Sex Med 2022;19:1412-1420.

Ejaculatory Function Following Stereotactic Body Radiation Therapy for Prostate Cancer.

BACKGROUND: Ejaculatory dysfunction is an important male quality of life issue which has not yet been studied in the setting of prostate stereotactic body radiation therapy (SBRT). AIM: The purpose of this study is to evaluate ejaculatory function following SBRT for prostate cancer. METHODS: Two hundred and thirty-one patients on a prospective quality of life study with baseline ejaculatory capacity treated with prostate SBRT from 2013 to 2019 were included in this analysis. Ejaculation was assessed via the Ejaculation Scale (ES-8) from the Male Sexual Health Questionnaire. Patients completed the questionnaire at 1, 3, 6, 9, 12, 18, and 24 months post-SBRT. Elderly patients (Age > 70) and those who received hormonal therapy were excluded from analysis. Patients were treated to 35-36.25 Gy in 5 fractions delivered with the CyberKnife Radiosurgical System (Accuray). OUTCOMES: Ejaculatory function was assessed by ES-8 scores (range 4-40) with lower values representing increased interference or annoyance. RESULTS: Median age at the time of treatment was 65 years. Median follow up was 24 months (IQR 19-24.5 months). 64.5% of patients had ED at baseline (SHIM < 22). The 2-year anejaculation rate was 15%. Mean composite ES-8 scores showed a decline in the first month following treatment then stabilized: 30.4 (start of treatment); 26.5 (1 month); 27.6 (3 month); 27.0 (6 month); 26.2 (9 month); 25.4 (12 month); 25.0 (18 month) and 25.4 (24 month). White race, higher pre-treatment SHIM (≥22), and higher ES-8 (≥31) at treatment start were significantly associated with a decreased probability of a clinically significant decline. Patient-reported ejaculate volume was significantly reduced at all time points post-SBRT. Ejaculatory discomfort peaked at 1 month and 9 months post-SBRT. Prior to treatment, 8.0% of men reported that they were very to extremely bothered by their ejaculatory dysfunction. The number of patients reporting this concern increased to 14.4% at one year and dropped to 11% at 24-months post-SBRT. CLINICAL TRANSLATION: Patients undergoing prostate SBRT may experience meaningful changes in ejaculatory function and should be counseled on the trajectory of these side effects. STRENGTHS & LIMITATIONS: This was a retrospective analysis of a prospectively maintained database. Subjective questionnaire responses captured limited aspects of ejaculatory function in this cohort. CONCLUSION: The high incidence of moderate to extreme bother in ejaculatory function before and after SBRT suggests a need for novel approaches to improving ejaculation. Sholklapper T, Creswell M, Cantalino J, et al. Ejaculatory Function Following Stereotactic Body Radiation Therapy for Prostate Cancer. J Sex Med 2022;19:771-780.

Crediting agricultural soil carbon sequestration.

Regional consistency is necessary for carbon credit integrity.

Decreased growth of wild soil microbes after 15 years of transplant-induced warming in a montane meadow.

The carbon stored in soil exceeds that of plant biomass and atmospheric carbon and its stability can impact global climate. Growth of decomposer microorganisms mediates both the accrual and loss of soil carbon. Growth is sensitive to temperature and given the vast biological diversity of soil microorganisms, the response of decomposer growth rates to warming may be strongly idiosyncratic, varying among taxa, making ecosystem predictions difficult. Here, we show that 15 years of warming by transplanting plant-soil mesocosms down in elevation, strongly reduced the growth rates of soil microorganisms, measured in the field using undisturbed soil. The magnitude of the response to warming varied among microbial taxa. However, the direction of the response-reduced growth-was universal and warming explained twofold more variation than did the sum of taxonomic identity and its interaction with warming. For this ecosystem, most of the growth responses to warming could be explained without taxon-specific information, suggesting that in some cases microbial responses measured in aggregate may be adequate for climate modeling. Long-term experimental warming also reduced soil carbon content, likely a consequence of a warming-induced increase in decomposition, as warming-induced changes in plant productivity were negligible. The loss of soil carbon and decreased microbial biomass with warming may explain the reduced growth of the microbial community, more than the direct effects of temperature on growth. These findings show that direct and indirect effects of long-term warming can reduce growth rates of soil microbes, which may have important feedbacks to global warming.