Anatomic maps of erogenous sensation and pleasure in the penis: are there difference between circumcised and uncircumcised men?

BACKGROUND: The effects of male circumcision on sexual function remain controversial. Heterogeneity across previous studies and low-quality scientific evidence have resulted in poor understanding of the effects of circumcision on erogenous sensation of the penis and orgasm function. AIM: In this study we sought to describe and assess differences in erogenous genital sensation and reported orgasm function in circumcised compared with uncircumcised men. METHODS: Adult male subjects who were recruited on a paid anonymous online survey platform were shown illustrations of 12 anatomic regions of the penis. Subjects were prompted to designate regions as pleasurable when touched during partnered sex and to rate each on a 1-10 scale, with higher erogeneity scores correlating with greater pleasure. Subjects were also asked to characterize their orgasms across 6 experiential domains. OUTCOMES: Outcomes were differences between circumcised and uncircumcised men in the probabilities that regions would be designated as pleasurable, average pleasure scores, and self-reported orgasm parameters. RESULTS: In total, 227 circumcised (mean [SD] age 46.6 [17.7] years) and 175 uncircumcised men (47.8 [18.1] years) completed the survey. There were no significant differences in average ratings across all regions between circumcised and uncircumcised men. However, significantly more circumcised men reported preferences for the tip of the penis (38% vs 17%, P = .02) and the middle third of the ventral penile shaft (63% vs 48%, P = .04). Additionally, there were no significant differences in orgasm quality and function across all queried domains between circumcised and uncircumcised cohorts. CLINICAL IMPLICATIONS: Our findings suggest that circumcision does not change how men describe erogenous genital sensation or how they experience orgasm. STRENGTHS AND LIMITATIONS: In this study we expanded upon existing literature regarding comparison of sexual function in circumcised and uncircumcised men in its scale and investigation of diverse domains. Limitations include the survey format of data collection. CONCLUSION: We found no differences in reported erogenous ratings or orgasm function between circumcised and uncircumcised men. These findings suggest that male circumcision does not negatively impact penile erogeneity or orgasm function.

"Patient Lost to Follow-up": Opportunities and Challenges in Delivering Primary Care in Academic Medical Centers.

BACKGROUND: Academic health centers (AHCs) face unique challenges in providing continuity to a medically and socially complex patient population. Little is known about what drives patient loss in these settings. OBJECTIVE: Determine physician- and patient-based factors associated with patient loss in AHCs. DESIGN: Retrospective cohort study, embedded qualitative analysis. SETTING: Academic health center. PARTICIPANTS: All visits from 7/1/2014 to 6/30/2019; 89 physicians (51%) participated in a qualitative analysis. MEASURES: Physician-based factors (gender, years of service, hours of practice per week, trainee status, and departure during the study period) and patient-based factors (age, gender, race, limited English proficiency, public health insurance, chronic illness burden, and severe psychiatric illness burden) and their association with patient loss to follow-up, defined as a lapse in provider visit greater than 3 years. RESULTS: We identified 402,415 visits for 41,876 distinct patients. A total of 9332 (22.3%) patients were lost to follow-up. Patient factors associated with loss to follow-up included patient age < 40 (HR 3.12 (2.94-3.33)), identification as non-white (HR 1.07 (1.10-1.13)), limited English proficiency (HR 1.18 (1.04-1.33)), and use of public insurance (HR 1.12 (1.04-1.21)). Provider factors associated with patient loss included trainee status (HR 3.74 (2.43-5.75)) and having recently departed from the practice (HR 1.98, 1.66-2.35). Structured interviews with clinical providers revealed unfavorable relationships with providers and staff (35%), inconvenience accessing primary care (23%), unreliable health insurance (18%), difficulty accessing one's primary care provider (14%), and patient/provider transitions (10%) as reasons for patient loss. CONCLUSIONS: Younger patient age, markers of social vulnerability, and physician transiency are associated with patient loss at AHCs, providing targets to improve continuity of care within these settings.

Association of comorbid depression with inpatient outcomes in critical limb ischemia.

There is a growing body of evidence that peripheral artery disease (PAD) may be impacted by depression. The objective of this study is to determine whether outcomes, primarily major amputation, differ between patients with depression and those without who presented to hospitals with critical limb ischemia (CLI), the end-stage of PAD. A retrospective cohort of patients hospitalized for CLI during 2012 and 2013 was identified from the National Inpatient Sample (NIS) using ICD-9 codes. The primary outcome was major amputation and secondary outcomes were length of stay and other complications. The sample included 116,008 patients hospitalized for CLI, of whom 10,512 (9.1%) had comorbid depression. Patients with depression were younger (64 ± 14 vs 67 ± 14 years, p < 0.001) and more likely to be female (55% vs 41%, p < 0.001), white (73% vs 66%, p < 0.001), and tobacco users (46% vs 41%, p < 0.001). They were also more likely to have prior amputations (9.8% vs 7.9%, p < 0.001). During the hospitalization, the rate of major amputation was higher in patients with comorbid depression (11.5% vs 9.1%, p < 0.001). In multivariable analysis, excluding patients who died prior to/without receiving an amputation (n = 2621), comorbid depression was associated with a 39% increased odds of major amputation (adjusted OR 1.39, 95% CI 1.30, 1.49; p < 0.001). Across the entire sample, comorbid depression was also independently associated with a slightly longer length of stay (ß = 0.199, 95% CI 0.155, 0.244; p < 0.001). These results provide further evidence that depression is a variable of interest in PAD and surgical quality databases should include mental health variables to enable further study.

Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women.

BACKGROUND: More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated. OBJECTIVE: We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women. STUDY DESIGN: We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment. RESULTS: Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician. CONCLUSION: Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

Association of tamoxifen use and ovarian function in patients with invasive or pre-invasive breast cancer.

The impact of long-term tamoxifen therapy on ovarian function is not known. Understanding these effects will help reproductive-aged patients who desire future pregnancy make more informed decisions regarding their treatment. This is a retrospective cohort study in patients identified through the UCSF Cancer Registry and SPORE database. We enrolled women with a history of ductal carcinoma in situ (DCIS) or early stage invasive breast cancer who were premenopausal at diagnosis and did not receive chemotherapy. Menstrual histories were obtained through electronic and paper surveys. We compared the age of menopause onset and menstrual pattern changes between women who received tamoxifen (TAM) and those who did not receive tamoxifen (control). Neither group received chemotherapy. 250 subjects were included in this study (125 TAM, 125 control). Mean age of menopause onset was 51.0 for both the groups and was not associated with duration of tamoxifen use or the age at tamoxifen initiation. Menstrual pattern changes, including amenorrhea, were more frequent in the TAM group than control group (any change: 48% TAM vs. 15 % control, p < 0.001; amenorrhea: 22% TAM vs. 3% control, p < 0.001). Older age was associated with an increased risk of developing amenorrhea within 6 months of starting tamoxifen (HR 1.32, p < 0.001). Menstrual pattern changes are common in premenopausal women taking tamoxifen. Tamoxifen use in the absence of chemotherapy is not associated with an earlier age onset of menopause in patients with DCIS or invasive breast cancer and is unlikely to significantly accelerate ovarian aging.

Randomized trial of drain antisepsis after mastectomy and immediate prosthetic breast reconstruction.

BACKGROUND: In this 2-site randomized trial, we investigated the effect of antiseptic drain care on bacterial colonization of surgical drains and infection after immediate prosthetic breast reconstruction. METHODS: With IRB approval, we randomized patients undergoing bilateral mastectomy and reconstruction to drain antisepsis (treatment) for one side, with standard drain care (control) for the other. Antisepsis care included both: chlorhexidine disc dressing at drain exit site(s) and irrigation of drain bulbs twice daily with dilute sodium hypochlorite solution. Cultures were obtained from bulb fluid at 1 week and at drain removal, and from the subcutaneous drain tubing at removal. Positive cultures were defined as ≥1+ growth for fluid and >50 CFU for tubing. RESULTS: Cultures of drain bulb fluid at 1 week (the primary endpoint) were positive in 9.9 % of treatment sides (10 of 101) versus 20.8 % (21 of 101) of control sides (p = 0.02). Drain tubing cultures were positive in 0 treated drains versus 6.2 % (6 of 97) of control drains (p = 0.03). Surgical site infection occurred within 30 days in 0 antisepsis sides versus 3.8 % (4 of 104) of control sides (p = 0.13), and within 1 year in three of 104 (2.9 %) of antisepsis sides versus 6 of 104 (5.8 %) of control sides (p = 0.45). Clinical infection occurred within 1 year in 9.7 % (6 of 62) of colonized sides (tubing or fluid) versus 1.5 % (2 of 136) of noncolonized sides (p = 0.03). CONCLUSIONS: Simple and inexpensive local antiseptic interventions with a chlorhexidine disc and hypochlorite solution reduce bacterial colonization of drains, and reduced drain colonization was associated with fewer infections.

Patient-reported outcomes and satisfaction after total skin-sparing mastectomy and immediate expander-implant reconstruction.

BACKGROUND: Total skin-sparing mastectomy (TSSM) with preservation of the nipple-areolar complex skin has become more widely accepted. Few studies looking at outcomes after TSSM and immediate reconstruction have focused on patient-reported outcomes and trends in satisfaction over time. METHODS: Prospective evaluation of patients undergoing TSSM and immediate expander-implant reconstruction was performed. Patients completed the BREAST-Q questionnaire preoperatively and again at 1 month, 6 months, and 1 year postoperatively. Mean scores in each BREAST-Q domain were assessed at each time point. Domains were scored on a 0- to 100-point scale. RESULTS: Survey completion rate was 55%; BREAST-Q scores were calculated from responses from 28 patients. Mean overall satisfaction with breasts declined at 1 month (69.8 to 46.1, P<0.001), but then returned to baseline by 1 year. Mean scores also declined at 1 month in the psychosocial (75.7-67.4, P=0.2) and sexual (58.3-46.7, P=0.06) domains, but returned to baseline by 1 year. Mean nipple satisfaction score was 76.4 at 1 year, with 89% of patients reporting satisfaction with nipple appearance. Satisfaction with nipple position and sensation was lower, with only 56% of patients reporting satisfaction with nipple position and 40% with nipple sensation. CONCLUSIONS: After TSSM and immediate reconstruction, patient satisfaction with their breasts, as well as psychosocial and sexual well-being, returns to baseline by 1 year. Although overall nipple satisfaction is high, patients often report dissatisfaction with nipple position and sensation; appropriate preoperative counseling is important to set realistic expectations.

Management of perimenopausal and menopausal symptoms.

Most women worldwide experience menopausal symptoms during the menopause transition or postmenopause. Vasomotor symptoms are most pronounced during the first four to seven years but can persist for more than a decade, and genitourinary symptoms tend to be progressive. Although the hallmark symptoms are hot flashes, night sweats, disrupted sleep, and genitourinary discomfort, other common symptoms and conditions are mood fluctuations, cognitive changes, low sexual desire, bone loss, increase in abdominal fat, and adverse changes in metabolic health. These symptoms and signs can occur in any combination or sequence, and the link to menopause may even be elusive. Estrogen based hormonal therapies are the most effective treatments for many of the symptoms and, in the absence of contraindications to treatment, have a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause. Non-hormonal treatment options are also available. Although a symptom driven treatment approach with individualized decision making can improve health and quality of life for midlife women, menopausal symptoms remain substantially undertreated by healthcare providers.

A distributed approach to the regulation of clinical AI.

Regulation is necessary to ensure the safety, efficacy and equitable impact of clinical artificial intelligence (AI). The number of applications of clinical AI is increasing, which, amplified by the need for adaptations to account for the heterogeneity of local health systems and inevitable data drift, creates a fundamental challenge for regulators. Our opinion is that, at scale, the incumbent model of centralized regulation of clinical AI will not ensure the safety, efficacy, and equity of implemented systems. We propose a hybrid model of regulation, where centralized regulation would only be required for applications of clinical AI where the inference is entirely automated without clinician review, have a high potential to negatively impact the health of patients and for algorithms that are to be applied at national scale by design. This amalgam of centralized and decentralized regulation we refer to as a distributed approach to the regulation of clinical AI and highlight the benefits as well as the pre-requisites and challenges involved.

Urinary Incontinence and Associated Female Sexual Dysfunction.

INTRODUCTION: Urinary incontinence (UI) and sexual dysfunction are common conditions often undiagnosed and untreated in women and are associated with decreased quality of life. AIM: To evaluate the relation between UI and female sexual dysfunction (FSD), considering incontinence type and the psychosocial and physiologic aspects of sexual function. METHODS: PubMed search of terms related to UI and FSD from 1979 to 2016 generated 603 published references, of which 26 were included. Nine additional studies came from bibliographic review. MAIN OUTCOME MEASURE: Rates and types of sexual dysfunction. RESULTS: In cross-sectional and case-control studies, UI was associated with increased rates and severity of FSD. Coital UI occurred in 24% to 66% of women with UI. Impaired body image, fear of coital UI, avoidance of sex, and complete abstinence were more common in women with UI. Deficits in desire, lubrication, satisfaction, and increased pain were found across numerous studies. Mixed UI was associated with more FSD than urgency UI and stress UI. Multiple studies suggest urgent UI is more bothersome than stress UI. Coital UI was associated with a urodynamic diagnosis other than genuine stress incontinence in 25% to 50%. Leakage at penetration was associated with stress UI; leakage at orgasm was associated more often with detrusor overactivity. CONCLUSION: Women's UI is associated with increased rates of sexual dysfunction, suggesting concurrent screening is warranted. Clarifying timing of coital leakage would facilitate targeted treatment. Standardization of FSD measurements could better elucidate the relation between UI and FSD. Duralde ER, Rowen TS. Urinary Incontinence and Associated Female Sexual Dysfunction. Sex Med Rev 2017;5:470-485.