Sexual well-being after menopause: An International Menopause Society White Paper.

Sexual well-being frequently declines following the menopause transition and can be associated with significant personal and relationship distress. This distress is the hallmark of female sexual dysfunction (FSD). FSD is highly prevalent in postmenopausal women. The prevalence of sexual problems increases with age, but conversely this is associated with decreasing distress with advancing age. This pattern has been seen across multiple international populations with varied cultural norms. While the etiology of FSD is multifactorial, the physiological changes of sex hormone insufficiency and postmenopausal symptoms, such as dyspareunia, are primary factors contributing to FSD at midlife. The International Menopause Society is working to increase awareness of FSD and to provide a framework for practitioners to address sexual medicine concerns. This White Paper aims to review the process of care for female sexual well-being following menopause, from initially approaching the discussion of FSD, to identifying clinical signs and symptoms, and ultimately determining the best available biopsychosocial therapies. As with most processes of care, the first step is often the most difficult. Health-care practitioners need to broach the topic of sexuality in the clinical setting. Lack of information on, comfort with, and biases about the topic of sexuality after menopause are significant hurdles that the International Menopause Society addresses in this document. Each member of the Writing Group remains committed to continued advocacy for the validity of FSD as a diagnosis, the need for therapies for women to be both available and included in health insurance coverage, and continued therapeutic research to provide evidence-based solutions.

Effect of once-daily tadalafil on confidence and perceived difficulty in performing sexual intercourse in men who were incomplete responders to as-needed PDE5 inhibitor treatment.

INTRODUCTION: For men with erectile dysfunction (ED), the expectation of difficulty and level of confidence in achieving and maintaining an erection have an impact on sexual performance. OBJECTIVE AND METHODS: This 12-week, double-blind study investigated once-daily tadalafil (2.5 mg titrated to 5 mg or 5 mg) (n = 176) or placebo (n = 79) on confidence and perceived difficulty in performing sexual intercourse in men with ED who were incomplete responders to as-needed phosphodiesterase-5 inhibitor therapy. The Confidence in Performing Sexual Intercourse Questionnaire (CPSIQ) and Difficulty in Performing Sexual Intercourse Questionnaire (DPSIQ) were administered at baseline and 12 weeks. RESULTS: The mean change in CPSIQ for the tadalafil group was 1.8, which represents a shift from 'very low' to 'moderate' sexual confidence vs. a mean change of 0.5 in the placebo group (p < 0.0001). The mean change in DPSIQ for tadalafil was 1.6, which represents a shift from 'very difficult' to 'moderately' or 'slightly difficult' sexual performance vs. a mean change of 0.4 in the placebo group (p < 0.0001). Among men receiving tadalafil with an International Index of Erectile Function-Erectile Function (IIEF-EF) end-point score of ≥ 26 or who achieved a minimal clinically important difference in IIEF-EF score at end-point, the mean changes in CPSIQ were 3.0 and 2.4, respectively (both p < 0.0001). CONCLUSION: Once-daily tadalafil vs. placebo improves confidence and decreases difficulty in performing sexual intercourse for men with ED who were incomplete responders to as-needed PDE5 inhibitor therapy.

Phosphodiesterase type 5 inhibitors' extended duration of response as a variable in the treatment of erectile dysfunction.

The phosphodiesterase type 5 (PDE5) inhibitors, sildenafil, tadalafil and vardenafil, are a class of medications that are safe and effective in treating erectile dysfunction (ED). Yet, resuming sexual activity following a period of abstinence in response to ED may be anxiety-provoking for the man, his partner and their relationship, causing the sexual encounter to become a stressful event. The differences between PDE5 inhibitors in terms of duration of action can be successfully utilized by healthcare professionals to mitigate some of the psychosocial barriers that interfere with treating ED. PDE5 inhibitors with a longer duration of responsiveness provide some men with ED and their partners, a treatment option that may offer greater flexibility and potentially less anxiety surrounding the resumption of sexual activity. Shorter-acting PDE5s may be preferred by men/couples with predictable sexual scripts, excellent communication strategies and concerns regarding the duration of side effects.

Further evidence of the reliability and validity of the premature ejaculation diagnostic tool.

This study details the further validation of the Premature Ejaculation Diagnostic Tool (PEDT), a five-item tool, developed to systematically apply the Diagnostic and Statistical Manual of Mental Disorders, revised version 4 (DSM-IV-TR), criteria in diagnosing presence or absence of premature ejaculation (PE). A total of 102 men completed the PEDT and were then interviewed by one of the seven clinical experts, who made a diagnosis of presence or absence of PE. The diagnoses from these two methods were compared to assess the convergent validity of PEDT. Retest reliability was also assessed, by men completing the PEDT a second time, approximately 2 weeks after the first administration. The level of agreement between clinical expert and PEDT diagnoses was very high (kappa-statistic=0.80 (95% CI=0.68-0.92)), and retest reliability was very good - Intraclass correlation coefficient=0.88. In summary, the PEDT is extensively validated, self-report measure that can systematically assess DSM-IV-TR criteria to provide accurate diagnoses of PE/no-PE.

A double-blind crossover trial of clomipramine for rapid ejaculation in 15 couples.

BACKGROUND: The purpose of this study was to assess the sexual and psychosocial efficacy of clomipramine for rapid ejaculation. METHODS: Fifteen physically healthy, self-selected couples (men had a mean age of 38 years) who met six eligibility criteria and did not meet five exclusion criteria participated in a variable-length, repeated measures, randomized, double-blind, placebo-controlled crossover study with a 2-month follow-up period. Sexual and psychosocial assessments were conducted at baseline, after placebo, after 25 mg/day of clomipramine, after 50 mg/day of clomipramine, and at the 2-month follow-up point. The major outcome measures included stopwatch timing of ejaculation latencies, modified Case Western Reserve University Sexual Function Questionnaire, Symptom Checklist-90-R, Dyadic Adjustment Scale, State-Trait Anxiety Inventory, and the Harder Self-Esteem Inventory. RESULTS: Baseline mean ejaculatory latency was 81 seconds; 25 mg/day of clomipramine increased it to 202 seconds and 50 mg/day of clomipramine to 419 seconds. This resulted in significantly greater sexual satisfaction scores for men and their partners (men, p < .001; women, p < .05), improvements in partner coital orgasmic attainment, and greater relationship and emotional satisfaction for the men. Withdrawal of the drug caused ejaculatory latencies to return to baseline. CONCLUSION: Clomipramine appears to be effective in significantly lengthening ejaculatory latencies and increasing sexual and relationship satisfaction. It can be a cost-effective chronic therapy for selected patients. These impressive results should not be expected in a less carefully screened population of men concerned about the timing of their orgasm during intercourse.

Sexual adaptation among single young adults with cystic fibrosis.

The sexual adaptation of 48 single young adults with cystic fibrosis and a comparably aged single group without chronic disease was assessed using interviews and questionnaires. The patients were also compared to a previously studied group of married patients with cystic fibrosis. Single female patients with cystic fibrosis began dating later, dated less often, felt less attractive, had less sexual desire, and had more sexual problems than did physically healthy female subjects. Single male patients with cystic fibrosis seemed to fare far better than their female counterparts and approximated the healthy male group in all parameters studied. For both the single and married groups with cystic fibrosis, no significant relationship between the severity of disease and sexual health was evident. The single patients were diagnosed at a significantly earlier age and their general health scores were poorer than the married patients. The vulnerability of female patients with cystic fibrosis to psychosexual disruption suggests that attention be focused on the differential effects of other chronic illnesses upon male and female adult sexual adaptation.

Twelve-month comparison of two treatments for erectile dysfunction: self-injection versus external vacuum devices.

This study directly compared two nonsurgical treatments for erectile dysfunction, self-injection of papaverine/phentolamine and external vacuum devices, in terms of usage rates, effectiveness, side effects, dropout rates, and impact on patient sexual and psychologic functioning. Both alternatives were regularly, successfully, and safely used by patients, though dropout rates were higher for self-injection. Both produced erections of improved quality, and effected sustained improvements in frequency of intercourse, orgasm, and sexual satisfaction. Spontaneous erections also improved with both treatments. General psychiatric symptomatology was decreased, and anxiety was improved. There were no differences between the two treatments in sexual or psychologic impact. Relative contraindications and esthetic considerations are presented.

EDITS: development of questionnaires for evaluating satisfaction with treatments for erectile dysfunction.

OBJECTIVES: To develop Patient and Partner versions of a psychometrically sound questionnaire, the EDITS (Erectile Dysfunction Inventory of Treatment Satisfaction), to assess satisfaction with medical treatments for erectile dysfunction. METHODS: Treatment satisfaction differs from treatment efficacy as it focuses on a person's subjective evaluation of treatment received. Twenty-nine items representing the domain of treatment satisfaction for men and 20 representing partner satisfaction were generated. Two independent samples of 28 and 29 couples completed all items at two points in time. Spearman rank-order correlations were derived to assess test-retest reliability and couple coefficients of validity. Internal consistency coefficients were calculated for both Patient and Partner versions and a content validity panel was used to analyze content validity. RESULTS: Only items that met all the following criteria were selected to comprise the final questionnaires: (a) range of response four or more out of five; (b) test-retest reliability greater than 0.70; (c) ratings by at least 70% of the content validity panel as belonging in and being important for the domain; and (d) significant correlation between the subjects' and partners' responses. Eleven patient items met criteria and formed the Patient EDITS; five partner items met criteria and formed the Partner EDITS. Scores on the two inventories were normally distributed with internal consistencies of 0.90 and 0.76, respectively. Test-retest reliability for the Patient EDITS was 0.98; for the Partner EDITS, it was 0.83. CONCLUSIONS: Reliability and validity were well established, enabling the EDITSs to be used to assess satisfaction with treatment modalities for erectile dysfunction and to explore the impact of patient and partner satisfaction on treatment continuation.

When an erection alone is not enough: biopsychosocial obstacles to lovemaking.

Giving men firm erections is relatively straightforward these days; getting them to make use of it regularly in lovemaking is more complicated. Discontinuation rates for any of the available medical treatments for erectile dysfunction, including sildenafil, have been found to range from 50% to 60%. Thus, there is a disproportionately high number of individuals who fail to continue using medical interventions compared to those for whom treatment is efficacious. If not efficacy, then what factors contribute to this puzzling dropout phenomenon? This article discusses the psychological resistances of men, women, and couples that contribute to their stopping treatment for erectile dysfunction. Some of the factors that may be responsible include: (1) the length of time the couple was asexual before seeking treatment; (2) the man's approach to resuming a sexual life with his partner; (3) the man's expectations of how sildenafil will change his life; (4) the partner's physical and emotional readiness to resume lovemaking; (5) the meaning for each partner of using a medical intervention to restore lovemaking; (6) the quality of the nonsexual relationship; and (7) unconventional sexual arousal patterns in the man. To be effective, clinicians must go beyond the simple restoration of erectile function to help patients become active lovemakers again.

Evidence based assessment of rapid ejaculation.

This manuscript reviews the clinical and scientific methods utilized to assess treatment outcome in rapid ejaculation. The current methods and measures are critically evaluated and suggestions for future research efforts are included.

Treatment satisfaction in patients with erectile dysfunction switching from prostaglandin E(1) intracavernosal injection therapy to oral sildenafil citrate.

Treatment satisfaction, subanalysed by demographic variables, was evaluated in patients switching from successful intracavernosal prostaglandin E(1) (PGE(1)) therapy to oral sildenafil citrate. The validated Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire was administered at the end of PGE(1) therapy and after 12 weeks of sildenafil treatment in a multicentre, open-label study. Men with erectile dysfunction (n=176) who were switched from stable PGE(1) therapy to sildenafil (25-100 mg) were equally satisfied with onset of action, duration of action, and confidence in ability to engage in sexual activity, but expressed greater overall treatment satisfaction with sildenafil (P<0.01), better ease of use (P<0.001), naturalness of erectile process (P<0.001), and intention to continue treatment (P<0.001). Partners (n=32) were overall more satisfied with sildenafil (P<0.05), and their responses correlated with patient satisfaction (r=0.68). Compared with PGE(1) injection, these data suggest that patients may be less likely to discontinue taking sildenafil treatment for their erectile dysfunction.

Development and validation of the Self-Esteem And Relationship (SEAR) questionnaire in erectile dysfunction.

Development and validation of a patient-reported measure of psychosocial variables in men with erectile dysfunction (ED) is described. Literature review, focus groups, and medical specialists identified 86 potential items. Redundant, ambiguous, or low item-to-total correlation items were removed. Data from 98 men reporting diagnosed ED and 94 controls assisted in final item selection and psychometric evaluation. Treatment responsiveness was evaluated in 93 men with ED in a 10-week open-label trial of sildenafil citrate (Viagra). The 14 chosen items resolved into two domains: Sexual Relationship (eight items) and Confidence (six items), the latter comprising Self-Esteem (four items) and Overall Relationship (two items) subscales. The resulting Self-Esteem And Relationship (SEAR) questionnaire demonstrated validity and reliability. The intervention study demonstrated responsiveness to beneficial treatment with significant improvement in scores (P=0.0001). The SEAR questionnaire possesses strong psychometric properties that support its validity and reliability for measuring sexual relationship, confidence, and particularly self-esteem.

Clinical approach to the sexuality of patients with spinal cord injury.

This article discusses four complex clinical perspectives on the sexual impact of spinal cord injury: the sexual equilibrium between two people, the sexual psychology of one individual, the general biology of the organically impaired person, and the sexual pathophysiology of the spinal cord deficit. These topics affect the re-establishment and maintenance of a sexual life after irreversible spinal cord trauma.

Injection therapy for impotence.

Injection of vasoactive drugs is an effective form of treatment for selected patients with impotence from virtually all causes. The two most commonly employed drugs in the United States are either papaverine alone or various combinations of papaverine and phentolamine. Patients with organic and mixed impotence are best suited for injection treatment, but selected patients with psychogenic impotence also benefit from therapy. After the patient is selected for injection therapy, he undergoes a series of trial injections in the physician's office. The incidence of priapism will be minimized if the initially administered doses are low and the patient is titrated to an appropriate dose level. Uncontrolled trials have revealed that injection treatment produces a satisfactory erection in 65 to 100 per cent of patients for a follow-up period of as long as 2 years with minimal side effects, but the dropout rate is high. If priapism does occur, it almost always responds readily to treatment with aspiration, low doses of an alpha-adrenergic agent, or both. The other common side effects are bruising or ecchymosis and nodule formation at the injection site. This latter complication has not been noted to cause significant abnormal penile curavature necessitating cessation of the program.

Pharmacologic treatment of rapid ejaculation.

There appears to be a great deal of excitement regarding the potential of clomipramine and serotonin reuptake inhibitor drugs to treat rapid ejaculation. I worry that pharmacologic intervention will be recommended indiscriminately by busy physicians unaware of the complexities of men's/couples' sexual equilibrium. Interdisciplinary teams need to develop thoughtful guidelines that address the thorny issues surrounding the evolution of this new treatment alternative.

The evaluation and management of erectile dysfunction.

Significant progress has been realized in the evaluation and treatment of erectile disorders during the past 15 years. The establishment of interdisciplinary teams and evolution of treatment centers have led to comprehensive, state-of-the-art evaluation and multiple innovative treatment options. Limitations in our knowledge, however, remain because age-related standards for diagnostic tests are not available. In some cases, we remain humble and uncertain about the validity of our diagnostic methods and our ability to offer proper treatments. The field is not standing still, however, and we expect that further refinements in evaluation techniques based on new findings in physiology and fresh psychological and medical approaches will make erectile dysfunction more efficiently and effectively treatable.

[The internist's view of hematuria (author's transl)]. / Erythrozyturie aus internistischer Sicht.

The symptoms of hematuria are easily and accurately detected through careful sediment diagnosis. The path from initial indications to diagnosis often means a major expenditure of laboratory methods, of bioptic excisions, and of radiologic procedures for the examination. Above all, vascular and infected lesions of the kidneys and of the eliminative urinary tracts can cause hematuria, which in every case requires clarification.

Group therapy with gender-identity patients--a four-year study.

Group psychotherapy has proven to be an ideal setting for treatment, observation, and evaluation of gender-dysphoric patients prior to, during, and after sex reassignment surgery. Forty-three percent of the patients seen in the Case Western Reserve University group-therapy program elected nonsurgical solutions. The types of changes and adaptations observed in the 28 group-therapy patients are divided into four categories and discussed.

Proverb familiarity and the mental status examination.

Asking patients to interpret proverbs is a traditional method of assessing abstract thinking ability. Familiarity with a proverb increases the likelihood of interpreting it correctly. Differences in proverb familiarity among patients could lead clinicians to incorrectly conclude that a patient is thinking concretely, and thus to underestimate the patient's cognitive ability. Clinicians should be aware of this possibility when assessing patients from different racial and gender groups. The authors surveyed 229 Afro-American and 104 Caucasian high school students to determine their familiarity with 25 proverbs. Thirty-seven clinicians were also asked to rate their patients' familiarity with the same proverbs. The authors found no differences in proverb familiarity between the black and white students or the male and female students. Clinicians' beliefs about proverb familiarity in their patients were found to be inaccurate.

The patient with erectile dysfunction: psychological issues.

Erectile dysfunction (ED) affects as many as 30 million men and their partners in the United States. Although clinicians now recognize that as many as 80% of cases of ED are organic in origin, psychological issues remain important for the ED patient.