Enhancing care: evaluating the impact of True North Sexual Health and Rehabilitation eTraining for healthcare providers working with prostate cancer patients and partners.

Background: Educational programs that enhance healthcare providers' competence in managing the care of patients with sexual dysfunction following prostate cancer treatments are needed to facilitate comprehensive sexual health treatments for patients and their partners. Aim: In this study we evaluated the impact of a real-world online sexual health educational intervention called the True North Sexual Health and Rehabilitation eTraining Program. This program is designed to increase healthcare providers' knowledge and self-efficacy in providing sexual healthcare to prostate cancer patients and their partners. Methods: Healthcare providers were invited to join a 12-week virtual training program. Participants completed precourse surveys (n = 89), retrospective prepost surveys (n = 58), and a 3-month follow-up survey (subset n = 18) to assess retention of relevant outcomes. Additionally, a course satisfaction survey was administered to participants (n = 57) at the end of the course. Outcomes: The main outcomes focused on participants' perceived knowledge and self-efficacy in conducting assessments and providing interventions for various relevant physical, functional, psychological, and relational domains of sexual dysfunction in prostate cancer patients and their partners. Results: According to the retrospective analysis of post-then-pre-survey results, graduates perceived that their knowledge of and self-efficacy in providing sexual health counseling improved after completing the course. The 3-month follow-up survey indicated that the course graduate self-efficacy remained high 3 months after the course. Furthermore, the satisfaction survey indicated that a vast majority (98.2%) of participants were satisfied with the educational intervention. Clinical Implications: This real-world sexual health educational intervention can increase self-efficacy and knowledge in healthcare providers who are supporting prostate cancer patients dealing with sexual dysfunction. Strengths and Limitations: The use of a retrospective post-then-pre-survey helped to mitigate response shift bias while minimizing data gaps. However, it is important to note that this investigation was not a traditional research study and lacked a control group, thus limiting causal attributions. Conclusion: The True North Sexual Health and Rehabilitation eTraining program acts as an accessible and effective resource for healthcare providers seeking specialized training in providing sexual healthcare for prostate cancer patients and their partners.

Variation in perceptions of genital ablation between aspiring eunuchs and individuals with paraphilic sexual fantasies.

Background: Although uncommon, some individuals assigned male at birth (AMAB) seek voluntary genital ablative procedures, and others fantasize about it. Aim: To learn more about the views of genital ablation and injuries in those who aspire to be castrated as compared with those who only fantasize about it. Methods: A survey was run on the Eunuch Archive internet community. Content analysis was conducted on the responses of 342 AMAB individuals with castration fantasy but no desire for actual surgery (fantasizers) vs 294 AMAB individuals who expressed a desire for genital ablation (aspiring). Outcomes: Study outcomes were responses to open-ended questions about genital ablations and injury. Results: Aspiring individuals were more likely to perceive a "physical appearance benefit" from orchiectomy, but fewer could recall how they first learned about the procedure. Some reasons that aspiring persons gave for desiring an orchiectomy included "achieving preferred self" and "health reasons." Fantasizers, in contrast, worried about the potential side effects of orchiectomy, and more believed there to be no benefit to it. Clinical Implications: Psychiatrists and other clinicians need to understand their patients' views on genital ablation to properly diagnose and provide the best personalized care. Strengths and Limitations: Strengths include a large sample of respondents. Limitations include the accuracy of the anonymous survey data. Conclusions: This study demonstrates divergent interests on genital ablation among AMAB individuals who have not had an any genital ablation yet have intense interest in the topic.

Fatigue in Prostate Cancer: A Roundtable Discussion and Thematic Literature Review.

Context: Cancer and its treatments cause fatigue in up to 90% of men with advanced prostate cancer. As men with prostate cancer are surviving longer, cancer-related fatigue is becoming increasingly important for clinicians to understand and proactively manage. Objective: The aim of this work is to identify knowledge gaps that may support healthcare professionals to recommend personalised fatigue management strategies. Evidence acquisition: This manuscript is based on a roundtable discussion held during the European Association of Urology 2022 Annual Symposium, combined with a review of the literature. Five core themes were generated from the roundtable: (1) meaning of fatigue in prostate cancer patients, (2) impact of fatigue, (3) association between fatigue and treatment selection, (4) benefits of managing fatigue, and (5) barriers to exercise. Evidence synthesis: Cancer-related fatigue has complex underlying aetiology and is a subjective experience that may be under-reported. Some studies have shown that techniques such as education, cognitive behavioural therapy, guided imagery, and progressive muscle relaxation can result in clinically meaningful improvements in fatigue. However, the largest body of evidence, and a theme echoed in the roundtable discussions, was the benefit of exercise on fatigue. Despite the benefits of exercise, for some men, objective barriers to exercise exist and knowledge of benefits does not automatically translate into implementation and adherence. Conclusions: Understanding the specific health needs of individual patients and their desired health outcomes is essential to identify personalised strategies for minimising fatigue. As an outcome of the roundtable meeting, we developed a quick reference guide for healthcare providers. A high-resolution copy can be downloaded from https://patients.uroweb.org/library/fatigue-in-prostate-cancer-patients-guide/. Patient summary: This article is based on dialogue between a group of specialists, patients, and caregivers, which took place at a roundtable meeting during the European Association of Urology 2022 Annual Symposium. The group discussed how healthcare providers can best support their patients who experience fatigue. The group subsequently developed a guide to help healthcare providers during appointments.

Barriers to Completing Preoperative Hair Removal for Penile Inversion Vaginoplasty.

Penile inversion vaginoplasty (PIV) is a gender-affirming surgical procedure where the skin of the penis and scrotum is reconstructed into the neovaginal lining. To prevent hair-bearing skin from becoming incorporated into the neovaginal canal, transgender patients are encouraged to undergo hair removal of their external genitalia. The goal of this preoperative hair removal is to minimize the risk of potential hair-related complications after vaginoplasty. To better support patients seeking preoperative hair removal and identify current treatment barriers, we surveyed patients about their progress and satisfaction with hair removal. A cross-sectional survey was constructed to assess patient experiences with hair removal in advance of PIV. Sixty-seven patients met the inclusion criteria, of which 46 participated (68.7%). Both laser hair removal (LHR) and electrolysis were used. Although all patients had completed some preoperative hair removal at the time of survey (average of 14 sessions), the cohort completed only two-thirds of their total expected hair clearance. Multiple peri-procedural pain management therapies were employed, but overall satisfaction with pain management was low (57.4 ± 5.0 out of 100). LHR was associated with significantly lower procedural pain compared to electrolysis (p < .001). The average global satisfaction with the hair removal process was 57.9 ± 5.7 and incidents of mistreatment were associated with a statistically significant reduction in overall satisfaction (p = .02). Most patients felt that hair removal was important prior to surgery. Overall, LHR and electrolysis were both utilized as effective preoperative hair removal modalities; however, LHR has better pain tolerability than electrolysis.

A Proposal for the Comprehensive Care of Men on Androgen Deprivation Therapy: Recommendations From the Multidisciplinary Prostate Cancer 360 Working Group.

INTRODUCTION: To promote comprehensive care of patients throughout the androgen deprivation therapy (ADT) prescribing process, the Prostate Cancer 360 (PC360) Working Group developed monitoring and management recommendations intended to mitigate or prevent ADT-associated adverse events. METHODS: The PC360 Working Group included 14 interdisciplinary experts with a dedicated clinical interest in prostate cancer and ADT management. The working group defined challenges associated with ADT adverse event management and then collaboratively developed comprehensive care recommendations intended to be practical for ADT prescribers. RESULTS: The PC360 Working Group developed both overarching recommendations for ADT adverse event management and specific recommendations across 5 domains (cardiometabolic, bone, sexual, psychological, and lifestyle). The working group recommends an interdisciplinary, team-based approach wherein the ADT prescriber retains an oversight role for ADT management while empowering patients and their primary and specialty care providers to manage risk factors. The PC360 recommendations also emphasize the importance of proactive patient education that involves partners or other support providers. Recommended monitoring and assessment tools, risk factor management, and patient counseling points are also included for the 5 identified domains, with an emphasis on lifestyle and behavioral interventions that can improve quality of life and reduce the risk for ADT-associated complications. CONCLUSIONS: Comprehensive care of patients receiving ADT requires early and ongoing coordinated management of a variety of health domains, including cardiometabolic, bone, sexual, psychological health. Patient education and primary care provider involvement should begin prior to ADT initiation and continue throughout treatment to improve patient and partner quality of life.

Scales for Assessing Male Sexual Function are not Entirely Applicable to Gay and Bisexual Men with Prostate Cancer.

Scales designed for assessing male sexual function may not be suitable for men of all sexual orientations. We reviewed frequently used sexual function scales and examined the item content and documentation of validation. These scales predominantly focus on general sexual function and erection. They lack questions on behaviors relevant to men-who-have-sex-with-men (MSM), such as anal sex, masturbation, or sexual activities outside of committed relationships. Additionally, the validation samples rarely mention inclusion of MSM, revealing a clear gap in the clinical evaluation tools available for MSM, who are experiencing sexual dysfunction from prostate cancer treatment side effects.

Urethroplasty Outcomes for Pars Fixa Urethral Strictures Following Gender-affirming Phalloplasty and Metoidioplasty: A Retrospective Study.

OBJECTIVE: To evaluate outcomes of three urethroplasty techniques for pars fixa (PF) urethral strictures and provide a treatment algorithm based on stricture characteristics. The PF is an essential anatomic region of the neourethra created in gender-affirming phalloplasty and metoidioplasty. Urethral strictures in this region present a reparative challenge given its unique anatomy and vascularization. METHODS: A total of 41 urethroplasties performed on 41 patients between March 2018 and June 2021 were reviewed at two surgical centers. A Heineke-Mikulicz (HM) repair was done for strictures under 20 mm when the proximal and distal urethral segments were mobile and supported a tension-free closure. Substitution urethroplasty with ventral onlay buccal mucosal graft was utilized for strictures under 40 mm not suitable for HM repair. Complex or long (≥40 mm) strictures were treated by two-stage Johansen urethroplasty. Success of each surgical approach was defined by a minimum of 12-month follow-up without the need for a repeat intervention. RESULTS: Mean follow-up was 30.2 months (range: 12.4-52.0 months). Mean stricture length was 16.9 mm (range: 2-55 mm). Most strictures (46%) were located at the distal PF. HM urethroplasty had a success rate of 44% (n = 16). Substitution urethroplasty had a success rate of 92% (n = 13). Two-stage Johansen urethroplasty had a success rate of 75% (n = 12). CONCLUSION: The success rates of PF urethral stricture repair ranged from 44% to 92% depending on the surgical approach, and the best reparative procedure depends on stricture length, severity, and local tissue mobility.

Exposures to information about castration and emotional trauma before puberty are associated with men's risk of seeking genital ablation as adults.

Background: Little is known about childhood experiences, outcomes, and self-recollections of those men who were voluntarily castrated as adults. Aim: The study sought to determine how learning about castration before and after 13 years of age is associated with differential childhood experiences, outcomes, and self-recollections of those who were voluntarily castrated as adults. Methods: We designed a survey of voluntarily castrated individuals, who learned about castration before and after 13 years of age. Our survey consisted of both validated questionnaires and questions. Data were from 208 individuals. Both descriptive and quantitative statistics were performed. Outcomes: Learning about castration before 13 years of age is associated with more adverse childhood experiences (ACEs) such as being threatened with castration and other forms of emotional, physical, and sexual trauma. Results: As compared with those who learned about castration after 13 years of age, those who knew about castration earlier were more likely to have self-injured their penis (χ2 1 = 5.342, P < 0.05), had thoughts of performing self-castration (χ2 1 = 10.389, P < 0.01), witnessed animal castration (χ2 1 = 10.023, P < 0.01), been threatened with castration as a child (χ2 1 = 21.749, P < 0.001), had childhood physical trauma (χ2 1 = 4.318, P < 0.05), had childhood emotional trauma (χ2 1 = 3.939, P < 0.05), and had childhood sexual trauma (χ2 1 = 5.862, P < 0.05). Clinical Implications: Mental health screening and support should be offered to any men seeking emasculating procedures in line with the World Professional Association of Transgender Health's Standards of Care Version 8. Strengths and Limitations: This study had a large sample size and used a validated questionnaire to evaluate for ACEs. The average age of respondents was above 50 years of age, which may increase recall bias. Conclusion: Understanding how ACEs influence the age when some eunuchs first desire, pretend, and become castrated can help clinicians develop better assessments and treatment protocols for individuals with male-to-eunuch gender dysphoria, and other conditions in which emasculating medical procedures are requested.

Vaginal self-lubrication following peritoneal, penile inversion, and colonic gender-affirming vaginoplasty: a physiologic, anatomic, and histologic review.

INTRODUCTION: Vaginal self-lubrication is central to the sexual satisfaction and healthy genitourinary function of patients who have undergone gender-affirming vaginoplasty (GAV). Secretory capacities of different neovaginal lining tissues have been variably described in the literature, with little evidence-based consensus on their success in providing a functionally self-lubricating neovagina. We review the existing neovaginal lubrication data and the anatomy, histology, and physiology of penile and scrotal skin, colon, and peritoneum to better characterize their capacity to be functionally self-lubricating when used as neovaginal lining. OBJECTIVES: The study sought to review and compare the merits of penile and scrotal skin grafts, spatulated urethra, colon, and peritoneal flaps to produce functional lubrication analogous to that of the natal vagina in the setting of GAV. METHODS: We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Medline, EMBASE, ClinicalTrials.gov, and the Cochrane Library databases were searched for peer-reviewed studies published prior to December 12, 2022, that (1) included data specific to transfeminine individuals; (2) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (3) included specific discussion of vaginal lubrication or fluid secretion following GAV utilizing penile skin, colonic tissue, or peritoneum. RESULTS: We identified 580 studies, of which 28 met our inclusion criteria. Data on neovaginal lubrication were limited to qualitative clinician observations, patient-reported outcomes, and satisfaction measures. No studies quantifying neovaginal secretions were identified for any GAV graft or flap technique. Anatomically, penile and scrotal skin have no self-lubricating potential, though penile inversion vaginoplasty may produce some sexually responsive secretory fluid when urethral tissue is incorporated and lubricating genitourinary accessory glands are retained. Colonic and peritoneal tissues both have secretory capacity, but fluid production by these tissues is continuous, nonresponsive to sexual arousal, and likely inappropriate in volume, and so may not meet the needs or expectations of some patients. The impact of surgical tissue translocation on their innate secretory function has not been documented. CONCLUSIONS: None of penile/scrotal skin, colon, or peritoneum provides functional neovaginal lubrication comparable to that of the adult natal vagina. Each tissue has limitations, particularly with respect to inappropriate volume and/or chronicity of secretions. The existing evidence does not support recommending one GAV technique over others based on lubrication outcomes. Finally, difficulty distinguishing between physiologic and pathologic neovaginal fluid secretion may confound the assessment of neovaginal self-lubrication, as many pathologies of the neovagina present with symptomatic discharge.

Patient Engagement in Health Research: Perspectives from Patient Participants.

BACKGROUND AND PURPOSE: Over the past decade, patient engagement (PE) has emerged as an important way to help improve the relevance, quality, and impact of health research. However, there is limited consensus on how best to meaningfully engage patients in the research process. The goal of this article is to share our experiences and insights as members of a Patient Advisory Committee (PAC) on a large, multidisciplinary cancer research study that has spanned six years. We hope by sharing our reflections of the PAC experiences, we can highlight successes, challenges, and lessons learned to help guide PE in future health research. To the best of our knowledge, few publications describing PE experiences in health research teams have been written by patients, survivors, or family caregivers themselves. METHODS: A qualitative approach was used to gather reflections from members of the Patient Advisory Committee regarding their experiences in participating in a research study over six years. Each member completed an online survey and engaged in a group discussion based on the emergent themes from the survey responses. RESULTS: Our reflections about experiences as a PAC on a large, pan-Canadian research study include three overarching topics (1) what worked well; (2) areas for improvement; and (3) reflections on our overall contribution and impact. Overall, we found the experience positive and experienced personal satisfaction but there were areas where future improvements could be made. These areas include earlier engagement and training in the research process, more frequent communication between the patient committee and the research team, and on-going monitoring regarding the nature of the patient engagement. CONCLUSIONS: Engaging individuals who have experienced the types of events which are the focus of a research study can contribute to the overall relevance of the project. However, intentional efforts are necessary to ensure satisfactory involvement.

Gender Differences among Healthcare Providers in the Promotion of Patient-, Person- and Family-Centered Care-And Its Implications for Providing Quality Healthcare.

The concept of "patient-centered care" (PCC) emphasizes patients' autonomy and is commonly promoted as a good healthcare practice that all of medicine should strive for. Here, we assessed how six medical specialties-pediatrics, OBGYN, orthopedics, radiology, dermatology, and neurosurgery-have engaged with PCC and its derivative concepts of "person-centered care" (PeCC) and "family-centered care" (FCC) as a function of the number of female physicians in each field. To achieve this, we conducted a scoping review of three databases-PubMed, CINAHL, and PsycInfo-to assess the extent that PCC, PeCC, FCC, and RCC were referenced by different specialties in the medical literature. Reference to PCC and PeCC in the literature correlates significantly with the number of female physicians in each field (all p < 0.00001) except for neurosurgery (p > 0.5). Pediatrics shows the most extensive reference to PCC, followed by OBGYN, with a significant difference between all disciplines (p < 0.001). FCC remains exclusively embraced by pediatrics. Our results align with documented cognitive differences between men and women that recognize gender differences in empathizing (E) versus systemizing (S) with females demonstrating E > S, which supports PCC/PeCC/FCC approaches to healthcare.

How I Built My Personal, Patient-Centered Health Care Team: Instead of Doctors, I Started With Students.

As a patient with cancer, I witnessed how beneficial it was to be treated by a multidisciplinary health care team. I realized I already had my own team, in a sense. That is because I had treated my research students as colleagues from the get-go, and I did not abandon them when they graduated and moved on.

Androgen deprivation therapy and radiation for prostate cancer-cognitive impairment, sleep, symptom burden: a prospective study.

OBJECTIVES: This paper (1) sought to compare sleep, mood and physical symptom profiles of men with prostate cancer (PCa) who experienced subjective and objective cancer-related cognitive impairment (CRCI) during the first year of treatment and (2) examine if fluctuations in mood and physical symptoms are associated with change in subjective or objective CRCI. METHODS: This prospective observational cohort study examined 24 new patients with PCa receiving androgen deprivation therapy (ADT) and radiation therapy (RT) during the first 12 months of treatment. Participants completed subjective and objective assessments of cognition, sleep continuity and self-report measures of insomnia, fatigue, depression and anxiety. Independent sample t-tests, correlations and hierarchical regressions were used to compare groups, explore associations, and assess change over time. Effects are reported as corrected Cohen's d (dc). RESULTS: Men with objective CRCI reported worse subjective time asleep (dc=0.47) and more depression (dc=0.55). Men with subjective CRCI reported worse insomnia (dc=0.99), hot flashes (dc=0.76), sleep quality (dc=0.54), subjective total sleep time (dc=0.41), wake after sleep onset (dc=0.71), sleep efficiency (dc=0.49), fatigue (dc=0.67) and objectively estimated sleep latency (dc=0.72) than men without subjective CRCI. Declines in perceived cognition was associated with higher anxiety (p=0.05), fatigue (p≤0.01) and symptoms of insomnia (p=0.01). Finally, subjective time awake during the night (p=0.03) and fatigue (p=0.02) were associated with subjective cognitive decline, controlling for objective change. CONCLUSIONS: Subjective concerns of CRCI appear more critical to patient experience than objective measurements in men with PCa who have received RT and ADT. Interventions to improve sleep may result in an improved perception of cognition.

Choosing Castration: A Thematic Analysis of the Perceived Pros and Cons of Genital Injuries and Ablation by Men Who Voluntarily Sought Castration.

Some men elect castration voluntarily without any clear medical reason. Here we aim to document their perception of genital ablation and injuries to better understand their motivations for castration. Participants completed an online survey with open-ended questions related to their perspectives on castration, genital ablation, and genital injuries. Thematic analyses were performed on the responses to these questions. Responses were obtained from 208 male castrated individuals (51.9 ± 16.0 years old). Among these, 154 were physically castrated, 36 chemically castrated, and 18 nullified (had testicles and penis removed). The majority learned about castration from media (55.8%) or animal castration (23.4%). The circumstances when they first wanted to be castrated varied greatly. Most (46.3%) wished to achieve an idealized self motivated by gender dysphoria, body integrity dysphoria, or wanting to be conspicuously non-sexual. The top themes we identified related to the respondents' perceptions of the pros of genital ablation were physical appearance, psychological benefit (i.e., a "eunuch calm"), and being non-sexual. Conversely, themes related to the cons they saw in having no genitals ranged from no disadvantages to loss of sexual/reproductive capability. Some perceived performing genital injury as a step toward ultimate castration or nullification. The respondents similarly varied in whether they saw any loss in having non-functional testicles. Perceptions in this regard appeared to differ depending on whether the respondents were taking supplemental androgens post-castration. Motivations for castration vary greatly between individuals. Clinicians need to understand men's diverse perceptions on castration in order to provide appropriate care for individuals with strong castration desire.

Serum estradiol levels decrease after oophorectomy in transmasculine individuals on testosterone therapy.

Transmasculine individuals, considering whether to undergo total hysterectomy with bilateral salpingectomy, have the option to have a concomitant oophorectomy. While studies have evaluated hormone changes following testosterone therapy initiation, most of those patients have not undergone oophorectomy. Data are currently limited to support health outcomes regarding the decision to retain or remove the ovaries. We performed a retrospective chart review of transmasculine patients maintained on high-dose testosterone therapy at a single endocrine clinic in Vancouver, British Columbia, Canada. Twelve transmasculine individuals who underwent bilateral oophorectomy and had presurgical and postsurgical serum data were included. We identified 12 transmasculine subjects as controls, who were on testosterone therapy and did not undergo oophorectomy, but additionally matched to the first group by age, testosterone dosing regimen, and body mass index. There was a statistically significant decrease in the estradiol levels of case subjects postoophorectomy, when compared to presurgical estradiol levels (P = 0.02). There was no significant difference between baseline estradiol levels between control and case subjects; however, the difference in estradiol levels at follow-up measurements was significant (P = 0.03). Total testosterone levels did not differ between control and case subjects at baseline and follow-up (both P > 0.05). Our results demonstrate that oophorectomy further attenuates estradiol levels below what is achieved by high-dose exogenous testosterone alone. Correlated clinical outcomes, such as impacts on bone health, were not available. The clinical implications of oophorectomy versus ovarian retention on endocrinological and overall health outcomes are currently limited.

Paraphilic Sexual Attraction to Males Without Genitals Is Associated with Traumatic Childhood Experience, Body Image, and Thoughts/Behaviors Related to Genital Ablation.

In rare cases, some male individuals are sexually attracted to men who have their genitals removed. We investigate here if paraphilic attraction to men without genitals was associated with childhood experience, body image, and thoughts/behaviors related to body modification. An online survey, consisting of both validated questionnaires and questions developed by our team, was launched on the Eunuch Archive and MTurk websites. Out of 875 participants, 48.5 and 32.2% reported being attracted to males without testicles or without a penis, respectively; 49.7 and 31.0% felt they would themselves be attractive without testicles and without a penis, respectively. In terms of body modification, many reported having tattoos (19.0%) and piercings (26.1%). About half (48.3%) had played as children with male action figures without genitals, i.e., GI Joe, and Ken dolls. Additionally, some participants reported having: (1) witnessed animal castration (23.7%); (2) having been threatened with castration during their childhood (11.9%); (3) receiving genital injuries inflicted by others (11.0%); (4) pretending to be castrated (60.2%); (5) thinking of self-castration (54.2%); or (6) injuring their own penis (23.4%). Having received genital injuries inflicted by others was associated with attraction to males without testicles (OR = 1.997, p < .05), but not for attraction to males without a penis. Paraphilic attraction to males without genitals (i.e., castrated or penectomized) was associated with feeling attractive without genitals, having pretended to be castrated, considering self-castration, and having injured one's own penis. In conclusion, paraphilic attraction to males without genitals may be associated with traumatic early life events, body image, and desire for one's own genital ablation.