Introduction.  Erectile dysfunction (ED) is highly prevalent among human immunodeficiency virus-seropositive (HIV+) men who have sex with men (MSM). There is a need for additional research to determine the correlates of HIV+ and HIV-seronegative (HIV−) MSM, especially regarding nonantiretroviral medication use.

Aims.  This study examined the prevalence of ED and the sociodemographic, medical conditions, medication use, and substance use correlates of ED among HIV+ and HIV− MSM.

Methods.  A modified version of the International Index of Erectile Function (IIEF) for MSM was self-administered by participants enrolled in the Multicenter AIDS Cohort Study, an ongoing prospective study of the natural and treated histories of HIV infection among MSM in the United States. The study sample included 1,340 participants, including 612 HIV+ and 728 HIV− men. Poisson regression with robust error variance was used to estimate prevalence ratios of ED in multivariable models in combined (HIV+/−) and separate analyses.

Main Outcome Measure.  ED was determined by the summed scores of a modified version of the IIEF validated among MSM.

Results.  Twenty-one percent of HIV+ MSM and 16% of HIV− MSM reported ED. Being >55 years of age, black race, cumulative pack years of smoking, cumulative antihypertensive use, and cumulative antidepressant use had significant positive associations with the prevalence of ED in the total sample. Among HIV+ men, duration of antihypertensive use and antidepressant use were significantly associated with increasing prevalence of ED. Among HIV− men, being >55 years of age, black race, and cigarette smoking duration were associated with increased prevalence of ED.

Conclusion.  Predictors of ED may differ by HIV status. Although smoking cessation and effective medication management may be important as possible treatment strategies for ED among all MSM, there may be a burden on sexual functioning produced by non-HIV medications for HIV+ men. Hart TA, Moskowitz D, Cox C, Li X, Ostrow DG, Stall RD, Gorbach PM, and Plankey M. The cumulative effects of medication use, drug use, and smoking on erectile dysfunction among men who have sex with men. J Sex Med **;**:**–**.

Introduction.  In pelvic organ prolapse (POP) repair, the use of synthetic mesh is not only increasing but also a subject of discussion. The focus shifts from anatomical toward functional outcome, with sexual function being an important parameter. One of the concerns with mesh usage in POP surgery is the possible negative effect on sexual function.

Aim.  To compare and assess sexual function in women and men after primary cystocele repair with or without trocar-guided transobturator mesh.

Methods.  One hundred twenty-five women with a symptomatic cystocele stage ≥ II were included in this multicenter randomized controlled trial and assessed at baseline and 6-month follow-up.

Main Outcome Measures.  Female sexual function was measured by the Female Sexual Function Index (FSFI) and male sexual function by the Male Sexual Health Questionnaire. A subgroup analysis of women with a participating partner was performed.

Results.  In the mesh group, 54/59 women vs. 53/62 in the anterior colporrhaphy group participated. In men, 29 vs. 30 participated. After surgery, FSFI scores were comparable for both treatment groups. However, within group analysis showed significant improvement on the domains pain (effect size = 0.5), lubrication (effect size = 0.4), and overall satisfaction (effect size = 0.5) in the colporrhaphy group. This improvement was not observed in the mesh group. A subgroup of women with a participating partner reported significantly higher baseline domain scores as compared with other women and did not report a significant improvement of sexual functioning irrespective of treatment allocation. Worsening of baseline sexual function was reported by 43% of women in the mesh group compared with 18% in anterior colporrhaphy group (P = 0.05). Male sexual functioning did not change in either group.

Conclusions.  Women after an anterior colporrhaphy report a significant and clinically relevant improvement of their sexual functioning, whereas women after a mesh procedure did not. Vollebregt A, Fischer K, Gietelink D, and van der Vaart CH. Effects of vaginal prolapse surgery on sexuality in women and men; results from a RCT on repair with and without mesh. J Sex Med **;**:**–**.

Introduction.  A new formulation of testosterone gel (1.62% testosterone gel) with increased viscosity and reduced volume of application has been shown to be safe and efficacious after 182 days of use in a phase 3, double-blind study in adult hypogonadal males.

Aim.  The objective of this study was to evaluate the efficacy and safety of the 1.62% testosterone gel after daily application to the skin in a 182-day (6-month) open-label extension of the initial 182-day double-blind study.

Methods.  One hundred and sixty-three subjects, aged 26 to 77 years, continued on active (Continuing Active subjects) 1.62% testosterone gel for the remainder of the study (364 days total). In 28 subjects who had previously received placebo (Formerly Placebo subjects), the dose was titrated to normal levels of serum total testosterone (300–1,000 ng/dL). Dose adjustments for both groups were allowed at specific visits to maintain serum testosterone within a normal range.

Main Outcome Measure.  The main outcome measure was the percentage of subjects with serum total testosterone average concentrations (C_av) within the normal range at day 364.

Results.  On day 364, 77.9% (95% confidence interval: 70.0, 84.6) of the Continuing Active subjects and 87.0% (66.4, 97.2) of the Formerly Placebo subjects had C_av values within the eugonadal range. The 1.62% testosterone gel was safe and well tolerated in this study.

Conclusion.  Treatment with 1.62% testosterone gel for up to 1 year (182 days for the Formerly Placebo subjects, 364 days for the Continuing Active subjects) was safe and efficacious, resulting in >77% of treated subjects achieving normal serum testosterone levels at final visit. Kaufman JM, Miller MG, Fitzpatrick S, McWhirter C, and Brennan JJ. One-year efficacy and safety study of a 1.62% testosterone gel in hypogonadal men: Results of a 182-day open-label extension of a 6-month double-blind study. J Sex Med **;**:**–**.

Introduction.  A well-tailored testosterone replacement treatment (TRT) in male hypogonadal athletes plays a pivotal role to restore physiological performances, to reduce health risks, and to guarantee the ethic of competition. Few studies evaluated individual androgens profiles during TRT in trained individuals.

Aim.  The aim of this article was to verify the efficacy in restoring eugonadal serum and urinary androgens profiles after testosterone enanthate (TE) and gel (TG) administration.

Methods.  Ten male Caucasian-trained volunteers affected by severe hypotestosteronemia (<8 nmol/L) were included. Serum androgens and urinary testosterone metabolites were evaluated, in the same subjects, before and weekly for 5 weeks after both a single intramuscular TE injection (250 mg) and during a daily administration of TG (50 mg/die of testosterone), respectively.

Main Outcome Measures.  The main outcome measures of this article were serum total testosterone (TT), dihydrotestosterone (DHT), calculated free and bioavailable testosterone (cFT, cBioT), 17-β-estradiol, and urinary glucuronide testosterone metabolites.

Results.  Supraphysiological TT concentrations were observed in 50% of our volunteers until 7 days after TE and in the 4% of total samples after TG. Serum DHT was high both after TE (all volunteers on day 7 and 50% on day 14) and during TG (32% of total samples). A relatively low number of samples showed normal cFT and cBioT both after TE and TG (20–44%, respectively). Urinary metabolites were related to the type of treatment and to serum androgens profile and resulted in the normal ranges from 15% to 60% of total samples.

Conclusion.  Besides well-known variations of mean serum TT, we showed a high percentage of serum and urinary samples with abnormal androgens, being TG safer than TE. We conclude that monitoring TRT with TT only may be inaccurate because of abnormal fluctuations of other circulating androgens. Further studies to identify the appropriate markers of eugonadism during TRT are highly warranted both in athletes and in non-athletes. Di Luigi L, Sgrò P, Aversa A, Migliaccio S, Bianchini S, Botrè F, Romanelli F, and Lenzi A. Concerns about serum androgens monitoring during testosterone replacement treatments in hypogonadal male athletes: a pilot study. J Sex Med **;**:**–**.

Introduction.  Primary headaches are common in women and impact on their quality of life and psychosocial functioning. Few data are available on sexuality in female headache sufferers.

Aim.  An observational pilot study was conducted to assess sexual function and distress in women treated for primary headaches in a tertiary university center.

Methods.  From a total of 194 women consecutively observed over a 3-month period, 100 patients were recruited. Migraine with and without aura, and tension-type headache, both episodic and chronic (CTTH), were diagnosed according to the International Classification of Headache Disorders. A detailed pharmacological history was collected, and anxiety and depression were assessed using validated scales. The Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised were administered.

Main Outcome Measures.  The main outcome measures are sexual symptoms and distress in women treated for primary headaches.

Results.  More than 90% of the women had a median FSFI full-scale score under the validated cutoff, while 29% reported sexual distress. Hypoactive sexual desire disorder (HSDD) was diagnosed in 20% of the women and the pain domain score (median 2, score range 0–6) was highly affected by the head pain condition. However, the FSFI domain and full-scale scores did not significantly differ by headache diagnosis. The women with CTTH displayed a high rate of sexual distress (45.5%) and a strong negative correlation between desire, arousal, and full-scale FSFI score and number analgesics/month (r: −0.77, P = 0.006; r: −0.76, P = 0.006; and r: −0.68, P = 0.02, respectively). Depression was positively correlated with sexual distress (r: 0.63, P = 0.001) only in the women with CTTH.

Conclusion.  Women treated for primary headaches were found to display a high rate of sexual symptoms and distress. Both migraine and tension-type headache were associated with sexual pain and HSDD, but women with CTTH seem to be more prone to develop sexual distress. Nappi RE, Terreno E, Tassorelli C, Sances G, Allena M, Guaschino E, Antonaci F, Albani F, and Polatti F. Sexual function and distress in women treated for primary headaches in a tertiary university center. J Sex Med **;**:**–**.

Introduction.  Deep infiltrating endometriosis (DIE) is a form of endometriosis in which the lesion penetrates for more than 5 mm under the peritoneal surface. It is a chronic disease which can impair women's sexual function. There is a growing body of evidence supporting combined surgical/medical treatment in the management of DIE.

Aims.  The aims of this article are to evaluate the impact of the laparoscopic full excision of endometriosis and postoperative combined oral contraceptives (COC) administration on sexual function in patients with DIE and to compare sexual function outcomes of women submitted to intestinal resection and nodule excision.

Methods.  It is a prospective cohort study in a tertiary care university hospital on 106 sexually active women, with histologically confirmed DIE, managed by laparoscopy and subsequent COC therapy for 6 months. Patients filled preoperatively and 6-month postoperatively a quality of sexual life questionnaire, the Sexual Health Outcomes in Women Questionnaire (SHOW-Q) and they ranked their symptom intensity using a 10-point visual analogue scale (VAS).

Main Outcome Measures.  Sexual function was measured through the SHOW-Q scores and pain symptoms through VAS scores. Intraoperative details, type of intervention and perioperative complications were noted.

Results.  Six months after surgery and postoperative COC treatment, a significant improvement was observed in the SHOW-Q domains of pelvic problem interference, sexual satisfaction and desire (P < 0.05). Laparoscopic management of DIE did not change significantly the orgasm area of the sexual functioning (P = 0.7). No significant difference was found in SHOW-Q scores between patients submitted to intestinal resection and patients submitted to intestinal nodule excision (P > 0.05).

Conclusions.  Sexual desire, satisfaction with sex and pelvic problem interference with intercourse are significantly improved after 6 months from laparoscopic excision of DIE combined with postoperative COC therapy. No difference in sexual outcomes was detected between patients submitted to intestinal resection and nodule excision. Mabrouk M, Montanari G, Di Donato N, Del Forno S, Frascà C, Geraci E, Ferrini G, Vicenzi C, Raimondo D, Villa G, Zukerman Z, Alvisi S, and Seracchioli R. What is the impact on sexual function of laparoscopic treatment and subsequent combined oral contraceptive therapy in women with deep infiltrating endometriosis? J Sex Med **;**:**–**.

Introduction.  Regular use of vaginal dilators has been recommended as a prophylactic measure following radiation treatment for gynecological cancers in order to minimize vaginal stenosis and promote optimal healing of the vagina. Despite the well-established reluctance of women to adopt this practice, little is known about the difficulties and concerns associated with vaginal dilator use.

Aim.  To investigate women's experiences with the vaginal dilator and to understand the psychosocial factors that influence women's adoption of rehabilitative dilator use.

Methods.  This is an exploratory qualitative study using semi-structured interviews with a sample of 10 women with a history of gynecological cancer and who were prescribed a vaginal dilator. Interviews were analyzed using the grounded theory method and examined for recurrent themes.

Main Outcome Measure.  The main outcome measure was a semi-structured interview comprised of open-ended questions designed to elicit information concerning topic areas relevant to gynecological cancer, vaginal dilator use, and sexuality.

Results.  The analysis resulted in five main categories underlying the core category of “From ‘Sex Toy’ to Intrusive Imposition.” These were: (i) embarrassing sex toy; (ii) reliving the invasion of treatment; (iii) aversive “hands-on” experience; (iv) not at the forefront of my recovery; and (v) minimizing the resistance.

Conclusions.  Rehabilitative vaginal dilator use is a complex, multifaceted, and personal phenomenon that carries deep psychological and emotional implications that make it intrusive. These findings may enhance the way in which vaginal dilators are introduced and help healthcare providers address better women's difficulties and concerns with the dilators. Ultimately, it may also lead to improved health maintenance and quality of life for women recovering from gynecological cancer. Cullen K, Fergus K, DasGupta T, Fitch M, Doyle C, and Adams L. From “sex toy” to intrusive imposition: A qualitative examination of women's experiences with vaginal dilator use following treatment for gynecological cancer. J Sex Med **;**:**–**.

Introduction.  Hypoactive sexual desire disorder (HSDD) is a common problem in postmenopausal women, but in the absence of an approved medical treatment in the United States, off-label testosterone use is widespread. Large, randomized controlled studies have demonstrated that transdermal testosterone improves sexual function and activity in postmenopausal women and has favorable short-term safety. However, a longer-term safety profile of testosterone must be established before a testosterone product for women is approved.

Aim.  To review current knowledge of the efficacy and safety of transdermal testosterone based on presentations at a satellite symposium during the 2011 annual meeting of the International Society for the Study of Women's Sexual Health.

Methods.  Pertinent information included in the presentations was augmented with relevant articles from the peer-reviewed literature.

Main Outcome Measures.  The rationale for testosterone therapy and results from phase III and other clinical studies with the testosterone patch in postmenopausal women with HSDD and findings from studies investigating the cardiovascular, breast, and endometrial effects of testosterone therapy.

Results.  Randomized, double-blind, placebo-controlled studies have established the efficacy of the transdermal testosterone patch for relieving symptoms of HSDD in surgically and naturally menopausal women with and without concomitant estrogen or estrogen/progestin therapy. The main side effects reported in clinical trials were increased hair growth and acne. Available safety data for testosterone, although not conclusive, were reassuring with respect to cardiovascular, breast, and endometrial outcomes. Interim data from a long-term phase III safety trial of a testosterone gel demonstrate a continued low rate of cardiovascular events and breast cancer in postmenopausal women at increased cardiovascular risk.

Conclusion.  Transdermal testosterone appears to be an effective and safe therapy for postmenopausal women with HSDD. Davis SR and Braunstein GD. Efficacy and safety of testosterone in the management of hypoactive sexual desire disorder in postmenopausal women. J Sex Med **;**:**–**.

Introduction.  Psychopathological origins of personally distressing, hypoactive sexual desire disorder (HSDD) in women are unknown, but are generally attributed to an inhibitory neural regulator, serotonin (5-HT). Flibanserin, a 5-HT_1A agonist and 5-HT_2A antagonist, shows promise as a treatment for HSDD.

Aim.  To test the hypothesis that female marmoset sexual behavior is enhanced by flibanserin and diminished by 8-OH-DPAT, in order to evaluate the efficacy of serotonergic modulation of female sexual behavior in a pairmate social setting comparable to humans.

Methods.  Sexual and social behavior were examined in eight female marmoset monkeys receiving daily flibanserin (15 mg/kg), 8-OH-DPAT (0.1 mg/kg), or corresponding vehicle for 15–16 weeks in a counterbalanced, within-subject design, while housed in long-term, stable male–female pairs.

Main Outcome Measures.  Marmoset pairmate interactions, including sexual and social behavior, were scored during weeks 5–6 of daily flibanserin, 8-OH-DPAT or vehicle treatment. 24-hour pharmacokinetic profiles of the drugs and their metabolites, as well as drug-induced acute symptoms of the 5-HT behavioral syndrome were also assessed.

Results.  Two-way analysis of variance reveals that flibanserin-treated females attract more male sexual interest (P = 0.020) and trigger increased grooming (P = 0.001) between partners. In contrast, 8-OH-DPAT-treated females show increased rejection of male sexual advances (P = 0.024), a tendency for decreased male sexual interest (P = 0.080), and increased aggression with their male pairmates (P = 0.049).

Conclusions.  While 8-OH-DPAT-treated female marmosets display decreased sexual receptivity and increased aggressive interactions with their male pairmates, flibanserin-treated female marmosets demonstrate increased affiliative behavior with their male pairmates. Such pro-affiliation attributes may underlie flibanserin's effectiveness in treating HSDD in women. Aubert Y, Gustison ML, Gardner LA, Bohl MA, Lange JR, Allers KA, Sommer B, Datson NA, and Abbott DH. Flibanserin and 8-OH-DPAT implicate serotonin in association between female marmoset monkey sexual behavior and changes in pair-bond quality. J Sex Med **;**:**–**.

Introduction.  Erectile dysfunction (ED) is reported in a high percentage of patients with central neurological disorders (CND).

Aim.  An up-to-date review on oral phosphodiesterase 5 inhibitors (PDE5): sildenafil, tadalafil, and vardenafil for individuals with CND and ED.

Main Outcome Measures.  Various questionnaires on ED, such as the International Index of Erectile Function composed of 15 questions.

Methods.  Internationally published clinical studies evaluating the efficacy and safety of PDE5 on subjects with CND and ED were selected.

Results.  Overall, 28 articles on PDE5 used to treat patients with CND and ED were included. With each of the three PDE5 compared to placebo or erectile baseline, literature reported significant statistical improvement (P < 0.01; P < 0.05) only in patients with spinal cord injury (SCI). PDE5 efficacy was documented for SCI patients up to 10 years. The most frequent predicable factor for PDE5 success was the presence of upper motoneuron lesion. Each of the three clinical sildenafil studies documented statistically significant improvement on erectile function in Parkinson's patients (P < 0.01; P < 0.05). Two studies reported discordant results about sildenafil's effectiveness on multiple sclerosis (MS) patients; one on tadalafil showed significant statistical efficacy on erection versus baseline (P < 0.01; P < 0.05). The only spina bifida article determined that sildenafil remarkably improved erectile function. Overall, drawbacks were mostly slight-moderate, except in subjects with multiple system atrophy where sildenafil caused severe hypotension.

Conclusions.  PDE5 represent first line ED therapy only for SCI patients, though treatment results through meta-analysis were not possible. Encouraging results are reported for Parkinson's and MS patients. PDE5 use for other CND patients is limited for various reasons, such as ED and concomitant libido impairment caused by depression and/or sexual endocrinology dysfunctions, and because PDE5 may cause a worsening of neurological illness. Medical centers staffed by health professionals able to counsel patients on the possible use of PDE5 are needed. Lombardi G, Nelli F, Celso M, Mencarini M, and Del Popolo G. Treating erectile dysfunction and central neurological diseases with oral phosphodiesterase type 5 inhibitors. Review of the literature. J Sex Med **;**:**–**.

Introduction.  Accumulated evidences have outlined the potential relation between insulin resistance and endothelial dysfunction. The impaired ability of endothelium to synthesize or release nitric oxide may provide a common pathophysiological mechanism in the development of metabolic syndrome (MtS) and erectile dysfunction (ED).

Aim.  The aim of this article was to investigate the genetic susceptibility of endothelial nitric oxide synthase (eNOS) G894T polymorphism underlying the development of both disorders.

Methods.  A total of 590 subjects with a mean (standard deviation) age of 55.3 years (4.1) were enrolled during a free health screening. Complete clinical data and questionnaires were taken for all subjects. Multivariate logistic regression analysis was used to determine the independent predictors of MtS and ED. The eNOS G894T polymorphism was determined using a polymerase chain reaction-restriction fragment length polymorphism method.

Main Outcome Measures.  The definition of MtS was according to the modified criteria developed by the Bureau of Health Promotion in Taiwan. Patients with ED were defined as those having a five-item International Index of Erectile Function (IIEF-5) <21.

Results.  Our results showed that the eNOS 894T allele carriers had significantly higher prevalence of MtS and ED (odds ratio [OR] = 1.64, 95% confidence interval [CI] = 1.05∼2.56, P = 0.02 and OR = 1.76, 95% CI = 1.11∼2.80, P = 0.01, respectively) after adjustment for each other and age. Also the T allele carriers had significantly lower IIEF-5 score and more MtS components than G allele carriers (P < 0.01 and P < 0.01, respectively), which were significantly associated with an increment of the T allele number (P < 0.05).

Conclusions.  The eNOS 894T allele carriers are at greater risk for both MtS and ED, suggesting that eNOS G894T gene polymorphism might play an implication as a common genetic susceptibility factor to develop both disorders. Lee Y-C, Huang S-P, Liu C-C, Yang Y-H, Yeh H-C, Li W-M, Wu W-J, Wang C-J, Juan Y-S, Huang C-N, Hour T-C, Chang C-F, and Huang C-H. The Association of eNOS G894T polymorphism with metabolic syndrome and erectile dysfunction. J Sex Med **;**:**–**.

Introduction.  Phosphodiesterase type 5 (PDE5) inhibitors have become standard treatment for erectile dysfunction (ED).

Aim.  To prospectively evaluate the safety and efficacy of avanafil, a novel PDE5 inhibitor, in men with mild to severe ED.

Methods.  In this multicenter, double-blind, Phase 3 trial, 646 subjects were randomized to receive avanafil (50 mg, 100 mg, 200 mg) or placebo throughout a 12-week treatment period. Subjects were instructed to take study drug 30 minutes prior to initiation of sexual activity. At least a 12-hour separation time between doses was required; no restrictions were placed on food or alcohol intake.

Main Outcome Measures.  Improvement in erectile function (EF) was measured by Sexual Encounter Profile questions 2 and 3 (SEP2 and SEP3) and by the EF domain of the International Index of Erectile Function (IIEF) questionnaire.

Results.  Mean change in percentage of successful sexual attempts (SEP2 and SEP3) and IIEF-EF domain score significantly favored all doses of avanafil over placebo (P ≤ 0.001). Secondary analyses demonstrated achievement of successful intercourse by subjects within 15 minutes of dosing. Of the 300 sexual attempts made during this interval, 64% to 71% were successful in avanafil-treated subjects compared with 27% in placebo-treated subjects. Successful intercourse was also demonstrated >6 hours post dosing, with 59% to 83% of the 80 sexual attempts successful in avanafil-treated subjects compared with 25% of placebo-treated subjects. The most commonly reported adverse events in subjects taking avanafil included headache, flushing, and nasal congestion; there were no drug-related serious adverse events.

Conclusion.  Following 12 weeks of avanafil treatment without food or alcohol restrictions, significant improvements in sexual function were observed with all 3 doses of avanafil compared with placebo. Successful intercourse was observed as early as 15 minutes and >6 hours after dosing in some subjects. Avanafil was generally well tolerated for the treatment of ED. Goldstein I, McCullough AR, Jones LA, Hellstrom WJ, Bowden CH, DiDonato K, Trask B, and Day WW. A randomized, double-blind, placebo-controlled evaluation of the safety and efficacy of avanafil in subjects with erectile dysfunction. J Sex Med **;**:**–**.

Introduction.  Premature ejaculation (PE) is a highly prevalent and complex syndrome that remains poorly defined and inadequately characterized. Pharmacotherapy represents the current basis of lifelong PE treatment.

Aim.  The goal of this study was to assess the role of phosphodiesterase type 5 inhibitors (PDE5-Is) in the treatment of patients with PE without associated erectile dysfunction (ED).

Main Outcome Measure.  The posttreatment intravaginal ejaculatory latency time was used as the primary end point of efficacy.

Methods.  A systematic review of the literature was performed by electronically searching the MedLine database for peer-reviewed articles regarding the mechanism of action and the clinical trials of PDE5 in the management of PE. A meta-analysis of these clinical studies was performed to pool the efficacy.

Results.  Twenty-nine articles that examined the supposed mechanisms of action and 14 articles that reported data from clinical studies were reviewed. The PDE5 may exert their influence by increasing the levels of nitric oxide both centrally (reducing sympathetic drive) and peripherally (leading to smooth-muscle dilatation of the seminal tract). These drugs may also induce peripheral analgesia to prolong the duration of the erection, increase confidence, improve the perception of ejaculatory control and overall sexual satisfaction, and decrease the postorgasmic refractory time for achieving a second erection after ejaculation. Concerning the efficacy, the meta-analysis shows an overall positive effect for the use of PDE5 as monotherapy or as components of a combination regimen in the treatment of PE. The major limitations of the published literature included poor study design, the absence of solid methodology, which was characterized by the lack of a unique PE definition, and the lack of appropriate endpoints for outcome evaluation of a placebo control arm and of Institutional Review Board approval.

Conclusion.  There is inadequate, partial basic, and clinical evidence to support the use of PDE5 for the treatment of PE. Asimakopoulos AD, Miano R, Agrò EF, Vespasiani G, and Spera E. Does current scientific and clinical evidence support the use of phosphodiesterase type 5 inhibitors for the treatment of premature ejaculation? A systematic review and meta-analysis. J Sex Med **;**:**–**.

Introduction.  The Sexual Function Questionnaire (SFQ) is a self-report outcome measure of female sexual function. It has recently been refined to create a 28-item version (SFQ28) including the addition of a new arousal-cognitive domain.

Aim.  This study aimed to validate the SFQ28 in female sexual arousal disorder (FSAD) and hypoactive sexual desire disorder (HSDD) populations and to develop a screening cut-score for the arousal-cognitive domain.

Methods.  Women with FSAD (n = 222) and HSDD (n = 114) and 303 women without female sexual dysfunction (FSD) completed the SFQ28, the Female Sexual Distress Scale (FSDS), and the Sexual Quality of Life-Female (SQOL-F) at a clinic visit. Retests were performed within FSD groups only (FSAD: n = 92, HSDD: n = 183), using postal questionnaires 7–14 days later. The optimal cut-score for the arousal-cognitive domain was based on diagnostic tests of sensitivity and specificity from a receiver operating characteristic curve.

Main Outcome Measures.  Psychometric analyses.

Results.  The factor analysis confirmed the domain structure of the SFQ28. The SFQ28 demonstrated excellent internal consistency, test retest reliability and known groups validity, and good convergent validity with the FSDS and SQOL-F for all domains except pain. The sensitivity/specificity analysis determined a screening cut-score of 5 for the arousal-cognitive domain.

Conclusion.  Given the replication of the psychometric data and the cut-scores for each domain, the SFQ28 is a robust measure that can be used in women with either FSAD or HSDD. Symonds T, Abraham L, Bushmakin AG, Williams K, Martin M, and Cappelleri JC. Sexual function questionnaire: Further refinement and validation. J Sex Med **;**:**–**.

Introduction.  More than half of intraoperative complications occur during dilatation of the corpora cavernosa, a critical step in the placement of any type of penile prosthesis, which can be especially difficult in a patient with corporal fibrosis. A late manifestation of cylinder placement can be impending erosion with lateral extrusion or medial deviation (into the urethra) of the distal tips. There are many different approaches to try and fix these surgical issues.

Aim.  The review article evaluates the many different surgical techniques prosthetic surgeons use in the management of intraoperative complications and lateral extrusion.

Methods.  A review of the literature was preformed with published results being evaluated to try to help guide the management of intraoperative complications and impending distal erosion. There is a special focus on dilation of the corpora cavernosa.

Main Outcomes Measures.  The article reviews and evaluates the outcomes of the landmark papers in the management of intraoperative complications and impending distal erosion.

Results.  Intraoperative complications of penile implant placement can be distressing for the prosthetic surgeon, but with proper recognition, most of these complications can be navigated with excellent postoperative results.

Conclusions.  This review article summarizes many of the techniques, outcomes, and new developments in the complicated field of penile prosthetic surgery to help guide the implanting surgeon. Henry GD and Laborde E. A review of surgical techniques for impending distal erosion and intraoperative penile implant complications: Part 2 of a three-part review series on penile prosthetic surgery. J Sex Med **;**:**–**.

Introduction.  Penile strangulation can be a challenging clinical situation and usually requires prompt treatment. The clinician should be aware of the various techniques to remove such devices.

Aim.  The aim of this article was to describe a new noninvasive technique, the “pseudo-pulley” method, to remove a penile constriction device.

Methods.  During an episode of medication-induced hypersexuality, a 63-year-old man presented to the emergency department with a cast iron locking nut of a vehicle towbar lodged at the base of the patient's penis.

Results.  The utilization of the “pseudo-pulley” method to remove the constriction device negated the need for more invasive measures. We outline a step-by-step description on this new technique. The patient's recovery was complete and uneventful.

Conclusion.  The current case report describes a noninvasive technique for removing a penile constriction device that does not rely on specialized equipment and industrial drills that can cause iatrogenic injury. Katz DJ, Chin W, Appu S, Harper M, Vukasin F, Tay YK, Pang C, and Dowling C. Novel extraction technique to remove a penile constriction device. J Sex Med **;**:**–**.

Introduction.  Androgen deprivation therapy (ADT) is the cornerstone in the treatment of advanced and metastatic prostate cancer (PC). However, recent publications suggest that ADT may increase cardiovascular (CV) problems (morbidity and mortality), most probably because androgens regulate fat distribution, insulin sensitivity, and lipid metabolism.

Aim.  The aim of the present review is to analyze different modalities of ADT, emphasizing advantages and possible related adverse sexual events.

Method.  A systematic search of published evidence was performed using Medline (from 1969 to September 2011).

Main Outcome Measure.  The most important studies regarding the relationship among testosterone, PC, and the role of ADT were reviewed.

Results.  There is unequivocal evidence that reducing androgen signaling to the hypogonadal range can reduce PC growth and patient symptoms; however, androgen dependency of prostate growth is evident only in the hypogonadal condition but not in the eugonadal state (the “saturation hypothesis”). There is clear evidence that ADT improves disease-free and overall survival only under two conditions: (i) in combination with primary radiation for locally advanced or high-risk diseases and (ii) as an adjuvant therapy for positive lymph node diseases after prostatectomy. On the other hand, it should be recognized that ADT can adversely affect not only traditional CV risk factor (including serum lipoproteins, insulin sensitivity, and obesity) but also sexual life, being associated with reduced libido and erectile, ejaculatory, and orgasmic disorders.

Conclusions.  Physicians should weigh the risk/benefit ratio before prescribing ADT. Corona G, Gacci M, Baldi E, Mancina R, Forti G, and Maggi M. Androgen deprivation therapy in prostate cancer: Focusing on sexual side effects. J Sex Med **;**:**–**.

Introduction.  The history of treatments for erectile dysfunction (ED) has involved a repeated pattern of uptake, followed by abandonment of the various therapies in the medium term. Even effective and simple to use medications are not necessarily continued; discontinuation rates range between 15% and 60%. Despite the association between partner sexual function and men's use of PDE5, no previous studies have reported any contact with partners of men taking PDE5 for their ED. This study involved both partners in couples followed up at least 1 year after treatment of ED.

Aim.  The study sought clarification of factors influencing adherence to, or discontinuation of, oral ED medications from couples. We hypothesized that many factors contribute to decision making about ED medication use at >12 months.

Main Outcome Measures.  The main outcome measures of this article were interviews and International Index of Erectile Function-erectile function domain.

Methods.  A total of 155 interviews were conducted seeking details of frequency of usage and preference for the drugs available; reasons for that choice, or for discontinuation of use, were also sought.

Results.  Of men interviewed, 71% were using PDE5 at 18 months. Most men interviewed were using the oral medications either 1–2x/week or 1–2x/month. Forty-four percent of men who had decreased their use of the medications reported less need for them. Thirty-four men said the main reason they were using less medication was cost. “Partner issues” from the men's perspective were seldom reported in this study. However, for a number of women, “partner issues” meant a range of problems from separation to alcohol abuse, lack of communication, and lack of confidence, or fear of failure.

Conclusions.  This is the first study to ask couples why they decided to continue or stop using PDE5 when followed up. Female partners provided a different perspective on “partner issues” often cited as reasons for discontinuing PDE5 use. It was also clear that discontinuation did not mean couples were no longer sexually active. Conaglen HM and Conaglen JV. Couples' reasons for adherence to, or discontinuation of, PDE type 5 inhibitors for men with erectile dysfunction at 12 to 24-month follow-up after a 6-month free trial. J Sex Med **;**:**–**.

Introduction.  Sexual dysfunction is common in patients with major depressive disorder (MDD). Antidepressant medications especially the selective serotonin reuptake inhibitors (SSRIs) may improve depressive symptoms but further decrease sexual function. Gepirone extended release (gepirone-ER) differs from the SSRIs in only affecting the 5-HT_1A receptor and has demonstrated efficacy in treatment of depression and sexual dysfunction in depressed women. This report describes the effect of gepirone-ER on sexual function in depressed men.

Aim.  The aims of this article were to study the effects of gepirone-ER on sexual function in men with MDD and to determine if positive effects are independent of antidepressant or anxiolytic activity.

Main Outcome Measures.  The main outcome measures of this article were Hamilton depression rating scale (HAMD-17), and changes in sexual functioning questionnaire (CSFQ).

Methods.  In an 8-week study, gepirone-ER, placebo, or fluoxetine were administered in a double-blind fashion to 181 depressed men. The CSFQ results were used to determine quality of sexual function. To test for an antidepressant or anxiolytic effect, a 50% reduction in HAMD-17 score separated antidepressant responders from nonresponders, and item 12 of the HAMD scale (psychic anxiety) scores of 0 or 1 separated anxiolytic responders from nonresponders.

Results.  Gepirone-ER treatment improved total sexual function compared with placebo measured by the CSFQ at weeks 4 (P = 0.012) and 8 (P = 0.046). At 4 weeks, almost every CSFQ domain is improved. The orgasm domain was especially improved, 67% by week 4. Gepirone-ER antidepressant and anxiolytic nonresponders showed significant improvement in sexual function. Fluoxetine treatment did not produce improvement. In fact, fluoxetine-treated subjects had lower scores on the total CSFQ, less than placebo, and significantly less than gepirone-ER.

Conclusion.  Gepirone-ER improves sexual dysfunction in depressed men. All domains of sexual function improved. Gepirone-ER has a pro-sexual effect independent of antidepressant or anxiolytic activity. Fabre LF, Clayton AH, Smith LC, Goldstein IM, and Derogatis LR. The effect of gepirone-ER in the treatment of sexual dysfunction in depressed men. J Sex Med **;**:**–**.

Introduction.  The existence of an anatomically distinct female G-spot is controversial. Reports in the public media would lead one to believe the G-spot is a well-characterized entity capable of providing extreme sexual stimulation, yet this is far from the truth.

Aim.  The aim of this article was to provide an overview of the evidence both supporting and refuting the existence of an anatomically distinct female G-spot.

Methods.  PubMed search for articles published between 1950 and 2011 using key words “G-spot,”“Grafenberg spot,”“vaginal innervation,”“female orgasm,”“female erogenous zone,” and “female ejaculation.” Clinical trials, meeting abstracts, case reports, and review articles that were written in English and published in a peer-reviewed journal were selected for analysis.

Main Outcome Measure.  The main outcome measure of this article was to assess any valid objective data in the literature that scientifically evaluates the existence of an anatomically distinct G-spot.

Results.  The literature cites dozens of trials that have attempted to confirm the existence of a G-spot using surveys, pathologic specimens, various imaging modalities, and biochemical markers. The surveys found that a majority of women believe a G-spot actually exists, although not all of the women who believed in it were able to locate it. Attempts to characterize vaginal innervation have shown some differences in nerve distribution across the vagina, although the findings have not proven to be universally reproducible. Furthermore, radiographic studies have been unable to demonstrate a unique entity, other than the clitoris, whose direct stimulation leads to vaginal orgasm.

Conclusions.  Objective measures have failed to provide strong and consistent evidence for the existence of an anatomical site that could be related to the famed G-spot. However, reliable reports and anecdotal testimonials of the existence of a highly sensitive area in the distal anterior vaginal wall raise the question of whether enough investigative modalities have been implemented in the search of the G-spot. Kilchevsky A, Vardi Y, Lowenstein L, and Gruenwald I. Is the female G-spot truly a distinct anatomic entity? J Sex Med **;**:**–**.

Introduction.  Several studies have shown that erectile function (EF) recovery in patients undergoing bilateral nerve sparing radical prostatectomy (BNSRP) improves significantly when phosphodiesterase type 5 inhibitors (PDE5) are administered following surgery.

Aim.  The aim of this article was to identify patients who may recover EF after retropubic BNSRP (BNSRRP) without PDE5.

Methods.  We included 293 patients treated with BNSRRP at a single center. Postoperative EF recovery was defined as an EF domain score of the International Index of Erectile Function (IIEF) ≥22. No patient received any treatment for postoperative erectile dysfunction (ED). Kaplan–Meier curves assessed time to EF recovery according to patient age, preoperative EF, and Charlson comorbidity index (CCI). Univariable and multivariable Cox regression models tested the association between predictors and EF recovery. Finally, the rate of EF recovery of untreated patients after BNSRP was compared with a subset of patients with similar preoperative characteristics but receiving PDE5.

Main Outcome Measure.  The main outcome measure of this article was the IIEF-EF domain score.

Results.  Overall, 105/293 (35.8%) reached an IIEF-EF ≥22 after a mean follow-up of 26.8 months. At multivariable analyses, age, preoperative IIEF-EF, and CCI achieved independent predictor status (all P ≤ 0.04). Patients <55 years had a 72.4% EF recovery rate compared with 30% of patients >70 years (P < 0.001). Similarly, preoperatively fully potent patients (IIEF-EF ≥26) had a 56.6% chance of recovering EF after surgery compared with 18% of patients with severe ED before surgery (P < 0.001). The rate of EF recovery in untreated patients <55 years and with a pre-op IIEF-EF ≥22 was higher but did not differ significantly from comparable patients receiving PDE5 (P = 0.11).

Conclusions.  Overall, the rate of EF postoperative recovery in patients left untreated after surgery is modest (35.8%). Although younger patients with a good preoperative EF may experience good EF recovery rates even without any treatment, use of PDE5 after surgery further improved their functional outcomes. Therefore, a therapy for ED should be offered to all patients treated with BNSRP. Gallina A, Ferrari M, Suardi N, Capitanio U, Abdollah F, Tutolo M, Bianchi M, Saccà A, Salonia A, Rigatti P, Montorsi F, and Briganti A. Erectile function outcome after bilateral nerve sparing radical prostatectomy: Which patients may be left untreated? J Sex Med **;**:**–**.

Introduction.  The out-of-pocket cost for an elective orchiectomy, which is often not covered by health insurance, is a significant barrier to male-to-female transsexuals ready to proceed with their physical transition. This and other barriers (lack of access to a surgeon willing to perform the operation, waiting times, and underlying psychological and psychiatric conditions) lead a subset of transsexual women to attempt self-castration. Little information has been published on the financial costs and implications of self-castration to both patients and health care systems.

Aim.  We compare the financial and psychological costs of elective surgical orchiectomy vs. self-castration in the case of a transsexual woman in her 40s.

Methods.  We interviewed the patient and her providers and obtained financial information from local reimbursement and billing specialists.

Results.  After experiencing minor hemorrhage following the self-castration, our patient presented to the emergency department and underwent a bilateral inguinal exploration, ligation and removal of bilateral spermatic cords, and complicated scrotal exploration, debridement, and closure. She was admitted to the psychiatric service for a hospital stay of three days. The total bill was US $14,923, which would compare with US $4,000 for an elective outpatient orchiectomy in the patient's geographical area.

Conclusions.  From a financial standpoint, an elective orchiectomy could have cost the health care system significantly less than a hospital admission with its associated additional costs. From a patient safety standpoint, elective orchiectomy is preferable to self-castration which carries significant risks such as hemorrhage, disfigurement, infection, urinary fistulae, and nerve damage. Healthcare providers of transsexual women should carefully explore patient attitudes toward self-castration and work toward improving access to elective orchiectomy to reduce the number of self-castrations and costs to the overall health care system. Further research on the financial implications of self-castration from different health care systems and from a series of patients is needed. St. Peter M, Trinidad A, and Irwig MS. Self-castration by a transsexual woman: Financial and psychological costs: A case report. J Sex Med **;**:**–**.

Introduction.  Gynecological exams continue to be underused among young women, possibly due to a woman's genital self-image.

Aims.  The purpose of this study was to (i) examine college women's genital image using the Female Genital Self-Image Scale (FGSIS); (ii) assess the reliability, validity, and factor structure of data collected on the FGSIS; and (iii) examine the relationship between FGSIS scores and gynecological exam behaviors.

Method.  Data were collected in November/December 2010 from 450 undergraduate women.

Main Outcome Measures.  Descriptive statistics were utilized to analyze demographic variables. A comprehensive psychometric assessment of the FGSIS included: (i) a reliability assessment of internal consistency; (ii) conducting a confirmatory factor analysis (CFA) to identify factor structure; and (iii) structural equation modeling and predictive discriminant analysis to asses the predictive qualities of the FGSIS on gynecological exam behavior.

Results.  CFA analyses yielded a two-factor FGSIS structure: X² (12, N = 450) = 49.77; P < 0.001, Root Mean Square Error of Approximation = 0.08, Comparative Fit Index = 0.98, Normed Fit Index = 0.97. Reliability assessments indicated very good internal consistency for the scale (α = 0.89), as well as for factor one (α = 0.86) and factor two (α = 0.82). Women who engaged in at least one gynecological exam during the past 24 months had a significantly more positive genital self-image than those who had not (t (449) = −2.501; P = 0.01).

Conclusions.  Data collected using the FGSIS were found to be valid and reliable in this sample, further supporting the utility of the scale and aiding in the understanding of college women's genital image using an underlying two-factor approach. This has important implications for the development of sexual health and women's health programs and discussions. Specifically, a two-factor FGSIS can aid medical and health professionals in better understanding relationships between genital image and gynecological exam behavior. DeMaria AL, Hollub AV, and Herbenick D. The Female Genital Self-Image Scale (FGSIS): Validation among a sample of female college students. J Sex Med **;**:**–**.

Introduction.  Fibromyalgia may have negative effects on sexual function in women.

Aims.  To evaluate the sexuality of women with fibromyalgia and healthy control subjects, and to investigate the relation between sexuality and clinical parameters of fibromyalgia.

Main Outcome Measures.  Female Sexual Function Index (FSFI), Tender Points Count (TPC), Beck Depression Inventory (BDI), Fibromyalgia Impact Questionnaire (FIQ), and Visual Analog Scale (VAS).

Methods.  Clinical evaluation and surveys were done with 126 women with fibromyalgia and 132 healthy women.

Results.  Patients with fibromyalgia had higher BDI scores and lower frequency of sexual intercourse than control subjects. The mean FSFI scores (total and all domains) were significantly lower in patients with fibromyalgia than control subjects. Mean FSFI scores (total and most domains) were significantly lower in patients with fibromyalgia who had BDI score ≥ 17 than those who had BDI score < 17. In women with fibromyalgia, a significant negative correlation was noted between total FSFI score, and both FIQ and BDI scores.

Conclusions.  Fibromyalgia has negative effects on female sexual function that are aggravated by depression. Yilmaz H, Yilmaz SD, Polat HAD, Salli A, Erkin G, and Ugurlu H. The effects of fibromyalgia syndrome on female sexuality: a controlled study. J Sex Med **;**:**–**.

Introduction.  Previous research has indicated that serotonergic genes may influence ejaculatory function. Attempts to investigate effects of polymorphisms in serotonergic genes have been carried out, but so far, no study has conducted exploratory genotype analyses regarding the serotonin receptor 1A, 1B, and 2C subtypes, which have been hypothesized to mediate the inhibitory effects of serotonin on ejaculation in rodents.

Aim.  The aim of the present study was to investigate effects of a total of six single nucleotide polymorphisms (SNPs) located in genes encoding serotonin receptor subtypes 1A, 1B, and 2C on self-reported ejaculation latency time.

Methods.  A retrospective self-report measure of ejaculation latency time was used to investigate ejaculatory function in a population-based sample of 1,399 male twins. DNA was collected using self-administered saliva sampling.

Main Outcome Measure.  Calculations of allelic effects were conducted using the Generalized Estimating Equations module of PASW 18.0, which appropriately controls for between-subjects dependence.

Results.  Out of six investigated polymorphisms, two SNPs (both serotonin receptor 5-HT_1B linked) had a significant main effect on ejaculation latency time. Of these, one (rs11568817) remained significant after Bonferroni correction for multiple testing, indicating that individuals homozygous for the G allele had significantly shorter ejaculation latencies.

Conclusions.  The results of this study support the hypothesis that serotonergic genes play a role in ejaculatory function in the general population. Replication of the results of the present study is warranted. Jern P, Westberg L, Johansson A, Gunst A, Eriksson E, Sandnabba K, and Santtila P. A study of possible associations between single nucleotide polymorphisms in the serotonin receptor 1A, 1B, and 2C genes and self-reported ejaculation latency time. J Sex Med **;**:**–**.

Introduction.  While erectile dysfunction (ED) and cardiovascular disease have long been known to share endothelial dysfunction as a common contributory underlying mechanism, little research has been conducted taking endothelial dysfunction as common ground to investigate the potential association between ED and gastric ulcers (GUs).

Aim.  This population-based case-control study aimed to investigate the association of ED with GU.

Methods.  This study used data from the Longitudinal Health Insurance Database 2000 in Taiwan. The study group comprised 6,906 patients who visited ambulatory care centers or were hospitalized with a diagnosis of ED. The comparison group was 20,718 randomly selected enrollees. Conditional logistic regression was used to examine associations between ED and prior GU.

Main Outcome Measure.  The prevalence and risk between cases and controls were calculated of having been previously diagnosed with GU.

Results.  Of the sampled subjects, 3,861 (14%) were diagnosed before the index date, 1,358 (19.7%) were cases, and 2,503 (12.1%) were controls (P < 0.001). After adjusting for hypertension, diabetes, hyperlipidemia, renal disease, coronary heart disease, obesity, alcohol abuse/alcohol dependence syndrome, and socioeconomic status (SES), conditional logistic regression analysis revealed that cases were more likely to have been diagnosed with GU than controls (odds ratio [OR] = 1.65, 95% confidence interval [CI] = 1.53–1.77). Stratification by age revealed that the youngest group (18–29) of ED patients had the most increased likelihood of having been previously diagnosed with GU when compared with matched controls (OR = 4.12, 95% CI = 2.41–7.03). The likelihood decreased with age, with the oldest group of ED patients having the least increased likelihood of prior GU when compared with matched controls (OR = 1.44, 95%CI = 1.23–1.68).

Conclusion.  Our findings suggest a positive association between prior GU and a subsequent diagnosis with ED. Keller JJ, Lin H-Yu, Chung S-D, and Lin H-C. A population-based study on the association between gastric ulcers and erectile dysfunction in Taiwan. J Sex Med **;**:**–**.

Introduction.  This study qualitatively explores perceptions of women who have experienced abortion care. It explores women's journey through abortion from confirmation of pregnancy to post-abortion.

Aim.  The study seeks to understand the implications of these perceptions for policy and practice.

Main Outcome Measures.  A qualitative study involving in-depth semi-structured interviews with 17 women, aged between 22 and 57 years, who had undergone legal induced abortion in the UK when they were 16 years or older. Participants were not recruited under the age of 16 because of the ethical and legal complexities of interviewing minors. Additionally, 16 years was deemed to be the most appropriate age as this is the legal age of consent in the UK.

Methods.  Participants were recruited from 12 community contraception and sexual health clinics in two NHS trusts, one in England and one in Wales. Participant recruitment was set at a minimum of 12 and participants were recruited on a “first come first served basis” (i.e., the first 12 who contacted the researcher). The number of participants was raised to seventeen as this was the number deemed to be the most suitable for data saturation in this particular qualitative research.

Results.  Women in this study understood abortion as highly taboo and a potentially personally stigmatizing event. These perceptions continued to affect disclosure to others, long after the abortion, and affected women's perceptions of the response of others, including society in general, significant others, and health professionals.

Conclusions.  Women's experiences of abortion may be influenced by perceived negative social attitudes. Health professionals and abortion service providers might combat the perceived isolation of women undergoing abortion by attending not only to clinical/technical aspects of the procedure but also to women's psychological/emotional sensitivities surrounding the event. Astbury-Ward E, Parry O, and Carnwell R. Stigma, abortion and disclosure—Findings from a qualitative study. J Sex Med **;**:**–**.

Introduction.  Little is known about the characteristics of sexual events during which individuals choose to use lubricant with condoms.

Aims.  The aims of this article were to evaluate the determinants of adding lubricant to condoms during baseline and at the event level, to assess the event-level variables' influence on adding lubricants to condoms, and to assess the event-level influence of using condoms with lubricant on event-level condom attitudes.

Methods.  A total of 1,874 men completed a 30-day Internet-based prospective daily diary study of sexual behavior and condom use.

Main Outcome Measures.  Baseline data included demographic variables and information about condom education. Daily diary data included reports of penile-vaginal sex regarding intercourse duration, intercourse intensity, intoxication level, condom application method, partner contraceptive method, and partner and relationship characteristics.

Results.  Lubricant was added to 24.3% of the study-provided condoms and 26.2% of the condoms selected by study participants. Those with more education and those who were married were more likely to add lubrication to condoms. Adding lubricant to condoms, a female partner putting the condom on with her hands and using contraception, and the event occurring with a wife (vs. girlfriend) was significantly associated with longer intercourse. Event-level lubricant and condom use significantly predicted lower willingness to buy the condom it was used with, as well as to recommend the condom. Adding exogenous lubricant was not related to the participants' confidence in condoms as a method to prevent pregnancy and sexually transmitted infections.

Conclusions.  The event-level nature of this study provided for a more comprehensive assessment of the situational factors that are associated with applying lubricant to condoms. Findings from this study suggest that men are adding lubricant to condoms for reasons other than to increase condom efficacy. Reece M, Mark K, Herbenick D, Hensel DJ, Jawed-Wessel S, and Dodge B. An event-level analysis of adding exogenous lubricant to condoms in a sample of men who have vaginal sex with women. J Sex Med **;**:**–**.

Introduction.  Little is known about Hypoactive Sexual Desire Disorder (HSDD) in men.

Aim.  To provide the first comprehensive characterization of men diagnosed with HSDD (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision [DSM-IV-TR]) using established patient-reported outcomes (PROs) and new PROs developed in line with U.S. Food and Drug Administration (U.S. FDA) guidance.

Methods.  This 4-week non-treatment study recruited men (N = 200) with or without symptoms of low sexual desire and related distress. Men with erectile dysfunction, serum testosterone <300 ng/dL, or depression were excluded. Men completed assessments of sexual desire and sex-related distress and underwent structured clinical interviews for the diagnosis of HSDD.

Main Outcome Measures.  Primary endpoints were scores on the Sexual Desire Inventory (SDI), Male Desire Scale (MDS), Sexual Concerns Inventory-Male (SCI-M), and Sexual Desire Relationship Distress Scale (SDRDS) on day 28, and University of California, Los Angeles (UCLA) Psychosexual Diary on days 21–27. Scores are presented as median (interquartile range).

Results.  There were no clinically relevant differences in age, serum testosterone, depressive symptomatology, erectile function, concomitant illness, or medication use between men with HSDD (N = 109) and men without HSDD (N = 91). However, clinically meaningful differences between men with and without HSDD were observed in sexual desire according to SDI score (40.0 [21.0] vs. 65.0 [25.0]) and MDS sexual desire domain score (18.0 [8.0] vs. 31.0 [13.0]), in sex-related distress according to SCI-M score (22.0 [12.0] vs. 6.0 [12.0]) and SDRDS score (36.0 [17.0] vs. 10.0 [16.0]), and in UCLA Psychosexual Diary sexual activity domain score (2.6 [2.7] vs. 4.9 [3.9]) (P < 0.0001, for all).

Conclusions.  Based on a brief structured interview, diagnosis according to DSM-IV-TR criteria for HSDD identified a population of men comparable with men without HSDD in age, serum testosterone, concomitant illness and medication use but distinct in their experience of sexual desire and distress associated with low desire. These controlled data characterize HSDD in men as a distinct sexual dysfunction. DeRogatis L, Rosen RC, Goldstein I, Werneburg B, Kempthorne-Rawson J, and Sand M. Characterization of Hypoactive Sexual Desire Disorder (HSDD) in men. J Sex Med **;**:**–**.

Introduction.  High prevalence of erectile dysfunction in young adults has raised much concern regarding early identification of risk factors for timely intervention.

Aim.  This study aimed at identifying young males at risk through a novel penile arterial waveform analyzing system.

Methods.  Between July 2009 and December 2010, 30 young adult volunteers of age 18 to 29 without known history of vascular diseases or erectile dysfunction were recruited.

Main Outcome Measures.  Basic demographic and anthropometric characteristics (i.e., age, body weight, body height, body mass index, waist circumference) were recorded. Blood samples were obtained for determining levels of testosterone, glycosylated hemoglobin, triglyceride, fasting sugar, low- and high-density lipoproteins (HDL). Data obtained from visual sexual stimulation (VSS) RigiScan and the penile arterial waveform amplitude (PAWA) ratios were compared in terms of their correlations with anthropometric and serum biochemical parameters using Pearson's correlation analysis.

Results.  PAWA ratios were found to correlate with Rigidity (tip and base) (r = 0.425, P = 0.019 and r = 0.664, P < 0.001, respectively). Significant associations of PAWA ratios were noted not only with serum testosterone level but also with risk factors for metabolic and cardiovascular diseases including total triglyceride, HDL, age, waist circumference, body mass index, and diastolic blood pressure. However, VSS RigiScan failed in identifying significant correlations with HDL, age, and diastolic blood pressure.

Conclusions.  Not only could the penile waveform analyzing system assess penile endothelial function in young adults, but the results also showed significant associations with their serum testosterone levels and metabolic parameters. The findings suggest that PAWA ratio may serve as an indicator for early identification and treatment of young adults at risk of erectile dysfunction. Wu H-T, Lee C-H, Chen C-J, and Sun C-K. Penile arterial waveform analyzing system for early identification of young adults with high risk of erectile dysfunction. J Sex Med **;**:**–**.

Introduction.  Flow-mediated vasodilation (FMD) of the brachial artery is a noninvasive tool used for endothelial function evaluation. There is increasing evidence that endothelial dysfunction is a common etiological factor for erectile dysfunction (ED) and cardiovascular events.

Aim.  To evaluate endothelial function with a high-resolution ultrasound device, to assess FMD in men diagnosed with ED and without clinical evidence of significant atherosclerotic disease, classified as “intermediate risk” according to the Framingham risk score (FRS).

Methods.  This is a case-control study that included 52 consecutive men. In all men with ED evaluated by a score less than 22 on International Index of Erectile Function-5 questionnaire (IIEF-5), clinical parameters such as blood pressure, waist circumference, hip circumference, body mass index, lipid profile, fasting glucose, and serum total testosterone were obtained. These parameters were compared with those men without diagnosis of ED (IIEF-5 score ≥ 22) (age-matched, also classified as “intermediate risk” according to the FRS). All underwent brachial artery ultrasound for assessment of FMD, as a noninvasive method to evaluate endothelial function. Statistical analysis was performed considering a P < 0.05.

Main Outcome Measures.  Endothelium-dependent FMD was evaluated in the right brachial artery with a high-resolution ultrasound machine following reactive hyperemia.

Results.  Thirty-four men were included in the ED group, and 18 were included in the group without ED. The mean ages were 59.61 ± 9.87 and 56.18 ± 10.93, respectively (P = 0.27). Clinical and laboratory evaluations were similar between men with and without ED (P > 0.05) except for waist circumference that was greater in patients with ED (mean = 100.85 cm vs. 96.05; P < 0.05). The percentage of FMD was higher in men without ED when compared with those with ED (mean FMD 11.33 ± 6.08% vs. 4.24 ± 7.06%, respectively; P = 0.001).

Conclusions.  Men without established atherosclerotic disease presenting with ED demonstrated a worse endothelial function. Averbeck MA, Colares C, de Lira GHS, Selbach T, and Rhoden EL. Evaluation of endothelial function with brachial artery ultrasound in men with or without erectile dysfunction and classified as intermediate risk according to the Framingham score. J Sex Med **;**:**–**.

Introduction.  Anencephaly is the most severe neural tube defect in human fetuses. There is an increasing need for tissue replacement in chronic diseases and reconstructive surgeries. Fetal tissues have been used as a substitute for native organs.

Aim.  The aim of this article was to compare the structure and morphology of the corpora cavernosa (CC) and spongiosum (SP) of penises from anencephalic and normal human fetuses.

Main Outcome Measures.  The main outcome measures of this study were the proposition of a new model for biological studies and tissue transplantation.

Methods.  We studied 11 penises from normal human fetuses, aged 14–23 weeks postconception (WPC), and five penises from anencephalic fetuses, aged 18–22 WPC. The organs were removed and processed by routine histological and immunolabeling techniques. Analysis of connective tissue (Cot), smooth muscle (SMC), and elastic fiber (EF) were performed in sections. Data were expressed as area density (Ad) using digital processing and software. Means were statistically compared using the unpaired t-test and linear regression was performed. Statistical significance was considered if P < 0.05.

Results.  The intracavernosal septum was present in all samples. We did not observe differences in the Ad of Cot and SMC in the penises of anencephalic fetuses when compared with normal ones. The simple linear regression suggested that during human development, there is a gradual increase in Cot (R² = +0.45) and a decrease of SMC (R² = −0.62) in the CC in both groups studied. Elastin was observed only in fetuses from 20th WPC.

Conclusions.  There was no difference in the structure of the CC and corpus SP of anencephalic fetuses compared with normal ones. Elastin was documented from 20th WPC, which suggests the maintenance of erectile function. Histochemistry and immunolabeling suggested that penile shaft development is maintained and unaltered in anencephalic fetuses. Further studies should be performed to analyze anencephalic fetuses as a potential tissue-donating group and a model for biological studies. de Carvalho JPM, Costa WS, Sampaio FJB, and Favorito LA. Anencephaly does not cause structural alterations in the fetal penis. J Sex Med **;**:**–**.

Introduction.  Some studies have highlighted the high prevalence of erectile dysfunction (ED) in patients with dermatological diseases such as psoriasis, chronic hand eczema, and systemic sclerosis. However, to date, there is still no study that has explored the relationship between ED and atopic dermatitis (AD).

Aim.  Using a population-based data set, this case-control study aimed to examine the association of ED with prior AD by comparing the risk of prior AD between patients with ED and matched controls in Taiwan.

Methods.  This study used administrative claims data from the Taiwan National Health Insurance program. We identified 3,997 patients with newly diagnosed ED as cases and randomly selected 19,985 subjects without a history of ED as controls. Conditional logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence interval (CI) for previously diagnosed AD between cases and controls.

Main Outcome Measure.  The prevalence and risk of having been previously diagnosed with AD between cases and controls were calculated.

Results.  Of the 23,982 sampled subjects, 1,758 (7.3%) had been previously diagnosed with AD; it was found among 425 (10.6%) cases and among 1,333 (6.7%) controls (P < 0.001). Conditional logistic regression analysis demonstrated that cases were more likely to have prior AD than controls (OR = 1.60, 95% CI = 1.42–1.80, P < 0.001) after adjusting for monthly income, geographic location, urbanization level, hypertension, diabetes, coronary heart disease, hyperlipidemia, obesity, and alcohol abuse/alcohol dependence syndrome.

Conclusions.  There was an association between ED and prior AD. We suggest that clinicians should be more attentive to sexual complaints from patients with AD. Chung S-D, Keller JJ, and Lin H-C. Association of erectile dysfunction with atopic dermatitis: A population-based case-control study. J Sex Med **;**:**–**.

Introduction.  The majority of human immunodeficiency virus (HIV) infections are acquired through unprotected sex between partners; only male or female condoms can reduce the chances of infection with HIV during a sexual act.

Aim.  This study was therefore designed to describe sexual risk history and identify factors associated with condom use among people living with HIV/acquired immunodeficiency syndrome (AIDS) (PLWHAs) in Ogun State, Nigeria.

Main Outcome Measures.  Main outcome measures are sexual and HIV risk history, safe sex practices, and condom use.

Methods.  This study is an analytical cross-sectional study. A total sample of all people living with HIV/AIDS attending secondary health facilities in Ogun State were recruited into the study.

Result.  A total of 637 were interviewed; median age at first sexual intercourse among the study participants was 19 years (mean age = 18.95, standard deviation [SD] = 4.148) with a median of two lifetime sexual partners (mean = 3.22, SD = 3.57). Majority (71.4%) of the respondents had not been diagnosed with a sexually transmitted infection other than HIV. Precisely 47.7% of men and 52.3% of women had two or more sexual partners in the last 6 months. Men were statistically significantly more likely to have multiple sexual partners when compared with women (P = 0.00). Significantly more women (69.8%) than men (30%) had sexual partners whose HIV status they did not know (P = 0.006). Predictors of condom use were individuals who had multiple sexual partners (odds ratio [OR] = 1.41, confidence interval [CI] = 1.05–1.83) and married (OR = 3.13, CI = 1.15–8.51) with higher level of education (OR = 2.78, CI = 1.39–5.79), with knowledge of partner's serostatus (OR = 2.53, CI = 1.50–4.28), and awareness of reinfection (OR = 1.90, CI = 1.22–2.95).

Conclusion.  The study indicates that the establishment of effective safe sex practices and condom use behavior among PLWHAs in low-income countries such as the study population requires adequate health education on the transmission of HIV/AIDS and the understanding of the dynamics of family life and gender issues. Amoran O and Ladi-Akinyemi T. Sexual risk history and condom use among people living with HIV/AIDS in Ogun State, Nigeria. J Sex Med **;**:**–**.

Introduction.  Erectile dysfunction (ED) is a frequent comorbidity in men with diabetes and is frequently overlooked in routine clinical evaluation. Albuminuria, a marker of endothelial dysfunction, may link to ED.

Aim.  The study evaluated the association of albuminuria with risk factors of ED in men with type 2 diabetes.

Methods.  The diagnosis of ED was based on a self-administered questionnaire containing Sexual Health Inventory for Men. Urinary albumin excretion rate was determined by urine albumin-to-creatinine ratio (UACR) in spot urine.

Main Outcome Measures.  The clinical variables and diabetes-associated complications to risk of ED were evaluated.

Results.  Of 666 patients who received the questionnaire, 455 patients completed it. Among them, 82.0%, 28.1%, and 35.8% reported having ED, severe ED, and albuminuria, respectively. The UACR level was significantly higher in ED (0.20 ± 0.83) and severe ED (0.34 ± 1.18) groups compared with non-ED group (0.07 ± 0.33). The presence of albuminuria adjusted for age and duration of diabetes was significantly associated with ED (OR = 2.76), and macroalbuminuria has stronger impact (OR = 4.49) than microalbuminuria (OR = 2.48). The other associated risk factors included hypertension, higher level of systolic blood pressure, lower level of serum hemoglobin, and estimated glomerular filtration rate. The presence of retinopathy, neuropathy, insulin therapy, using calcium channel blocker, and higher level of HbA1c further correlated with severe ED. Men with severe ED have higher prevalence of subnormal testosterone than the no ED patients. The high sensitivity C-reactive protein level, and the presence of metabolic syndrome were not risk factors. The 211 nonrespondents to the questionnaire had similar or worse risk profiles compared with the ED patients.

Conclusion.  Albuminuria is an important independent risk factor of ED in men with diabetes after adjustment of age and diabetes mellitus duration. Identification and control of albuminuria and other associated risk factors might play a role in the prevention or reversal of ED. Chuang Y-C, Chung M-S, Wang P-W, Lee W-C, Chen C-D, Chang H-W, Yang KD, Chancellor MB, and Liu RT. Albuminuria is an independent risk factor of erectile dysfunction in men with type 2 diabetes. J Sex Med **;**:**–**.

Introduction.  Recurrent vulvovaginitis is an important trigger for inflammatory processes that in many cases may result in vulvovaginal pain. Vulvodynia, a vulvar disorder, can also cause a lot of pain in the female genitals. The sexual function in women with vulvodynia or recurrent vulvovaginitis will possibly be negatively affected and therefore should be evaluated.

Aim.  To assess sexual function in women with recurrent vulvovaginal candidiasis (RVVC) and localized provoked vulvodynia (LPV) in comparison with women without lower genital tract dysfunction.

Methods.  A 1-year cross-sectional study evaluated sexual function in 58 women (11 with RVVC, 18 with LPV, and 29 controls) seen at a university outpatient clinic. Sexual function was assessed by taking into account the results obtained from the application of the Female Sexual Function Index (FSFI) questionnaire. Kruskal–Wallis, Mann–Whitney, chi-square, and Fisher's tests were used for statistical analysis.

Main Outcome Measure.  FSFI, a validated questionnaire in Portuguese.

Results.  There were no significant differences in the three groups with respect to age, marital status, schooling, race, body mass index, contraceptive method, and parity. The FSFI questionnaire total score found was 25.51 (±5.12), 21.17 (±5.15), and 29.56 (±3.87) for the RVVC, LPV, and control groups, respectively. The scores were significantly statistically lower in the study groups compared with the control group (P < 0.05). Women with RVVC and LPV also had lower total scores compared with 26.55 values, considered a cutoff score for sexual dysfunction in literature. The LPV group showed a significant difference and scored worse in the domains of arousal, lubrication, orgasm, satisfaction, and pain but not in the domain of sexual desire. The same occurred with the RVVC group but only for the domains of orgasm and satisfaction.

Conclusion.  Women with RVVC and LPV had significantly more symptoms of sexual dysfunction than women without lower genital tract diseases. Giraldo PC, Polpeta NC, Juliato CRT, Yoshida LP, Amaral RLG, and Junior JE. Evaluation of sexual function in Brazilian women with recurrent vulvovaginal candidiasis and localized provoked vulvodynia. J Sex Med **;**:**–**.

Introduction.  To our knowledge, here we report the first case of nonischemic priapism following penile tattooing.

Aim.  To report the first case of nonischemic priapism following penile tattooing.

Methods.  A case with tattooing-induced priapism is presented including subjective reporting, physical examination, and laboratory/radiologic evaluations.

Results.  A 21-year-old man, presented with partially rigid penis of 3-month duration. On examination, the penis was half rigid, with a tattoo on its dorsal surface, and a smaller tattoo on the glans (Figure 1). The patient initially stated that the tattoo had been created years ago, but later admitted that he had it created just before the occurrence of priapism. A traditional tattooist created the tattoo manually, using a handheld needle. Bleeding from deep penile tissue for several days complicated the tattooing.

Known etiologies of priapism were investigated and ruled out. Specifically, perineal injury, leukemia, sickle cell trait, thalassemia, urinary tract infection, neurogenic, neoplastic, infectious, toxic, and pharmacological causes were actively investigated and ruled out. There was no history of alcohol consumption or smoking. Aspirated penile blood was bright red. Cavernous blood gas measurements confirmed high oxygen and low carbon dioxide content, diagnostic of arterial priapism.

There was no embolization facility in Kermanshah. In fact, there are few experts in superselective embolization in Iran. We referred the patient for superselective embolization. However, he underwent a nonindicated Sacher procedure. Predictably, the procedure was unsuccessful. At present, the patient continues to have priapism. Because of the painless nature of erections, moderately good preservation of erectile function during intercourses, and disappointment with former surgery, the patient declined further therapies, and he lives with his condition.

Conclusions.  Tattooing should be added to the etiologies of nonischemic priapism. Considering this case, we discourage penile tattooing. Zargooshi J, Rahmanian E, Motaee H, and Kohzadi M. Nonischemic priapism following penile tattooing. J Sex Med **;**:**–**.

Introduction.  This is a report of a very rare case of proven postcoital penile drug eruption in a patient following vaginal use of triple sulfa vaginal cream by his partner.

Aim.  To report the rare case of cross-reaction following vaginal use of triple sulfa vaginal cream in partner.

Methods.  A case of postcoital penile drug eruption in a patient following vaginal use of triple sulfa vaginal cream in his partner is presented including subjective reporting, physical examination, and laboratory evaluations.

Results.  We report a 42-year-old man with known sensitivity to trimethoprim/sulfamethoxazole (co-trimoxazole) who developed a penile drug eruption at the glans after having intercourse with his wife, who was taking sulfathiazole/sulfacetamide/sulfabenzamide (triple sulfa) vaginal cream. The nature of the lesion was confirmed by a rechallenge test.

Conclusion.  To our knowledge, this is the fourth case of proven postcoital penile drug eruption in a patient following vaginal use of triple sulfa vaginal cream in his partner. Our case illustrates the importance of history taking. In clinical practice of urology, it is not rare to see patients who present with strange penile lesions following coitus. To reach a correct diagnosis, one should obtain a drug history of the sexual partner and allergic history of the patient in such cases. Zargooshi J, Kavoussi H, Rahmanian E, Motaee H, Kohzadi M, and Nourizad S. Postcoital penile drug eruption in a co-trimoxazole-sensitive patient following vaginal use of triple sulfa vaginal cream by his partner. J Sex Med **;**:**–**.

Introduction.  Urethral coitus is rarely reported in the literature. The majority of reported cases have been secondary to vaginal agenesis or hymenal anomalies.

Aim.  We report a case of urethral coitus in a paraplegic patient with a patulous urethra resulting from chronic indwelling catheter use, with the unfortunate presentation of bladder rupture and evisceration per urethra. To our knowledge, this is the only report of urethral coitus due to sequelae from an indwelling catheter, as well as the only report of the subsequent complication of bowel evisceration per urethra.

Results.  After initial temporization at an outside facility, we were able to perform primary cystorrhaphy. There was no need for bowel resection. The patient has chosen to defer her decision on permanent reconstruction.

Conclusions.  Urethral coitus is rare and the subsequent ramifications can be devastating, particularly in neurologically impaired patients. This unusual case speaks to the importance of properly caring for the neurogenic bladder. Brown ET, Koski ME, and LaCour SM. Bowel evisceration through the bladder neck in a paraplegic female secondary to urethral coitus. J Sex Med **;**:**–**.

Introduction.  The weight of erectile dysfunction (ED) among the various determinants of psychological distress in men with spinal cord injury (SCI) remains to be clarified.

Aim.  The aim of this article was to evaluate psychological distress features in SCI men with or without ED.

Methods.  Forty consecutive patients with neurologically stable SCI were included in the study. Functional independence (FI) was assessed by Barthel Index (BI), which was divided into global score (questions 1–10) and bowel/bladder subscore (questions 5 and 6). Erectile function was evaluated with Sexual Health Inventory for Men (SHIM).

Main Outcome Measures.  Psychological distress was assessed with the Symptom Checklist-90-revised (SCL-90-R), scoring nine primary dimensions and their combination as Global Severity Index, a global index of psychological distress.

Results.  All SCL-90-R scores and the percentage of patients with scores >75th percentile of the entire study population were significantly higher in the group with ED (N = 21) than without ED (N = 19). Most of SCL-90-R subscales were inversely correlated with SHIM score. ED was exhibited by a high proportion (84%) of men with thoracolumbar lesions but by no patients with cervical lesions. Men with cervical lesions exhibited significantly lower SCL-90-R scores than those with thoracolumbar lesions, in spite of lower FI. However, the thoracolumbar group also reported a more severe bowel/bladder dysfunction. At multivariate logistic regression analysis, ED score significantly explained the variance of most of SCL-90-R dimension scores, whereas no association was revealed between global BI and any score of SCL-90-R dimensions. Bowel/bladder BI explained only to a very low extent the variance of depressive symptoms.

Conclusions.  Healthcare providers should be aware of the importance of managing ED in spinal cord-injured men, as it represents a major determinant of their psychological distress, independently of the degree of FI impairment. Barbonetti A, Cavallo F, Felzani G, Francavilla S, and Francavilla F. Erectile dysfunction is the main determinant of psychological distress in men with spinal cord injury. J Sex Med **;**:**–**.

Introduction.  Changes in the pubic region resulting from abdominoplasty may have a psychosexual impact. Thus, it is important to study the influence of physical changes on the sexuality of patients after abdominoplasty.

Aim.  To evaluate the effects of the elevation of the mons pubis and consequent exposure of the clitoris in the vulvar commissure on the sexual functioning and sexual satisfaction of women who underwent abdominoplasty.

Methods.  Data were presented as mean ± standard deviation. Nineteen women with a mean age of 35 ± 7 years, mean body mass index of 23 ± 2 kg/m² and who expressed a desire to undergo abdominoplasty were selected from consecutive patients attending the abdominal plastic surgery outpatient unit of a university hospital.

Main Outcome Measures.  Physical change (measured by the distance between the xiphoid process and vulvar commissure [xipho-vc]), sexual functioning, and sexual satisfaction (assessed with the Sexuality Assessment Scale), and body image (measured using the Body Shape Questionnaire [BSQ]) were evaluated preoperatively and 6 months after abdominoplasty.

Results.  There was a significant reduction (P = 0.0004; z = −3.53) in the xipho-vc distance 6 months after abdominoplasty compared with baseline (mean difference 3.63 ± 2.79 cm), corresponding to an elevation of the mons pubis and consequent exposure of the clitoris. All patients reported a significant improvement in sexual functioning and sexual satisfaction 6 months after abdominoplasty when compared with baseline (P = 0.0001; z = −3.83). BSQ scores indicated an improvement in the patients' concerns about body shape (P = 0.0003; z = −3.58).

Conclusion.  Our results suggest that physical change and the new position of the clitoris may have a positive impact on sexuality. de Brito MJA, Nahas FX, Bussolaro RA, Shinmyo LM, Barbosa MVJ, and Ferreira LM. Effects of abdominoplasty on female sexuality: A pilot study. J Sex Med **;**:**–**.

Introduction.  Sexual dysfunction in men, such as erectile dysfunction, hypogonadism, and premature ejaculation, generates considerable attention. Its association with physical and psychological health is an issue which should be addressed seriously.

Aim.  A review of the literature pertaining to the correlation between sexual dysfunction and physical and psychological health.

Methods.  PubMed search for relevant publications on the association between sexual dysfunction in men and physical and psychological health.

Main Outcome Measure.  Clinical and epidemiological evidence that demonstrates the association between sexual dysfunction in men and physical and psychological health.

Results.  Sexual dysfunction, i.e., erectile dysfunction, hypogonadism, and premature ejaculation, has been shown to be associated with physical and psychological health. There is a strong correlation between sexual dysfunction and cardiovascular disease, metabolic syndrome, quality of life, and depression.

Conclusion.  The association between men's sexual dysfunction and physical and psychological health is real and proven. Therefore, it should not be taken lightly but instead treated as a life-threatening medical problem. Tan HM, Tong SF, and Ho CCK. Men's health: Sexual dysfunction, physical, and psychological health—Is there a link? J Sex Med **;**:**–**.

Introduction.  The number of women with gestational diabetes mellitus (GDM) is growing worldwide in parallel with the obesity epidemic. The diagnosis of GDM leads to substantial modifications in the daily routine of these women, and these adjustments could potentially affect their sexual function. There are no previous studies on the sexual function of patients with GDM.

Aim.  The aim of this study was to investigate the sexual function of patients with GDM in comparison with healthy pregnant women at the same gestational age.

Methods.  Brazilian women in the third trimester of pregnancy with and without GDM were invited to participate in this cross-sectional study while waiting for their antenatal care visits at a single public tertiary teaching institution between March and December 2010. The Brazilian version of the Female Sexual Function Index (FSFI) questionnaire was used to assess sexual function.

Main Outcome Measures.  Desire, arousal, lubrication, orgasm, sexual satisfaction, and pain during and after coitus in the last 4 weeks, measured according to a standardized and validated questionnaire.

Results.  A total of 87 participants were enrolled (43 healthy women and 44 with GDM). There were no significant differences in the sociodemographic characteristics of both groups. The total FSFI scores of GDM patients was 21.0 ± 9.59 compared with 22.3 ± 9.17 for healthy women (P = 0.523). Difficulty in desire was the most common sexual dysfunction symptom in both groups, being reported by 42% and 50% of GDM and healthy women, respectively (P = 0.585).

Conclusion.  The sexual function of Brazilian patients with GDM does not differ significantly from that of healthy pregnant women at the same gestational age. Ribeiro MC, Nakamura MU, Scanavino Mde T, Torloni MR, and Mattar R. Female sexual function and gestational diabetes. J Sex Med **;**:**–**.

Introduction.  A population of lumbar spinothalamic cells (LSt cells) has been demonstrated to play a pivotal role in ejaculatory behavior and comprise a critical component of the spinal ejaculation generator. LSt cells are hypothesized to regulate ejaculation via their projections to autonomic and motor neurons in the lumbosacral spinal cord.

Aim.  The current study tested the hypothesis that ejaculatory reflexes are dependent on LSt cells via projections within the lumbosacral spinal cord.

Methods.  Male rats received intraspinal injections of neurotoxin saporin conjugated to substance P analog, previously shown to selectively lesion LSt cells. Two weeks later, males were anesthetized and spinal cords were transected. Subsequently, males were subjected to ejaculatory reflex paradigms, including stimulation of the dorsal penile nerve (DPN), urethrogenital stimulation or administration of D3 agonist 7-OH-DPAT. Electromyographic recordings of the bulbocavernosus muscle (BCM) were analyzed for rhythmic bursting characteristic of the expulsion phase of ejaculation. In addition, a fourth commonly used paradigm for ejaculation and erections in unanesthetized, spinal-intact male rats was utilized: the ex copula reflex paradigm.

Main Outcome Measures.  LSt cell lesions were predicted to prevent rhythmic bursting of BCM following DPN, urethral, or pharmacological stimulation, and emissions in the ex copula paradigm. In contrast, LSt cell lesions were not expected to abolish erectile function as measured in the ex copula paradigm.

Results.  LSt cell lesions prevented rhythmic contractions of the BCM induced by any of the ejaculatory reflex paradigms in spinalized rats. However, LSt cell lesions did not affect erectile function nor emissions determined in the ex copula reflex paradigm.

Conclusions.  These data demonstrate that LSt cells are essential for ejaculatory, but not erectile reflexes, as previously reported for mating animals. Moreover, LSt cells mediate ejaculation via projections within the spinal cord, presumably to autonomic and motor neurons. Staudt MD, Truitt WA, McKenna KE, de Oliveira CVR, Lehman MN, and Coolen LM. A pivotal role of lumbar spinothalamic cells in the regulation of ejaculation via intraspinal connections. J Sex Med **;**:**–**.

Introduction.  Studies show a positive impact of gender reassignment treatment on the quality of life (QOL) of transgender persons, but little is known about the influence of their socioeconomic status.

Aim.  First, to assess health-related QOL of transgender men and women and compare it with a general population sample, second, to investigate the differences between transgender men and transgender women, and third, to analyze how their levels of QOL differ according to socioeconomic and transition data.

Methods.  One hundred forty-eight current and former transgender patients of a gender identity clinic participated in a large QOL study.

Main Outcomes Measures.  Health-related QOL was measured using the Short Form 36-Item Questionnaire.

Results.  The QOL of transgender women did not differ significantly from the general Dutch female population, although transgender men showed reduced mental health-related QOL compared with the general Dutch male sample. Transgender women had a lower QOL than transgender men for the subscales physical functioning and general health, but better QOL for bodily pain. Time since start of hormone use was positively associated for transgender women with subscales bodily pain and general health, and negatively associated for transgender men with the subscale role limitations due to physical health problems. There was no significant difference in QOL between the group who had undergone genital surgery or surgical breast augmentation and the group who did not have these surgeries. Transgender men with an erection prosthesis scored significantly better on the subscales vitality and (at trend level) on role limitations due to emotional problems. A series of univariate analyses revealed significantly lower QOL scores for transgender persons that were older, low educated, unemployed, had a low household income, and were single.

Conclusions.  Specific social indicators are important in relation to health-related QOL of transgenders in a context of qualitative and adequate medical care. Motmans J, Meier P, Ponnet K, and T'Sjoen G. Female and male transgender quality of life: Socioeconomic and medical differences. J Sex Med **;**:**–**.

Introduction.  Erectile dysfunction (ED) is related to several co-morbidities including obesity, metabolic syndrome, cigarette smoking, and low testosterone, all of which have been reported to be associated with adverse prostate cancer features.

Aim.  To examine whether preoperative ED has a relationship with adverse prostate cancer features in patients who underwent radical prostatectomy (RP).

Methods.  We analyzed data from our institution on 676 patients who underwent RP between 2001 and 2010. Crude and adjusted logistic regression models were used to investigate the association between preoperative ED and several pathological parameters. The log-rank test and multivariate proportional hazards model were conducted to determine the association of preoperative ED with biochemical recurrence (BCR).

Main Outcome Measures.  The Expanded Prostate Cancer Index Composite (EPIC) instrument was used to evaluate preoperative erectile function (EF). Preoperative normal EF was defined as EPIC-SF ≥ 60 points while ED was defined as preoperative EPIC-SF lower than 60 points.

Results.  Preoperatively, a total of 343 (50.7%) men had normal EF and 333 (49.3%) men had ED. After adjusting for covariates, preoperative ED was identified a risk factor for positive extracapsular extension (OR 1.57; P = 0.029) and high percentage of tumor involvement (OR 1.56; P = 0.047). In a Kaplan-Meier curve, a trend was identified that patients with ED had higher incidence of BCR than men with normal EF (P = 0.091). Moreover, using a multivariate Cox model, higher preoperative EF was negatively associated with BCR (HR 0.99; P = 0.014).

Conclusions.  These results suggest that the likelihood for adverse pathological outcomes as well as BCR following prostatectomy is higher among men with preoperative ED, though these results require validation in larger datasets. The present study indicates that preoperative ED might be a surrogate for adverse prostate cancer outcomes following RP. Kimura M, Bañez LL, Gerber L, Qi J, Tsivian M, Freedland SJ, Satoh T, Polascik TJ, Baba S, and Moul JW. Association between preoperative erectile dysfunction and prostate cancer features—An analysis from the Duke Prostate Center Database. J Sex Med **;**:**–**.

Introduction.  The etiology of gender identity disorder (GID) remains largely unknown. In recent literature, increased attention has been attributed to possible biological factors in addition to psychological variables.

Aim.  To review the current literature on case studies of twins concordant or discordant for GID.

Methods.  A systematic, comprehensive literature review.

Results.  Of 23 monozygotic female and male twins, nine (39.1%) were concordant for GID; in contrast, none of the 21 same-sex dizygotic female and male twins were concordant for GID, a statistically significant difference (P = 0.005). Of the seven opposite-sex twins, all were discordant for GID.

Conclusions.  These findings suggest a role for genetic factors in the development of GID. Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, De Baere E, and T'Sjoen G. Gender identity disorder in twins: A review of the case report literature. J Sex Med **;**:**–**.

Introduction.  Penile augmentation has been reported in the literature by injecting various materials by nonmedical persons.

Aim.  This study aims to present our experience in management of penile augmentation complications associated with injection or implantation of industrial silicone by lay persons.

Main Outcome Measures.  Early surgical intervention can lead to faster recovery and better cosmetic and functional outcome.

Methods.  Two patients had injection of industrial silicone paste, and the other two had industrial silicone ring implantation. All the patients except one were presented after 13 months of the procedure. Patients with industrial silicone ring presented with multiple sinuses of penile skin in one, and abscess discharge pus from the site of implanted ring in the other. Both patients with injected silicone paste presented with swelling and deformity of the penis that interfered with their intercourse. Silicone ring patients underwent skin incision and drainage of the infected materials and extraction of the implants with delayed skin closure. The two patients with silicone paste injection underwent two-stage penile reconstructions using scrotal flap.

Results.  Patients with extracted rings had smooth recovery with acceptable cosmetic outcome. One of them was not initially satisfied with the length of his penis that was overcome by short-term use of vacuum device. One of the patients with silicone paste injection had wound infection that was successfully treated with local wound care. Both had satisfactory penile length and acceptable cosmetic outcome. All patients had normal erectile function postoperatively.

Conclusion.  Complications of using industrial silicone injection can be drastic, and awareness of the public can avoid using of this material for penile augmentation. Shamsodini A, Al-Ansari AA, Talib RA, Alkhafaji HM, Shokeir AA, and Toth C. Complications of penile augmentation by use of nonmedical industrial silicone. J Sex Med **;**:**–**.

Introduction.  There is a body of experimental evidence that mice and rats use chemical signals to avoid sexual contact with infected conspecifics. In contrast to animals, body scent of sick humans is employed only in medical diagnostics.

A modification of human body odor, due to an infection, has not been studied as a potential signal for choice of a sexual partner. It might, however, be especially important for sexually transmitted infections (STI) because many such infections have no obvious external manifestations.

Aim.  In this study, we have investigated odor pleasantness of young men infected with gonorrhea, Neisseria gonorrhoeae.

Methods.  We collected armpit sweat and saliva from young men (17–25 years old) belonging to three groups: healthy persons (N = 16), young men infected with gonorrhea, Neisseria gonorrhoeae (N = 13), and persons recovered due to specific therapy (N = 5). The sweat samples odor was then assessed by healthy young women (17–20 years old). Concentrations of cortisol, testosterone, immunoglobulin A (IgA), and immunoglobulin G (IgG) were measured in saliva by means of enzyme-linked immunosorbent assay.

Main Outcome Measures.  Subjective rates of odor pleasantness, association of scent of armpit sweat with odor descriptors, stepwise regression of odor pleasantness and salivary cortisol, testosterone, IgA, and IgG.

Results.  The odor from infected individuals was reported as less pleasant in comparison with the odor of healthy and recovered young men. The scent of infected men was more frequently associated by raters with the descriptor “putrid.” Odor pleasantness of the male sweat correlated negatively with concentration of the nonspecific salivary IgA and IgG, which was measured as an indicator of current immunoenhancement.

Conclusion.  Perhaps, the immune-dependent reduction of the scent pleasantness in the acute phase of STI is part of an evolutionary mechanism ensuring, unconsciously, avoidance of a risky romantic partner. Moshkin M, Litvinova N, Litvinova EA, Bedareva A, Lutsyuk A, and Gerlinskaya L. Scent recognition of infected status in humans. J Sex Med **;**:**–**.

Introduction.  Female genital mutilation/cutting (FGM/C), in particular, type III, also called infibulation, can cause various long-term complications. However, posttraumatic neuroma of the clitoris is extremely rare; only one case was previously reported in the literature.

Aim.  The aim of this study was to describe the case of a patient presenting a clitoral neuroma post-FGM/C in detail and her successful multidisciplinary treatment.

Methods.  We report the case of a 24-year-old woman originating from Somalia presenting a type III a–b FGM/C who attended our outpatient clinic at the Geneva University Hospitals complaining of primary dysmenorrhea and a post-mutilation painful clitoral mass. The mass was clinically diagnosed as a cyst and surgically removed. Histopathological analysis revealed that it was a posttraumatic neuroma and a foreign body granuloma around the ancient surgical thread. Our patient was also offered a multidisciplinary counseling by a specialized gynecologist on FGM/C, a sexologist, and a reproductive and sexual health counselor.

Results.  One month after surgical treatment, the vulvar pain was over.

Conclusions.  This is the second case of clitoral neuroma after FGM/C reported and the first with complete clinical, as well as histopathological documentation and multidisciplinary care. Considering the high frequency of clitoral cysts in case of infibulation, clitoral neuroma should be considered in the differential diagnosis. In this case, if symptomatic, the treatment should be surgery, clinical follow-up, and counseling. If necessary, appropriate sexual therapy should be offered too. Abdulcadir J, Pusztaszeri M, Vilarino R, Dubuisson JB, and Vlastos A-T. Clitoral neuroma after female genital mutilation/cutting: A rare but possible event. J Sex Med **;**:**–**.

Introduction.  Higher testosterone (T) is tied to risk-taking, especially in financial domains but also in health domains relevant to acquiring sexually transmitted infections (STIs). However, safer sex constructs could themselves carry the possibility of “social risk” due to sexual stigma or embarrassment, or could involve boldness or confidence because they could represent status displays of frequent sexual activity.

Aim.  To determine how T and behaviorally relevant attitudes about sexual risk-taking are linked, to better understand biopsychosocial aspects of sexual health related to STIs.

Methods.  In 78 first-year male college students, we examined correlations between salivary T and behaviorally relevant safer sex attitudes assessed via questionnaires.

Main Outcome Measures.  T, via saliva; safer sex attitudes, via a composite and the University of California, Los Angeles Multidimensional Condom Attitudes Scale (MCAS).

Results.  Higher T was significantly correlated with higher scores on the following: safer sex likelihood composite, r(73) = 0.33, P = 0.003; the MCAS safer sex resilience, r(32) = 0.36, P = 0.037; and the MCAS condom purchase comfort, r(32) = 0.37, P = 0.031. Associations between T and safer sex likelihood and resilience were still robust after controlling for potential confounds, though the association between T and purchase comfort diminished to a trend.

Conclusions.  Higher T was positively linked with safer sex attitudes, especially those most closely tied to STI risk avoidance. Thus, future research and interventions for STI prevention should address the possibility that safer sex may be paradoxically perceived as a “bold” or “risky” choice even as it decreases STI risk. van Anders SM, Goldey KL, Conley TD, Snipes DJ, and Patel DA. Safer sex as the bolder choice: Testosterone is positively correlated with safer sex behaviorally relevant attitudes in young men. J Sex Med **;**:**–**.

Introduction.  Bladder exstrophy is a rare condition that may lead to severe psychosexual malformation and require a lifelong follow-up.

Aim.  We describe the long-term sexual outcome of patients with bladder exstrophy treated at our institution at early stage.

Methods.  Thirty patients with mean age of 26 years (range 18–35 years) were included in the study. Fifteen patients underwent staged primary reconstruction, five patients underwent complete primary repair, and 10 patients underwent primary or secondary ureterosigmoidostomy.

Main Outcome Measures.  Evaluation consisted of pediatric medical records, interview questionnaire including the psychosexual history, International Index of Erectile Function (IIEF), and semen analysis.

Results.  Erectile functions were maintained in 28 patients based on IIEF domain score. In all cases, penile length was objectively less than average (mean 7.65 cm). Seven patients were not satisfied with their penile length, and four cases complained of slight curvature. Ten patients were married (33%), of whom four patients had children (after normal conception in three, and after assisted reproductive technique in one). The remaining 20 patients were not married because of the feeling of sexual inadequacy to be able to engage in sexual intercourse (six patients), afraid of the cosmetic appearance of the genitalia (10 patients), and incontinence (four patients). Retrograde ejaculation was documented in 16 cases (53.5%), low volume ejaculate in eight cases (26.5%), and anejaculation in six cases (20%). Cosmetic outcome was considered satisfactory by 50% of the patients. Sixteen patients voided per urethra, four performed clean intermittent catheterization, and 10 patients had ureterosigmoidostomy diversion. Urinary tract infection was documented in 20% of the cases, and recurrent attacks of pyelonephritis in 10% of the cases.

Conclusion.  Long-term outcome of bladder exstrophy repair in male patients showed fair results with respect to sexual function with more or less stable sexual relationship. We should do our best to solve the problem of those with restricted sexual lives. Salem HK and Eisa M. Long-term follow-up (18–35 years) of male patients with history of bladder exstrophy (BE) repair in childhood: Erectile function and fertility potential outcome. J Sex Med **;**:**–**.

Introduction.  Inflatable penile prosthetic implants are a reliable treatment for erectile dysfunction. Mechanical failures now are the most common reason for revision of this type of device, and autoinflation is a common cause for device revision. There are currently no published surgical treatments for this malfunction.

Aim.  To describe a simple outpatient surgical revision for an automatically inflating device using laparascopic dissection.

Main Outcome Measures.  Complete deflation of penile prosthesis on follow-up visit, intraoperative and postsurgical complications, and length of procedure.

Methods.  We performed a retrospective review of patients treated for inflatable penile prosthesis autoinflation with laparascopic capsulotomy to release constricting connective tissue rind surrounding the device reservoir at a single institution. We collected information about etiology of impotence, surgical procedures relating to implant and revision of prosthetic devices, and follow-up evaluations.

Results.  Four patients underwent laparascopic capsulotomy to treat autoinflation. Mean operative time was 45 minutes, and no adverse surgical or perioperative outcomes occurred. All four patients had deflated corporal cylinders at the time of follow-up evaluation.

Conclusions.  Laparascopic capsulotomy is an easy and reliable method of treating inflatable penile prosthesis autoinflation that can be performed in the outpatient setting. Abbosh PH, Thom MR, and Bullock A. Laparascopic capsulotomy to treat autoinflation of inflatable penile prostheses. J Sex Med **;**:**–**.

Introduction.  Recent data have shown that plasmakinetic enucleation of the prostate (PKEP) is a novel and effective procedure for symptomatic benign prostatic hyperplasia (BPH); however, data on patient sexual function after PKEP remain scarce.

Aims.  This study aims to evaluate the impact of PKEP on sexual function in men with lower urinary tract symptoms because of BPH.

Methods.  One hundred eighty-six consecutive patients who underwent the PKEP procedure were prospectively enrolled in this study. The International Index of Erectile Function (IIEF-15) and the International Prostate Symptom Score with quality of life scores were completed and compared preoperatively and at 1, 3, 6, and 12 months postoperatively. At each follow-up visit, maximum urinary flow rates, transrectal ultrasound-assessed prostate volume, postvoid residual urine volume, and serum prostate-specific antigen level were also measured and compared with the baseline.

Main Outcome Measures.  The IIEF global score and its five domains scores were evaluated for each patient, and the Friedman test or chi-square test was used to identify changes from the baseline.

Results.  There was a slight and nonsignificant increase in the IIEF global score and four of its five domains scores (i.e., erectile function, intercourse satisfaction, sexual desire, and overall satisfaction) at each postoperative assessment (P > 0.05 for all). However, a statistically significant reduction was observed in the orgasmic function domain score of IIEF at 3 months (P = 0.016), 6 months (P < 0.001), and 12 months (P < 0.001), respectively, along with the corresponding retrograde ejaculation rates of 48.7%, 49.4%, and 48.8%.

Conclusions.  PKEP has no negative influence on the quality of erections measured by the self-administered IIEF questionnaire, but it significantly lowers the orgasmic function domain score, reflecting probably postoperative retrograde ejaculation. These findings are important in preoperative counseling of the patients undergoing PKEP for symptomatic BPH. Zhao Z, Ma W, Xuan X, Ou L, Liang Y, and Zeng G. Impact of plasmakinetic enucleation of the prostate (PKEP) on sexual function: Results of a prospective trial. J Sex Med **;**:**–**.

Introduction.  The impact of undernutrition on endocrine and exocrine gonadatrope function is poorly known in male anorexia nervosa (AN) patients.

Aim.  The aim of this study was to compare the pituitary–gonadal function of male AN subjects with that of healthy controls, Kallmann syndrome (KS) patients, and female AN subjects.

Methods.  Observational monocentric cross-sectional study performed in 31 male and 25 female subjects with restrictive-type AN, 22 male and 20 female controls, and nine male KS patients.

Main Outcome Measures.  Hormonal parameters are as follows: follicule stimulating hormone (FSH), luteinizing hormone (LH), sex hormone binding globulin, estradiol, testosterone, inhibin B, thyroid hormones, growth hormone (GH), insulin-like growth factor 1 (IGF-1), cortisol, adrenocorticotropic hormone (ACTH), dehydroepiandrosterone sulfate, and leptin.

Results.  Similar abnormalities of free T3, GH, IGF-I, cortisol, and leptin were found in men as in AN women with equivalent undernutrition status when compared with corresponding controls. Low levels of LH, FSH were found in both male and female AN patients. In male AN, total testosterone was found lower than in controls but higher than in KS, while a lack of estradiol was noticed in AN women. Sex hormones variations were directly related to weight gain only in AN men. No relationship was found between sex hormones and leptin variation for both sexes. In AN men, inhibin B levels were similar to that of controls and did not correlate with testosterone levels.

Conclusions.  Significant differences of undernutrition impact on gonadal status were noticed between male and female AN subjects, including partial preservation of testosterone release and probable preservation of exocrine function, according to the normal inhibin B levels. Galusca B, Leca V, Germain N, Frere D, Khalfallah Y, Lang F, and Estour B. Normal inhibin B levels suggest partial preservation of gonadal function in adult male patients with anorexia nervosa. J Sex Med **;**:**–**.

Introduction.  Zoophilia has been known for a long time but, underreported in the medical literature, is likely a risk factor for human urological diseases.

Aim.  To investigate the behavioral characteristics of sex with animals (SWA) and its associations with penile cancer (PC) in a case-control study.

Methods.  A questionnaire about personal and sexual habits was completed in interviews of 118 PC patients and 374 controls (healthy men) recruited between 2009 and 2010 from 16 urology and oncology centers.

Main Outcome Measures.  SWA rates, geographic distribution, duration, frequency, animals involved, and behavioral habits were investigated and used to estimate the odds of SWA as a PC risk factor.

Results.  SWA was reported by 171 (34.8%) subjects, 44.9% of PC patients and 31.6% of controls (P < 0.008). The mean ages at first and last SWA episode were 13.5 years (standard deviation [SD] 4.4 years) and 17.1 years (SD 5.3 years), respectively. Subjects who reported SWA also reported more venereal diseases (P < 0.001) and sex with prostitutes (P < 0.001), and were more likely to have had more than 10 lifetime sexual partners (P < 0.001) than those who did not report SWA. SWA with a group of men was reported by 29.8% of subjects and SWA alone was reported by 70.2%. Several animals were used by 62% of subjects, and 38% always used the same animal. The frequency of SWA included single (14%), weekly or more (39.5%), and monthly episodes (15%). Univariate analysis identified phimosis, penile premalignancies, smoking, nonwhite race, sex with prostitutes, and SWA as PC risk factors. Phimosis, premalignant lesions, smoking, and SWA remained as risk factors in multivariate analysis. However, SWA did not impact the clinicopathological outcomes of PC.

Conclusion.  SWA is a risk factor for PC and may be associated with venereal diseases. New studies are required in other populations to test other possible nosological links with SWA. Zequi SC, Guimarães GC, da Fonseca FP, Ferreira U, de Matheus WE, Reis LO, Aita GA, Glina S, Fanni VSS, Perez MDC, Guidoni LRM, Ortiz V, Nogueira L, Rocha LCA, Cuck G, da Costa WH, Moniz RR, Dantas Jr. JH, Soares FA, and Lopes A. Sex with animals (SWA): Behavioral characteristics and possible association with penile cancer. A multicenter study. J Sex Med **;**:**–**.

Introduction.  Postpartum sexual health education was once routinely administered to postpartum women, but few interventions were specifically described or clearly based on theory, and few sexual interventions affected women's sexual behaviors.

Aim.  To evaluate the effectiveness of a refined theory-based interactive postpartum sexual health education program (IPSHEP) in enhancing postpartum women's sexual behavior and health.

Methods.  For this prospective, randomized controlled trial, 250 participants were randomized to three groups. Experimental group A received our refined theory-based IPSHEP. Experimental group B received only an interactive, self-help pamphlet. The control group received routine education (a 10- to 15-minute educational talk and a sexual health pamphlet without an interactive design). Data were collected at baseline, 3 days, 2 months, and 3 months postpartum.

Main Outcome Measure.  Postpartum women's sexual self-efficacy (SSE), diversity of sexual activity (DSA), return to sexual activity, and sexual satisfaction (SS).

Results.  Women who received our theory-based postpartum sexual health education program had significantly greater SSE (P < 0.05) and greater DSA (P < 0.05), and tended to resume their sexual life earlier than women in the routine teaching and interactive pamphlet-only groups (P < 0.05). However, the SS levels of postpartum women who received our program did not differ significantly from those of women who received routine teaching or the interactive pamphlet only.

Conclusions.  Our findings suggest that a theory-based postpartum sexual health education program improved women's sexual health and sexual behavior and that the transtheoretical model can be translated into practice, supporting its use to enhance the sexual health of postpartum women. Despite the lack of a significant effect on SS, women who received our theory-based postpartum sexual health education program tended to maintain their prepregnancy level of SS in early postpartum. Lee J-T and Tsai J-L. Transtheoretical model-based postpartum sexual health education program improves women's sexual behaviors and sexual health. J Sex Med **;**:**–**.

Introduction.  Selective serotonin reuptake inhibitors (SSRIs) are antidepressants that cause sexual dysfunction. The SSRI fluoxetine (FLX) appears to particularly affect the ejaculatory response. Ejaculation is regulated both at brain and spinal levels.

Aim.  To study the acute and chronic effects of FLX on male rat copulatory behavior, trying to distinguish between brain and spinal cord FLX-induced changes on the ejaculatory response.

Methods.  Sexually experienced male rats were intraperitoneally injected with 5 or 10 mg/kg FLX and tested for sexual behavior during 60 minutes on days 1, 7, and 14 of treatment. After a 2-day drug holiday, the males chronically treated with the high FLX dose were spinalized to record spontaneous and mechanically evoked genital motor patterns of ejaculation (GMPEs). In addition, independent groups were used to evaluate the acute effects of 1, 3, or 10 µg/rat FLX (intravenously) on the GMPE.

Main Outcome Measures.  Number of ejaculatory series and their parameters; electromyographic recordings of the GMPE in the bulbospongiosus muscles and their parameters.

Results.  Acute FLX injection slightly affected sexual behavior display and dose-dependently inhibited the expression of the GMPE. Chronic FLX treatment did not inhibit copulation but produced deficits in the parameters related to ejaculation after the high dose. In these animals, the response capacity of the spinal generator of ejaculation (SGE) as well as the number of discharges in the GMPE was decreased as a result of chronic FLX treatment.

Conclusions.  Chronic FLX treatment produces inhibitory effects on male rat copulation, particularly on ejaculation, some of which are exerted directly at the SGE. Hueletl-Soto ME, Carro-Juárez M, and Rodríguez-Manzo G. Fluoxetine chronic treatment inhibits male rat sexual behavior by affecting both copulatory behavior and the genital motor pattern of ejaculation. J Sex Med **;**:**–**.

Introduction. Eurycoma longifolia Jack (Simaroubaceae) has the reputation as a male aphrodisiac because it is claimed to increase virility and sexual prowess. Nevertheless, whether or not E. longifolia regulates directly the muscle tone of corpus cavernosa and/or seminal vesicle (SV) remains unclear. Even until now, the compositions that could account for its aphrodisiac property are still unknown

Aim.  We examined the effect of 9-hydroxycanthin-6-one (9-HC-6-one), a β-carboline alkaloid isolated from E. longifolia, on penile erection and ejaculation, and further elucidated the mechanism of action.

Main Outcome Measures.  9-HC-6-one induces penile erection and delays ejaculation.

Methods.  Drug's effect was studied on rat corpus cavernosum (CC) and SV in vitro, and on the changes in intracavernosal pressure (ICP) after IC injection and intraluminal pressure (ILP) of the SV after hypogastric nerve stimulation (HNS), respectively.

Results.  9-HC-6-one relaxed significantly phenylephrine (PE)-precontracted CC. Such response was not attenuated by endothelium disruption, N^G-nitro-L-arginine methyl ester, or 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one treatment, suggesting that a nitric oxide/cyclic guanosine monophosphate-dependent pathway was precluded. 9-HC-6-one attenuated PE-induced contraction by blocking cell surface and internal calcium channels with a higher potency for internal calcium release. This compound also antagonized calcium-evoked contraction in Ca²⁺-free, high K⁺-depolarizing condition, suggesting that interfering with the entry of calcium through voltage-dependent channels also contributed to 9-HC-6-one-induced corporal relaxation. After IC application of 9-HC-6-one, a significant rise in ICP was observed as compared with the application of normal saline. 9-HC-6-one relaxed significantly norepinephrine (NE)- and KCl-precontracted SV, and antagonized NE-induced oscillatory contraction as potent as clomipramine. Finally, the HNS-evoked increase in ILP was dose-dependently repressed after challenge by 9-HC-6-one.

Conclusion.  9-HC-6-one might be the active component that contributed to the aphrodisiac effect of E. longifolia by antagonizing the smooth muscle tone of CC as well as SV probably through interfering with Ca²⁺ mobilization. Chiou W-F and Wu T-S. 9-Hydroxycanthin-6-one induces penile erection and delays ejaculation. J Sex Med **;**:**–**.

Introduction.  There has been little research published on the impact of intrauterine contraceptive (IUC) methods on sexual functioning.

Aims.  This study aimed: (i) to assess different aspects of sexual functioning, including the prevalence of sexual dysfunction in women using a levonorgestrel intrauterine system (LNG-IUS); (ii) to compare this prevalence with that among copper-releasing intrauterine device (Cu-IUD) users; and (iii) to identify the relationship between psychological variables and sexual functioning in women using one of the aforementioned IUCs.

Methods.  In a multicenter cross-sectional study, 845 women with an IUC were invited to fill out a questionnaire. The latter was returned by 402 (48%) of them: 353 women were LNG-IUS users (88%) and 49 were Cu-IUD users (12%). The questions asked pertained to depression, well-being, marital relation quality, and sexual functioning.

Main Outcome Measures.  Sexual functioning was measured with the Short Sexual Functioning Scale.

Results.  One-third of LNG-IUS users (33%) reported a sexual dysfunction. Of those, 20% reported an increased sexual desire, 25% a decreased sexual desire, 5% arousal problems, and 8% orgasm problems. Women using a LNG-IUS did not differ significantly in distribution, type, or prevalence (32.9% vs. 36.7%) of sexual dysfunction, nor in depressive symptoms (Beck Depression Inventory score; 4.7 vs. 3.9; P = 0.33), general well-being (WHO-5 well-being scale score; 16.8 vs. 17.7; P = 0.170), or partner relationship quality (Dyadic Adjustment Scale score; 107 vs. 108; P = 0.74) compared to Cu-IUD users. Overall, the perceived influence of IUCs on sexual functioning was in the lower range and did not differentiate LNG-IUS greatly from Cu-IUD-users.

Conclusion.  Women using a LNG-IUS do not differ from those wearing a Cu-IUD with regard to psychological and sexual functioning. The perceived impact of IUD use on sexuality should not be overestimated. Enzlin P, Weyers S, Janssens D, Poppe W, Eelen C, Pazmany E, Elaut E, and Amy J-J. Sexual functioning in women using levonorgestrel-releasing intrauterine systems as compared to copper intrauterine devices. J Sex Med **;**:**–**.

Introduction.  Selective serotonin reuptake inhibitor is one of the most widely used antidepressant and commonly associated with female sexual dysfunction (FSD).

Aims.  This study compares the prevalence of FSD between patients on escitalopram and fluoxetine. The risk factors for FSD were also examined.

Methods.  A cross-sectional study involved 112 female depressed patients (56 each group) who were in remission (as defined in the fourth edition of Diagnostic and Statistical Manual of Mental Disorders [DSM-IV] during the past 2 months with no significant signs or symptoms of the disturbance and Montgomery–Asberg Depression Rating Scale score of ≤10) from the psychiatric clinic in a university hospital. The rates of sexual dysfunction between the two groups were compared.

Main Outcome Measures.  The subjects were interviewed by using Structured Clinical Interview for DSM-IV. Sexual dysfunction was assessed with the Malay Version of the Female Sexual Function Index.

Results.  The prevalence of FSD was 44.6% for all patients, 55.4% for the fluoxetine group, and 33.9% for the escitalopram group. Multivariate logistic regression analysis showed no significant difference in the risk of FSD between the two groups. Moderate to high dosing was the only significant associated factor for FSD (odds ratio = 4.89, 95% confidence interval = 1.94–12.33).

Conclusion.  There was no significant difference in the risk of having FSD between patients treated with fluoxetine or escitalopram. Patients on higher dosage of antidepressant have higher risk of having FSD. Sidi H, Asmidar D, Hod R, and Ng CG. Female sexual dysfunction in patients treated with antidepressant—comparison between escitalopram and fluoxetine. J Sex Med **;**:**–**.

Introduction.  The penis has been compared to a barometer of endothelial health, erectile dysfunction (ED) being an early sign of endothelial dysfunction.

Aim.  The aim of the study was to investigate the extent of the association between ED and endothelial dysfunction in patients with human immunodeficiency virus (HIV) infection on antiretroviral therapy.

Methods.  In this observational cross-sectional study, we evaluated the prevalence and factors associated with ED in a cohort of 133 HIV-infected men.

Main Outcome Measures.  The International Index of Erectile Function, ultrasound assessment of brachial artery flow mediated dilatation (FMD), and multi-slice computed tomography for coronary artery calcifications (CAC) as surrogates of endothelial dysfunction, the Adult Treatment Panel III criteria to diagnose metabolic syndrome (MS), plasma total testosterone (hypogonadism), and a visual analogue scale (VAS) of aesthetic satisfaction of the face and of the body (psychological distress associated with lipodystrophy).

Results.  Thirty-nine (29.32%) patients had mild ED, 14 (10.52%) patients had moderate ED, and 26 (19.55%) patients had severe ED. Prevalence of ED ranged from 45% to 65%, respectively, in patients less than 40 and more than 60 years old. MS was present in 20 (25%) patients with ED and 13 (24%) patients without ED (P value = 0.87). Prevalence of ED neither appeared to be associated with MS as a single clinical pathological entity nor with the numbers of its diagnostic components. FMD < 7% was present in 25 (32%) patients with ED and 18 (33%) patients without ED (P value = 0.83), and CAC > 100 was present in 8 (10%) patients with ED and 5 (9%) patients without ED (P value = 0.87). A stepwise multivariable logistic regression analysis was used to find predictors of ED. Independent predictors were VAS face (odds ratio [OR] = 0.85, 95% confidence interval [CI] 0.73–0.99, P = 0.049) and age per 10 years of increase (OR = 1.73, 95% CI 1.02–2.94, P = 0.04).

Conclusions.  Age constituted the most important risk factor for ED, which was related to aesthetic dissatisfaction of the face leading to negative body image perception. Guaraldi G, Beggi M, Zona S, Luzi K, Orlando G, Carli F, Ligabue G, Rochira V, Rossi R, Modena MG, and Bouloux P. Erectile dysfunction is not a mirror of endothelial dysfunction in HIV-infected patients. J Sex Med **;**:**–**.

Introduction.  Opioid-dependent men suffer from sexual dysfunctions in the short and long term. The medications used for long-term pharmacotherapy of opioid dependence also affect sexual functioning, though this has been a poorly investigated area so far.

Aim.  To study the sexual dysfunction in opioid-dependent men receiving buprenorphine and naltrexone maintenance therapy.

Methods.  A semistructured questionnaire and Brief Male Sexual Functioning Inventory (BMFSI) was administered to a sample of 60 sexually active men, receiving buprenorphine (n = 30) and naltrexone (n = 30) maintenance therapy for opioid dependence.

Main Outcome Measures.  Prevalence of premature ejaculation, erectile dysfunction, low sexual desire, weakness due to semen loss, and overall satisfaction.

Results.  About 83% of the men on buprenorphine and 90% on naltrexone reported at least one of the sexual dysfunction symptoms. The commonly reported dysfunctions were premature ejaculation (83% in buprenorphine and 87% in naltrexone), erectile dysfunction (43% in buprenorphine and 67% in naltrexone), and loss/reduction in sexual desire (33% in buprenorphine and 47% in naltrexone). On BMSFI however, there were no significant differences among both the groups.

Conclusions.  Opioid dependence as well as its pharmacological treatment is associated with sexual dysfunctions, which has clinical implication. Future research should explore this further using biochemical analyses. Ramdurg S, Ambekar A, and Lal R. Sexual dysfunction among male patients receiving buprenorphine and naltrexone maintenance therapy for opioid dependence. J Sex Med **;**:**–**.

Introduction.  The HIV prevalence among men who have sex with men (MSM) is increasing sharply in China. Many MSM have female sexual partners, representing a bridge of transmitting HIV to the general population. Circumcision reduces the risk of HIV prevention via heterosexual intercourse.

Aim.  The study investigated the prevalence and factors related to willingness to undergo circumcision when MSM were informed that circumcision could reduce risk of heterosexual HIV transmission.

Methods.  An anonymous cross-sectional survey was conducted in Jiangsu, China. A total of 157 MSM with bisexual behaviors in the last six months were recruited using snowball sampling.

Main Outcome Measures.  Self-reported circumcision status and foreskin conditions were recorded. HIV-related knowledge, risk perceptions, risky sexual behaviors, cognitive and behavioral intention factors regarding circumcision were assessed.

Results.  Among all respondents, 5.7% were circumcised. In the uncircumcised subsample, the willingness to be circumcised increased from 8.1% to 35.1% after they were informed about the 50% risk reduction effect of circumcision regarding heterosexual HIV transmission. Risk behaviors, uncertainty about the prevalence of HIV among MSM, perception of overly long foreskin, peer's suggestion, disagreement with the statements “MSM in general are not willing to be circumcised” and “circumcisions are for children, not for adults” and self-efficacy for circumcision were significantly associated with willingness for circumcision given the hypothetical risk reduction effect (OR = 2.37 and 3.11, respectively, P < 0.05). Perception of overly long foreskin, self-efficacy, and having used a condom in the last episode of sex with a woman remained significantly associated with the conditional willingness for circumcision in the multivariate analysis (OR = 3.03, 2.84 and 2.42, respectively, P < 0.05).

Conclusions.  Interventions promoting circumcision among bisexual MSM, based on the risk reduction effect on heterosexual HIV transmission, are likely to be successful. Such programs should focus on increasing self-efficacy and may consider utilizing a peer educator approach. Lau JTF, Yan H, Lin C, Zhang J, Choi K-C, Wang Z, Hao C, Huan X, and Yang H. How willing are men who have sex with men in China to be circumcised for the sake of protecting his female sex partner? J Sex Med **;**:**–**.

Introduction.  Vacuum erection devices (VEDs) are becoming first-line therapies for the treatment of erectile dysfunction and preservation (rehabilitation) of erectile function following treatment for prostate cancer. Currently, there is limited efficacy of the use of phosphodiesterase type 5 inhibitors in elderly patients, or patients with moderate to severe diabetes, hypertension, and coronary artery disease.

Aim.  The article aims to study the role of VED in patients following prostate cancer therapy.

Results.  Alternative therapies such as VED have emerged as one of the primary options for patients refractory to oral therapy. VED has also been successfully used in combination treatment with oral therapy and penile injections. More recently, there has been interest in the use of VED in early intervention protocols to encourage corporeal rehabilitation and prevention of postradical prostatectomy veno-occlusive dysfunction. This is evident by the preservation of penile length and girth that is seen with early use of the VED following radical prostatectomy. There are ongoing studies to help preserve penile length and girth with early use of VED following prostate brachytherapy and external beam radiation for prostate cancer. Recently, there has also been interest in the use of VED to help maintain penile length following surgical correction of Peyronie's disease and to increase penile size prior to implantation of the penile prosthesis.

Conclusion.  VEDs can be one of the options for penile rehabilitation after prostate cancer therapy. Pahlajani G, Raina R, Jones S, Ali M, and Zippe C. Vacuum erection devices revisited: Its emerging role in the treatment of erectile dysfunction and early penile rehabilitation following prostate cancer therapy. J Sex Med **;**:**–**.

Introduction.  Hyperprolactinemia (hyperPRL)-related hypogonadism or suppression of human chorionic gonadotropin (hCG)-induced testosterone (T) release is hypothesized to be mediated by a testicular interstitial macrophage and tumor necrosis factor alpha (TNF-α)-involved blockage.

Aim.  To test if the lower T response after hCG challenge in the hyperPRL rats is reversed by administrating anti-TNF-α antibody (Ab).

Methods.  HyperPRL was induced by allografting two anterior pituitary (AP) glands per rat. Control rats were grafted with similar amount of cerebral cortex. The testicular interstitial cells (TIC) were isolated from the testis 6 weeks after grafting. TIC was treated with anti-TNF-α Ab with or without hCG. The other groups of rats received intra-testicular or intra-muscular anti-TNF-α Ab 7 days before in vitro study. The TIC isolated from each testis was incubated and T release with or without hCG challenge were measured.

Main Outcome Measures.  Prolactin (PRL) and T were measured by radioimmunoassay. TNF-α was measured by enzyme-linked immunosorbent assay (ELISA).

Results.  When low dose of anti-TNF-α Ab was administered to the TIC incubation, the effects of PRL-related suppression of hCG-stimulated T release were not significant. While a higher dose of anti-TNF-α Ab almost abolished the suppressive effects of PRL to hCG-stimulated T release. Prior intra-testicular or intra-muscular administration of anti-TNF-α Ab reversed the suppressive effects of AP grafting on TIC's T release. This was demonstrated in groups with anti-TNF-α Ab injection both 7 and 1 day prior to TIC incubations.

Conclusions.  The data support the hypothesis that the suppression of hCG-induced T release associated with hyperPRL is through a TNF-α-mediated mechanism to suppress the Leydig cells. The effect of anti-TNF-α Ab is durable for at least 7 days. Besides intra-testicular injection, there might be other ways available for administrating Ab. Anti-TNF-α Ab has a potential therapeutic application on hyperPRL-induced hypogonadism or suppression of hCG-induced T release. Huang WJS, Yang L-Y, Pu H-F, Tsai Y-T, and Wang PS. The effects of anti-TNF-α antibody on hyperprolactinemia-related suppression of hCG-induced testosterone release in male rats. J Sex Med **;**:**–**.

Introduction.  Prostate-specific antigen (PSA) has been recently related to cardiovascular system in a multifactorial way. Arterial stiffness is a independent predictor of cardiovascular events and is involved in the pathogenesis of hypertension. The aim of the present study was to investigate whether PSA values, are associated with arterial stiffness indices in patients with essential arterial hypertension.

Methods.  The study comprised 150 consecutive male patients (mean age 60 years) with uncomplicated never-treated essential hypertension. All patients underwent a complete clinical and laboratory evaluation, including measurement of PSA levels. Aortic stiffness and arterial wave reflection assessment was made by using carotid-femoral (PWVc-f) pulse wave velocity and aortic augmentation index corrected for heart rate (AIx75). Patients with prostate cancer or benign prostate hyperplasia (PSA > 4 ng/mL) were excluded from the study.

Results.  PSA was positively associated with waist-to-hip ratio (r = 0.235, P = 0.04), PWVc-f (r = 0.426, P < 0.001), AIx75 (r = 0.264, P = 0.001), and high sensitivity C-reactive protein (hsCRP; r = 0.376, P < 0.001). In categorization to PSA quartiles, patients in the higher quartile presented with higher waist-to hip ratio (P = 0.009), PWVc-f (P < 0.00001), AIx75 (P < 0.001) and hsCRP (P < 0.001) values. In multivariate analysis after adjustment for various confounders PSA remained a significant determinant of PWVc-f values (beta [SE] = 0.477 [0.13], R² = 0.405, P < 0.001).

Conclusion.  The present study points towards an association between PSA levels and aortic stiffness in untreated essential hypertensive males. Potential causal relationships between PSA and arterial stiffness remain to be further explored. Vyssoulis G, Karpanou E, Kyvelou S-M, Vlachopoulos C, Tzamou V, and Stefanadis C. Prostate-specific antigen levels are associated with arterial stiffness in essential hypertensive patients. J Sex Med **;**:**–**.

Introduction.  Painful ejaculation (PE) is an uncommon condition and it is usually associated with prostatitis, chronic pelvic pain syndrome, benign prostatic hyperplasia, ejaculatory duct obstruction, radical prostatectomy, and prostate radiation. Topiramate (TPM) is a new antiepileptic drug with recognized efficacy in neuropathic pain.

Aim.  The study is aimed to evaluate TPM efficacy in ejaculation pain.

Methods.  Following a spinal cord injury, a 53-year-old man was referred to our institute for persistent PE. Neurological examination showed mild hypoesthesia of the genital area. Urogenital examination, neurophysiological tools, and computed tomography of the dorso-lumbar spine were normal.

Main Outcome Measures.  The main outcome measure was the visual analogue scale.

Results.  Since pain was refractory to conventional neuropathic pharmacological therapies, TPM was introduced up to 150 mg daily with a dramatic improvement of PE.

Conclusions.  TPM may be considered as a valid therapeutic option for the treatment of PE. Calabrò RS, Marra A, Quattrini F, Gervasi G, Levita A, and Bramanti P. Central neuropathic pain: An unusual case of painful ejaculation responding to topiramate. J Sex Med **;**:**–**.

Introduction.  Sexual dysfunction is one of the major secondary complications in the diabetic. Mucuna pruriens, a leguminous plant identified for its antidiabetic, aphrodisiac, and improving fertility properties, has been the choice of Indian traditional medicine.

Aim.  Objective of the present study was to analyze the efficacy of M. pruriens on male sexual behavior and sperm parameters in long-term hyperglycemic male rats.

Methods.  Male albino rats were divided as group I control, group II diabetes induced (streptozotocin [STZ] 60 mg/kg of body weight (b.w.) in 0.1 M citrate buffer), group III diabetic rats administered with 200 mg/kg b.w. of ethanolic extract of M. pruriens seed, group IV diabetic rats administered with 5 mg/kg b.w. of sildenafil citrate (SC), group V administered with 200 mg/kg b.w. of extract, and group VI administered with 5 mg/kg b.w. of SC. M. pruriens and SC were administered in single oral dosage per day for a period of 60 days. The animals were subjected to mating behavior analyses, libido, test of potency, and epididymal sperms were analyzed.

Main Outcome Measure.  The mating behavior, libido, test of potency, along with epididymal sperms were studied.

Results.  The study showed significant reduction in sexual behavior and sperm parameters in group II. Daily sperm production (DSP) and levels of follicular stimulating hormone, luteinizing hormone, and testosterone were significantly reduced in group II, whereas the animals with diabetes administered with seed extract of M. pruriens (group III) showed significant improvement in sexual behavior, libido and potency, sperm parameters, DSP, and hormonal levels when compared to group II.

Conclusion.  The present work reveals the potential efficacy of ethanolic seed extract of M. pruriens to improve male sexual behavior with androgenic and antidiabetic effects in the STZ-induced diabetic male rats. This study supports the usage of M. pruriens in the Indian system of medicine as sexual invigorator in diabetic condition and encourages performing similar study in men. Suresh S, and Prakash S. Effect of Mucuna pruriens (Linn.) on sexual behavior and sperm parameters in streptozotocin-induced diabetic male rat. J Sex Med **;**:**–**.

Introduction.  Plasma chitotriosidase (ChT) activity is associated with the presence of atherosclerosis and is a new cardiovascular risk marker. Although available evidence supports its role in atherogenesis, there is a lack of an obvious correlation between plasma ChT activity and erectile dysfunction (ED).

Aim.  Our aim was to investigate the association of the level of serum ChT activity with ED.

Main Outcome Measures.  Erectile function was assessed using Sexual Health Inventory for Men (SHIM). Serum fasting lipid profile (plasma total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, and triglycerides); sex hormones (luteinizing hormone, follicle-stimulating hormone, prolactin, total testosterone, and estradiol); and thyroid-stimulating hormone were measured. Plasma ChT activity, as well as K_m, V_max, optimum pH, and heat stability of the ChT were also assessed. Penile duplex ultrasound examination before and after intracavernous injection of 20 µg prostaglandin E1 (PGE₁), pudendal nerve conduction tests and sensory-evoked potential studies were done to identify patients with arteriogenic ED. Intima-media thickness (IMT) and plaque formation of common carotid artery were determined bilaterally using B-mode ultrasonography.

Methods.  A total of 124 normolipidemic patients with ED and 120 healthy controls were recruited for this study.

Results.  Serum ChT activity in patients with ED (116 ± 18 nmol/h/mL) was significantly higher than in normal control subjects (51 ± 12 nmol/h/mL) (P < 0.001). There was a significant positive correlation between plasma ChT activity and (i) severity of ED and (ii) duration of ED (r = 0.68, P = 0.004; and r = 0.62, P = 0.01 respectively).We also found that all ChT kinetic parameters assessed (K_m, V_max, and optimum pH) in plasma of ED patients were significantly different from those of normal controls (all P < 0.001). The results of heat stability analysis, demonstrated that plasma ChT activity in the normal individuals was more stable than in the patients with arteriogenic ED (P < 0.001). A significant correlation was seen between the plasma ChT activity and the mean common carotid IMT (r = 0.78, P = 0.002). Moreover, a significant correlation was seen between the severity of ED and mean common carotid IMT (r = 0.74, P = 0.003). We did not address chitotriosidase genotype.

Conclusions.  Our results indicate that plasma ChT activity is increased in normolipidemic patients with arteriogenic ED, suggesting its possible role in the pathophysiology of arteriogenic ED. The clinical significance of this increase should be assessed in further studies. Safarinejad MR, and Safarinejad SH. Plasma chitotriosidase activity and arteriogenic erectile dysfunction: Association with the presence, severity, and duration. J Sex Med **;**:**–**.

Introduction.  There has recently been a growing acceptance that it is not only heterosexual functioning of surgically adjusted genitalia which should be considered when measuring the treatment outcome of persons with disorders of sex development (DSD) but also their overall sexual quality of life (SexQoL).

Aim.  A comprehensive cross-sectional investigation of SexQoL of persons with 46,XY DSD.

Methods.  Forty-seven persons with 46,XY DSD (age 17–60 years) were examined by means of a questionnaire on various aspects of SexQoL. Scores were compared to a nonclinical convenience sample consisting of 145 women. Data were analyzed separately for diagnostic subgroups. Furthermore, persons whose external genitalia had been surgically corrected were compared with persons whose genitalia had been left unaltered.

Main Outcome Measures.  The Multidimensional Scale of Sexuality, the German Questionnaire on Feelings of Inadequacy in Social and Sexual Situations (FUSS), items on sexual dysfunctions according to DSM-IV-TR and self-constructed measures on sexual-activity history (e.g., previous sexual experience), sexual anxieties, and satisfaction with overall sex life and sexual function comprised the standardized assessment instruments.

Results.  Compared with the nonclinical group, persons with 46,XY DSD had more often no partner (P = 0.056), felt more insecure in social (Mdn_DSD = 17.0, Mdn_comparison = 12.0, P = 0.001) and sexual situations (Mdn_DSD = 17.0, Mdn_comparison = 11.0, P = 0.006), had more sexual problems (Mdn_DSD = 4.0, Mdn_comparison = 3.0, P = 0.001), and were less satisfied with overall sex life (Mdn_DSD = 3.0, Mdn_comparison = 4.0, P = 0.000) and sexual function (Mdn_DSD = 4.0, Mdn_comparison = 4.0, P = 0.000). Results were inconsistent with regard to sexual-activity history (e.g., previous sexual experience). Participants who underwent genital surgery showed less dyspareunia (P = 0.027) but more fear of injuries during intercourse (P = 0.019) than those whose genitals were left unaltered.

Conclusions.  SexQoL of persons with 46,XY DSD may be impaired. Differences in SexQoL between diagnostic subgroups, effect of corrective genital surgery, and the influence of gender assignment will have to be further investigated in future studies. Schönbucher V, Schweizer K, Rustige L, Schützmann K, Brunner F, and Richter-Appelt H. Sexual quality of life of individuals with 46,XY disorders of sex development. J Sex Med **;**:**–**.

Introduction.  Delivery of vardenafil (for improvement of erectile function) via the inhaled route of administration may be advantageous in that this avoids extensive first pass metabolism and may therefore increase the bioavailability (hence the reliability of absorption) and shorten the time of pharmacological onset of activity. A unique nebulizer design has been developed by the sponsor (Advanced Medical Institute Pty Ltd) that is capable of delivering relatively large volumes of drug.

Aim.  The primary objective of the Phase 1 study was to assess and compare the pharmacokinetics of a single dose of vardenafil 10-mg tablet and a single dose of vardenafil solution administered via inhalation using an ultrasonic nebulizer device. Secondary objective was to assess the safety of vardenafil administered via inhalation using an ultrasonic nebuliser device.

Methods.  Two-part study in healthy volunteers. Dose-ranging study was performed in two subjects to determine the appropriate inhalational dose, followed by an open, randomized, crossover, single dose pharmacokinetic study in 12 subjects, which compared a single 10-mg oral dose to the inhalation dose.

Main Outcome Measures.  C_max, C_max/Dose, T_max, k_e, t_1/2, AUC_0–t, AUC_t–∞, AUC_0–∞, AUC_0–∞/Dose, and % area extrapolated.

Results.  The two treatments are not bioequivalent, with vardenafil absorbed and eliminated faster and with less variability using the nebulizer for drug delivery. Administration via the inhalational route was not associated with any clinically significant changes in blood pressure or heart rate, and no serious adverse events were recorded, demonstrating an acceptable safety profile.

Conclusion.  To our knowledge, this is the first report of the administration of vardenafil HCl via the pulmonary route of administration. This trial demonstrates that vardenafil HCl may be administered using the ultrasonic nebulizer to reach blood levels comparable with those produced by a vardenafil 10-mg oral tablet, faster and using less drug. This new route of administration may potentially improve the onset of action, reliability, and safety for this class of drug. Berry B, Altman P, Rowe J, and Vaisman J. Comparison of pharmacokinetics of vardenafil administered using an ultrasonic nebulizer for inhalation vs. a single 10-mg oral tablet. J Sex Med **;**:**–**.

Introduction.  The use of manualized treatment programs offers a useful research framework for assessing psychotherapeutic interventions for female sexual dysfunctions (FSDs), but it does not address all issues related to methodological rigor and replication, and raises new research issues in need of discussion.

Aims.  The goals of this manuscript are to review the literature on treatment trials utilizing manualized psychotherapy treatments for FSD and to explore the benefits and research issues associated with the flexible use of treatment manuals.

Methods.  The method used was the review of the relevant literature.

Results.  While the use of manualized treatments for FSDs can address certain methodological issues inherent in psychotherapy research, flexibility in manual administration is necessary in order to allow tailoring for individual needs that can be beneficial to both the participant and the research. The flexible use of manuals, as opposed to strict manual adherence, may also be more relevant for clinical utility.

Conclusions.  In order to administer manualized treatments for FSDs with appropriate flexibility, while also maximizing internal validity and replicability, the authors recommend that predetermined decision rules be utilized to guide individual tailoring, that potential gaps in the manual be identified and addressed, and that differing levels of motivation and readiness for treatment be taken into consideration in the treatment protocol. Hucker A and McCabe MP. Manualized treatment programs for FSD: Research challenges and recommendations. J Sex Med 2012;9:350–360.