Retropubic tape surgery for stress urinary incontinence: can women be cured without voiding dysfunction?

PURPOSE: Retropubic tension free vaginal tape (RP-TVT) has become the gold standard for surgical management of female stress urinary incontinence but is associated with voiding dysfunction (VD). We developed for more than 10 years a reproductible and totally tension free tape procedure. Our goal is to determine efficiency of this technique compared to the incidence of VD. METHODS: We retrospectively reviewed patients who underwent RP-TVT in our center between 2011 and 2019. Subjective cure, VD (determined as maximum urinary flow rate (Qmax) < 15 mL/s or post void residual (PVR) volume > 150 mL, or tape's section or resection requirement for underactive bladder (UB) with significant PVR) was assessed at 1 year. The main objective was the evaluation of subjective cure and VD at 1 year. RESULTS: On the 319 patients reviewed, 93% of the patients were dry and 10.9% presented VD at one year. UB (OR = 5.01 [1.55-16.44], p = 0.008), preoperative Qmax < 15 mL/s (OR = 0.89 [0.84-0.95], p = 0.001) and previous incontinence surgery (OR = 4.20 [1.54-11.46], p = 0.005) were associated with VD. Acute urinary retention concerned 4.7% of the population and all were resolved after 6 weeks postoperatively. We reported 0.3% of de novo urgency and patients without VD showed a significant decrease of their voiding time at 1 year. CONCLUSION: The placement of RP-TVT without intraoperative tightening seems to be a safe technique ensuring a high cure rate and low occurrences of bladder outlet obstruction.

[Validation of a new self-questionnaire to assess sexuality in patients operated on for urinary incontinence or genital prolapse (Pelvi-Perineal Surgery Sexuality Questionnaire - PPSSQ)]. / Validation d'un nouvel auto-questionnaire d'évaluation de la sexualité chez les patientes opérées d'une incontinence urinaire ou d'un prolapsus génital (Pelvi-Perineal Surgery Sexuality Questionnaire ­ PPSSQ).

INTRODUCTION: The main objective of this study was to validate a new questionnaire evaluating sexual health, in a population of sexually active women or not, who have surgery for stress urinary incontinence or pelvic organ prolapse with or without mesh reinforcement. MATERIAL AND METHODS: After the development of a first version of the questionnaire by members from the main French societies involved in the study of women's sexuality, a linguistic validation of the content of the questionnaire was carried out through semi-structured interviews. Then, a psychometric validation was carried out in a prospective multicenter cohort study. The questionnaire was evaluated in terms of acceptability, quality, dimensionality, internal consistency, temporal stability, sensitivity to changes and construction validity. RESULTS: Linguistic validation was carried out in 25 patients. Psychometric validation was carried out in 297 women (291 with available data) operated on for urinary incontinence by midurethral sling (n=79) or for pelvic organ prolapse by the vaginal route with mesh (n=105), without mesh (n=22) or by laparoscopic sacrocolpopexy (n=85) between January 18, 2013 and January 18, 2016. Within the 288/291 women who had filed the question No. 1 allowing to know their sexual "status", 159 (55%) women were sexually active and 129 (45%) women were not sexually active before surgery. Within the 288 women, 165 had completed the questionnaire preoperatively and at 12 months and 111 had completed the questionnaire at 12 months and 12 months+1 week. The questionnaire was well accepted by the women and of good quality. All the questions were kept, but a change in the order and numbering of the questions had to be made. Two clinically relevant dimensions were identified in this analysis: a "sexual health" dimension comprising 5 questions and a "discomfort and pain" dimension comprising 3 questions. The overall questionnaire and both dimensions had good reliability and moderate to excellent temporal stability. A statistically significant association was demonstrated between question 15 and the improvement reported by PGI-I and the anatomical success rate on POP-Q classification. A strong correlation was found between the "sexual health" score and the total FSFI score. CONCLUSION: The Pelvi-Perineal Surgery Sexuality Questionnaire (PPSSQ) is a 13-question self-questionnaire validated in a population of sexually active women or not, operated on for stress urinary incontinence or pelvic organ prolapse by laparoscopy or vaginal surgery, with or without mesh. LEVEL OF EVIDENCE: 4.

[Clinical practice guidelines: Synthesis of the guidelines for the surgical treatment of primary pelvic organ prolapse in women by the AFU, CNGOF, SIFUD-PP, SNFCP, and SCGP]. / Recommandations pour la pratique clinique : synthèse des recommandations pour le traitement chirurgical du prolapsus génital non récidivé de la femme par l'AFU, le CNGOF, la SIFUD-PP, la SNFCP, et la SCGP.

OBJECTIVE: Develop guidelines for surgery for primary pelvic organ prolapse (POP). METHODS: Literature review, establishment of levels of evidence, external review, and grading of recommendations by 5 French academic societies: Association Française d'Urologie, Collège National des Gynécologues et Obstétriciens Français, Société Interdisciplinaire d'Urodynamique et de Pelvi-Périnéologie, Société Nationale Française de Colo-proctologie, and Société de Chirurgie Gynécologique et Pelvienne. RESULTS: It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (grade B). A bowel preparation before vaginal (grade B) or abdominal surgery (grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (grade C).

[Clinical practice guidelines: Summary of recommendations for first surgical treatment of female pelvic organ prolapse by 5 French academic societies: AFU, CNGOF, SIFUD-PP, SNFCP, and SCGP]. / Recommandations pour la pratique clinique : Synthèse des recommandations pour le traitement chirurgical du prolapsus génital non récidivé de la femme par l´AFU, le CNGOF, la SIFUD-PP, la SNFCP et la SCGP.

OBJECTIVE: Providing clinical practice guidelines for first surgical treatment of female pelvic organ prolapse. METHODS: Systematic literature review, level of evidence rating, external proofreading, and grading of recommendations by 5 French academic societies: Association française d'urologie, Collège national des gynécologues et obstétriciens français, Société interdisciplinaire d'urodynamique et de pelvi-périnéologie, Société nationale française de coloproctologie, and Société de chirurgie gynécologique et pelvienne. RESULTS: It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (Grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (Grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (Grade B). A bowel preparation before vaginal (Grade B) or abdominal surgery (Grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (Grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (Grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (Grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (Grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (Grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (Grade C). Clinical practice guidelines. © 2016 Published by Elsevier Masson SAS.

[Is the use of synthetic mesh by vaginal route decrease the risk of cystocele recurrence? Clinical practice guidelines]. / Une interposition prothétique synthétique inter-vésico-vaginale implantée par voie vaginale diminue-t-elle le risque de récidive de cystocèle ? Recommandations pour la pratique clinique.

INTRODUCTION: The use of prosthetic surgery by vaginal route has been widely used to try to reduce the risk of prolapse recurrence in the surgical treatment of vaginal cystoceles. Specific complications including type of erosion have led to randomized studies comparing surgery by vaginal route with and without use of Mesh. METHOD: This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systemactic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement (AP)). RESULTS: The use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1). However, there is no difference in the functional outcome and there is an increase in the number of reoperations related to specific complications, including vaginal erosions. CONCLUSION: If the use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1), no difference in functional outcome and the increased number of related reoperations specific complications including vaginal erosions, do not argue for the systematic use of mesh in the treatment of primary cystocele. It must be discussed case by case basis taking into account a risk-benefit uncertain at long-term (grade B). Its use should be supported by additional studies focused on specific populations at risk of recurrence. © 2016 Published by Elsevier Masson SAS.

[Vaginal surgery and transanal approach for posterior vaginal wall prolapse: Guidelines for clinical practice]. / Traitement par voie basse des colpocèles postérieures : recommandations pour la pratique clinique.

OBJECTIVE: The aim was to review the safety and efficacy of surgery for posterior vaginal wall prolapse by vaginal route, in order to identify a therapeutic algorithm based on benefit/risk evaluation of each surgical procedure. MATERIAL AND METHODS: We performed a review of the litterature published up to september 2015 (PubMed, Medline, Cochrane library, Cochrane database of systemactic reviews) according to the HAS methodology. Level evidence (1 to 4) was determined for each study as well as evidence based recommendations (A, B, C or professional agreement). RESULTS: Posterior vaginal wall prolapse include mid and low rectoceles and high, beyond levator ani, defects (vaginal vault prolapse, enterocele). Patients with these prolapses frequently complain of bowel symptoms. Due to their high incidence in women, these symptoms require a careful evaluation before surgery in order to correlate them to the prolapse. Repair of the rectovaginal fascia without levatorplasty is recommended in mid rectoceles by vaginal route. The transvaginal approach is superior to the transanal approach for repair of posterior wall prolapse. Biological grafts are not recommended. Due to the lack of evaluation and to the morbidity of polypropylene meshes, there is no indication for their use in the first line surgical procedure of posterior compartment prolapse in the transvaginal approach. Superficial colpoperineorraphy must be proposed only in the symptomatic low rectoceles. Sacrocolpopexy is the procedure of choice for vaginal vault prolapse, but there is still a place for non-prothetic vault suspension by vaginal route according to the age of patients, comorbidities and associated surgical procedures. CONCLUSIONS: Surgical option by vaginal route must be proposed only in symptomatic posterior vaginal wall prolapse. An anorectal evaluation can be required before surgery to avoid worsening of preoperative symptoms or a de novo fecal incontinence, which can lead to a dramatic impairment of patients' quality of life in this functional surgery. © 2016 Published by Elsevier Masson SAS.

[Are there selection criteria between abdominal approach and vaginal route for genital prolapse surgical management?]. / Existe-t-il des critères de choix entre les voies abdominale et vaginale dans la cure du prolapsus génital ?

INTRODUCTION: The never ending debate over the surgical approach of genital prolapse repair (abdominal versus vaginal route) is as passionate as ever. The available literature may support a multidisciplinary analysis of our expert daily practice. OBJECTIVE: Our purpose was to define selection criteria for surgical approach between abdominal and vaginal route in the management of genital prolapse by reviewing the literature. MATERIAL AND METHODS: Systematically review of the literature concerning comparative anatomical and functionnal results of surgery of pelvic organ prolaps by vaginal or abdominal route. RESULTS: We were confronted to the lack of data in the literature, with few prospective randomized comparative studies. Many limitations were identified such as small populations in the studies, no description of sub-population, multiplicity of surgical procedures. Moreover, vaginal route was compared to sacral colpopexy by open abdominal approach, whereas laparoscopic sacrocolpopexy is now recommended. Only one prospective randomized comparative trial assessed laparoscopic sacrocolpopexy and vaginal approach, in which was used a mesh withdrawn from the market. CONCLUSION: The lack of available randomized trials makes it impossible to define HAS compliant guidelines on this topic. However, selection criteria for each surgical approach and technique were drawn from experts' advices. © 2016 Published by Elsevier Masson SAS.

[Intrinsic sphincter deficiency and female urinary incontinence]. / Insuffisance sphinctérienne et incontinence urinaire de la femme.

OBJECTIVE: Stress urinary female incontinence (SUI) is primary due to intrinsic sphincter deficiency (ISD) and urethral hypermobility. Despite a lack of standardised international definition, ISD needs to be clearly diagnosed in order to be correctly treated. This work is an update about the female ISD produced from a review of a published article. MATERIAL AND METHODS: This review of article published on this subject in the Medline (Pubmed database), selected according to their scientific relevants, of consensus conferences and published guidelines, has been performed by the committee for women pelvic floor surgery of the French Urological Association. RESULTS: Although there is no international consensus definition, we can consider that the ISD is a composite concept combining urodynamic data (MUCP < 20 or 30 cmH20) and one or more clinical information (no urethral mobility, negative urethral support test, failure of a first surgery, leakage during abdominal straining, high stress incontinence scores). Imaging can provide additional evidence for intrinsic sphincter deficiency diagnosis, but the correlation between imaging and function remains low. By standardizing methodology and interpretations to better diagnose women with ISD, it may be possible to improve preoperative planning and outcomes for these patients. A retropubic midurethral sling can be performed as a first surgery. In case of a lack of urethral mobility, the artificial urinary sphincter (AUS) remains the gold standard. Adjustable continence therapy (ACT(®)) can be proposed as an alternative option. The efficacy and safety of muscle-derived cell therapy in ISD needs more studies. Injection of bulking agents may be an option according to the severity and the expectations of the patient. Bladder overactivity needs to be treated as first-line in case of mixed urinary incontinence. In elderly women, a careful evaluation of the bladder contractility and comorbidity must be performed. A geriatric evaluation can be necessary. CONCLUSION: Clinical and paraclinical assessment allow to confirm the diagnosis of female ISD, to estimate its severity, and to identify associated mechanisms of incontinence (urethral hypermobility, bladder overactivity) to choose the most adapted treatment.

[French language validation of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire - IUGA revised (PISQ-IR)]. / Validation linguistique en français du Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire - Révisé IUGA (PISQ-IR).

OBJECTIVES: To report a linguistically validated French version of the PISQ-IR (the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire IUGA-Revised). METHODS: PISQ-IR is a valid, reliable, and responsive measure of sexual function in both sexually active or inactive women with pelvic floor disorders. Validation process was performed according the IUGA guidelines. The French version of the PISQ-IR was developed after two independent translations (English>French), one back translation (French>English), cognitive debriefing with a sample of 25 women with pelvic floor disorders attending the gynecologic clinic in the university hospital of Nîmes and a critical review by experts in the field of urogynecology and sexuality. RESULTS: The PISQ-IR is a self-administered questionnaire, which overcomes some shortcomings of the initial version. Questionnaire includes 20 questions, the first one to clarify sexual activity: part 1 of the questionnaire is for non-sexually active women and contains 5 questions and the second part is for sexually active women and contains 12 or 14 questions depending on whether or not the women has a partner. CONCLUSION: This paper reports the linguistically validated French version of the PISQ-IR. Psychometric validation of the French PISQ-IR is currently ongoing and when completed, the scoring system will be shortly published in addition to the definitive version of the questionnaire.

[Anatomy and physiology of sexuality]. / Anatomie et physiologie de la sexualité.

Knowledge of the physiology of male and female sexuality has advanced considerably. Initially there is always desire with its biological neuroendocrine components and its emotional field which is particularly marked in women. There is a distinction between "spontaneous" sexual desire related to intrinsic affective, cognitive stimuli, and fantasies, and "reactive" sexual desire in response to physical arousal. There are similarities between men and women concerning the activation of cerebral zones in sexual arousal contexts in laboratory conditions. The neural pathways for sexual arousal are similar between men and women, bringing into play the sympathetic centres of the thoracic and lumbar spinal cord and, at the sacral level, the parasympathetic center and the motoneurons controlling the muscular contractions of the pelviperineal striated muscles. Genital sensitivity is mainly transmitted by the pudendal nerve in both men and women. Sexual arousal in men consists of penile erection, and ejaculation accompanied with orgasm. In women, sexual arousal causes increase in blood to flow to the vagina leading to lubrication and to the vulva leading to the erection of the clitoris and vulvar hyperaemia. The orgasm which can be multiple in women is accompanied by contractions of the striated perineal muscles. Several neurotransmitters are closely involved in the control of sexuality at the central level: dopamine, ocytocin, serotonin, and peripheral: nitric oxide and noradrenaline in men, vasoactive intestinal peptide and neuropeptide Y in women.

[Sexual desire disorders in women]. / Troubles du désir sexuel féminin.

OBJECTIVE: To evaluate the clinical presentation of women's sexual desire disorders (SDD) and therapeutic options, suggested in the literature. MATERIAL AND METHODS: Review of articles published on this subject in the Medline database, selected according to their scientific relevance, of consensus conferences and published guidelines. RESULTS: Female sexual desire is eminently multifactorial. The clinician should take into account the distress of the woman presenting with a SDD by relating this to the sexual history and the general context (pathological, biological…) together with the relationship with the partner. Other sexual disorders should be considered particularly arousal disorders which are frequently associated with SDD in women. SDD is one of the most difficult symptoms of female sexual dysfunction to treat since it is difficult to delimit the normal and the pathological. Without desire, the lack of sexual activity cannot be perceived as suffering. However, the consequences of this situation mean that she will consult the specialist fearing either that she could lose her partner, or that she is different in a normative society. CONCLUSION: A woman who is fulfilled will not have a problem with desire. The therapeutic objective can be to re-establish reactive desire in the affective context of the couple. The complexity and the multifactorial nature of TDS in women means that no unique solution is satisfactory; the initial assessment and a precise aim for therapeutic management are essential.

[Women's arousal disorders]. / Troubles de l'excitation chez la femme.

OBJECTIVE: To evaluate the clinical presentation of women's arousal disorders (AD) and therapeutic options, suggested in the literature. PATIENTS AND METHODS: Review of articles published on this subject in the Medline database, selected according to their scientific relevance, of consensus conferences and published guidelines. RESULTS: Women's AD form three clinical entities. The most well known is a lack of lubrication and genital congestion in response to a sexual stimulus corresponding to an objective AD. More recently, subjective AD has been identified, with decrease of perception of arousal. In practice these two cases are frequently associated. The prevalence of objective AD varies from 9 to 38%, with a peak after the menopause. The prevalence of the subjective AD, much less studied, is among 17%. All clinical studies have reported an absence of correlation between physiological response, genital arousal, and the subjective response, which makes it difficult to clinically assess and manage these disorders. After the menopause, a lack of estrogen is a major factor in decrease in lubrication and poor vaginal trophicity. Clinical examination is essential for the assessment of these symptoms. Subjective AD and sexual desire disorders both have etiological psychological and contextual factors very similar. They mutually sustained and are grouped together in the new classification of DSM-V in one definition. CONCLUSIONS: Anxiety and a lack of harmony with the partner are among the factors, which affect adversely women's sexual desire and also subjective arousal. For this reason a sexo/psychotherapy is often necessary even for menopausal women. For them local hormonal therapy with estrogen is also recommended in case of lubrication or vaginal trophicity problem.

[Women's orgasmic disorders]. / Les troubles de l'orgasme féminin.

OBJECTIVE: To evaluate the clinical presentation of women's orgasmic disorders (OD) and therapeutic options, suggested in the literature. MATERIAL AND METHODS: Review of articles published on this subject in the Medline (Pubmed) database, selected according to their scientific relevance, of consensus conferences and published guidelines. RESULTS: At present it is thought that the orgasm is a potentiality which a woman can learn to develop with experience, and practice over time. Primary anorgasmia in young females (<35 years) is very often due to lack of experience or lack of skill in the partner or partners. Secondary anorgasmia is often linked to difficulties of live, more rarely to problems with the partner. In both cases, informed advice to the patient and her partner can provide simple ways of modifying and diversifying sexual practice, slight changes can be sufficient. For the woman, learning to "let go" is essential. Speaking to the partner can help to eliminate and diversify sexual behaviour which can be responsible for this problem. However, OD, particularly the secondary type, is less attributable to the male performance than to the emotional and affective aspect. Primary anorgasmia, if total, persisting in the mature woman, evokes more structural problems (body image, sexual abuse, guilt…) and requires specialized management. CONCLUSIONS: Currently, female sexual desire is often evoked, however, one woman in four suffers from OD to a greater or lesser extent. Orgasmic dysfunction in women is frequent and is the second most common reason for consulting a sexologist. Evaluating the context is essential to differentiate primary from secondary OD, in order to give an appropriate treatment.

[How to manage a woman with a sexual complaint in clinical practice?]. / En pratique, comment faire devant une femme exprimant une plainte sexuelle?

OBJECTIVE: To describe the main female sexual dysfunctions, their mechanisms, and the broad outlines of their therapeutic management. MATERIAL AND METHODS: Review of consensus conferences and published guidelines on this subject and a reflexion from our own clinical experience, in urogynaecological practice. RESULTS: Female sexual dysfunction is frequent and can present in different ways; pain, problems concerning desire and satisfaction. These symptoms can be associated with concomitant male sexual dysfunction. These symptoms can be managed by a gynaecologist if he/she is trained accordingly. Knowledge of this is essential for a gynaecologist in daily practice but also for an urologist treating both female urinary incontinence or pelvic prolapse and male sexual dysfunction. CONCLUSION: Women's sexual disorders can considerably affect the quality of life of the partner and the couple. As the patients hesitate to speak of such matters the clinician should begin the dialogue with simple open questions.

[Male sexual dysfunctions and homosexuality]. / Dysfonctions sexuelles masculines et homosexualité.

INTRODUCTION: The homosexuality, which expresses itself through a varied and complex behavior that those whom are shared by the heterosexual majority, is not that a simple sexual behavior, obvious or not, but a whole set of attitudes, affects, preferences, values, lifestyle which concern profoundly the individual, as the heterosexuality. MATERIAL AND METHODS: A review of the literature using PubMed database has been performed to select 38 articles. RESULTS: Among sexual difficulties met by the gays, erectile dysfunction and hypoactive sexual desire are the more frequent. Concerning the ejaculation disorders observed in the gay population, premature ejaculation is rather rare in comparison with heterosexual men; however delayed ejaculation or anejaculation are more frequent. Painful sexual disorders in particular anodyspareunia are also reported. Sexual disorder management must follows the classic rules but it is necessary to be aware how to approach the specific questions affecting the homosexual persons. Still the homosexual person has to find a competent therapist, "opened" to the sexual problem of the homosexuals, with the aim of a care privileging the efficiency to efficacy in the respect for the truth of the homosexual person. CONCLUSION: The homosexuality is the only one of the "unusual" sexual conducts to possibly concern the daily medical practice due to is prevalence. The management of sexual dysfunctions must privilege the "meeting" in a quest of sense in front of any sexual symptom, whatever the individual sexual orientation.

[The couple: An essential entity?]. / Le couple: une entité incontournable?

OBJECTIVE: To evaluate the urological management of the relationship of the couple with both male and female sexual dysfunction. MATERIALS AND METHODS: Review of the guidelines published on this subject in the Medline database together with our own clinical experience in this field. RESULTS: To optimize therapy the urologist should consider the couple when a patient presents with a sexual symptom otherwise the risk of inappropriate, unsuccessful treatment is high. If a dysfunctional relationship is clearly present, with major conflict between the partners or a marked lack of communication, these negative couples must be seen for sex therapy within a multidisciplinary approach. Even with a positive couple, without major conflict, it is advisory to include the partner in the diagnosis and the treatment, for her attitude as a factor which can influence the sexual motivation of the couple, the means and results of the management. In addition, poor knowledge of a sexual problem concerning the woman, whether this predates the partner's dysfunction or not, can impede the efficacy of pharmaceutical treatment. CONCLUSION: Thus, the couple should be seen as a clinical entity with its own fulfillment, which plays an important role in treatment effectiveness, in compliance. Adapting the management to the real expectations of the patient and the couple is essential. With the possible help of the pharmacological treatments of sexual symptoms, a work on all aspects of the couple's dysfunction should bring a new harmony in sexual and affectionate aspects of the relationship.