Pelvic Floor Behaviour, Psychology, Sexology (part I)

Ethical issues in HIV.
Dhai A, Noble R
Best Pract Res Clin Obstet Gynaecol 2005 Apr;19(2):255-67. Epub 2004 Dec 13.

The number of people with HIV/AIDS continues to increase globally. Women, who represent the subgroup with the fastest rate of increase, are usually informed of their serostatus by the obstetrician/gynaecologist. As treatment of infected women raises a number of ethical issues, an understanding of the theoretical background for ethical decision making is requisite to ensure these problems are resolved within a morally appropriate framework. Vigorous debate has arisen from the tensions between the competing goals of HIV testing, third party disclosure, management of the critically ill HIV-infected woman, infertility management in the background of HIV/AIDS, and gender-based violence as cause or result of acquiring HIV infection. Women may be differently empowered economically, socially and culturally. What may be a satisfactory solution in the context of the USA and Europe may be far from ideal in that of the developing world.

Laboratory markers associated with progression of HIV infection.
Kiepiela P, Smith AN, Rosenberg E
Best Pract Res Clin Obstet Gynaecol 2005 Apr;19(2):243-54. Epub 2005 Jan 25.

Infection with HIV may develop to AIDS at different rates in different individuals, with a spectrum varying from rapid progression to long-term non-progression. The variable course of HIV-1 infection causes emotional trauma for the infected person and complicates the design and interpretation of therapeutic trials because of unrecognized differences in prognosis. Owing to the variable clinical expression of HIV infection, the use of non-clinical disease markers has become important to patient management. Thus, it is essential to have tests which can accurately assess the stage of infection in an individual, as well as predict its course and monitor its progression. These laboratory tests are valuable during the period of clinical latency and subsequently supplement various clinical parameters.

HIV and gynaecological infections.
Sebitloane MH
Best Pract Res Clin Obstet Gynaecol 2005 Apr;19(2):231-41. Epub 2004 Dec 13.

Human immunodeficiency virus (HIV) infection primarily affects women during their reproductive years, and the co-existence of gynaecological infections is not surprising, given the fact that HIV is mainly acquired via heterosexual contact. Most gynaecological infections are themselves sexually acquired, and have the potential to increase the risk both of acquiring and transmitting the HI virus. As most sexually transmitted infections are asymptomatic, there is a need to improve methods of diagnosis and algorithms for early detection of sexually transmitted infections. HIV infection, however, particularly advanced disease, may alter the clinical presentation, course and response to conservative treatment for some of the sexually transmitted infections.

Impact of vaginal surgery on sexuality and quality of life in women with urinary incontinence or genital descensus.
Helstrom L, Nilsson B
Obstet Gynecol Surv 2005 Apr;60(4):230-1.

One hundred eighteen women scheduled to undergo surgical treatment for urinary incontinence (n = 41) or genital descensus (n = 77) agreed to participate in a study of general health and well-being, urinary symptoms, and sexuality after vaginal surgery. Changes were measured by a questionnaire administered both 1 day before and again 1 year after surgery. One hundred one women (86%) completed the follow-up questionnaire.After 1 year, 19% of the women who underwent surgery for urinary symptoms reported that they regretted having the surgery compared with only 2% of those who were treated for vaginal prolapse (P = 0.05). Seventeen percent of the women in both groups said their prolapse symptoms were worse, but 50% of the incontinence group and 74% of those in the prolapse group reported an improvement in prolapse symptoms (P <0.001; and P <0.001 for change in scores from baseline). None of the women with incontinence reported a worsening of their symptoms of urinary frequency compared with 14% of the women who were treated for vaginal prolapse (P <0.001). Urinary frequency symptoms had improved for 82% of the incontinence group and 40% of the prolapse group (P <0.001; and P <0.00 for change).Forty-five of 88 sexually active women completed both questionnaires. Overall, the total score for sexual variables decreased. The decrease was greater for those treated for prolapse (P <0.05 for difference). A decrease in frequency of intercourse was seen in the incontinence group compared with a slight increase in the prolapse group (P <0.001). Dyspareunia remained essentially unchanged; however, the prolapse group reported a slight worsening of symptoms, which was not significant.There were no differences in quality-of-life scores before and after surgery.

[Sexual function after radical prostatectomy does not affect global patient satisfaction]
Descazeaud A, Chaskalovic J, Debre B, Zerbib M, Peyromaure M
Prog Urol 2004 Dec;14(6):1177-80.

OBJECTIVES: To evaluate the quality of life after retropubic radical prostatectomy (RP) and its impact on global patient satisfaction concerning the treatment received. PATIENTS AND METHODS: 142 questionnaires were sent to patients treated for a localized prostate cancer by RP alone, with a minimum follow-up of 2 years. The questionnaire was the validated French version of the "UCLA-Prostate Cancer Index". A question concerning global patient satisfaction with treatment was added. RESULTS: 102 questionnaires were returned and analysed. The mean age of the patients at the time of RP was 63.8 years and the mean follow-up was 48 months. Evaluation of global satisfaction showed that 35/102 (343%) patients were very satisfied, 45/102 (44.1%) were satisfied, 15/102 had no opinion, 4/102 (3.9%) were dissatisfied and 3/102 (29%) were very dissatisfied. General quality of life scores ranged from 72 to 87 on a scale from 1 to 100 (where 100 corresponds to the best quality of life). For specific quality of life, the mean scores for sexual function and dysfunction were 27.5 and 25.1, respectively. The mean scores for urinary function and dysfunction were 72.5 and 67.8, respectively. Urinary function scores and seven of the nine general quality of life items were significantly correlated with better global patient satisfaction, but sexual function was not related to global satisfaction. CONCLUSIONS: Although sexual function is markedly altered after RP, it does not affect global patient satisfaction with the treatment received. Urinary function and general quality of life are significantly correlated with global satisfaction.

Postoperative acute confusional state in typical urologic population: incidence, risk factors, and strategies for prevention.
Hamann J, Bickel H, Schwaibold H, Hartung R, Forstl H
Urology 2005 Mar;65(3):449-53.

OBJECTIVES: To determine the incidence of, and predictors for, the acute confusional state (ACS) in older patients after urologic surgery. ACS is among the most common complications after surgery in older patients. It is associated with increased postoperative morbidity, longer hospital stays, and greater mortality. Agitation caused by ACS might have deleterious consequences in a large proportion of older patients, especially after urologic surgery. Only a few studies, of highly selected urologic procedures, have been reported, and all showed an astonishingly low percentage of patients with this distressing condition. METHODS: We examined 100 consecutive, older patients (age 60 years or older), prospectively, before and after urologic surgery, to determine both the incidence of, and the predictors for, ACS. RESULTS: Only 7 of the 100 patients developed postoperative ACS. The risk factors identified were preoperative cognitive deficits, pre-existing depression, impaired vision, and the operative time. CONCLUSIONS: These results suggest that postoperative ACS is relatively rare after urologic surgical procedures; however, patients who are likely to develop ACS can be identified, prompting consideration for prophylactic antidelirium care.

A practical approach to intersex.
Bomalaski MD
Urol Nurs 2005 Feb;25(1):11-8, 23; quiz 24.

The realm of intersex presents a challenge to the family as well the health care provider. As the physical aspects of diagnosis and management have become better understood, it has become apparent that there are psychological and social aspects that we have only begun to understand. A general overview of intersex issues that may confront the urologic practitioner, and the current concepts of diagnosis and management, are provided.

Stress and the gastrointestinal tract.
Bhatia V, Tandon RK
J Gastroenterol Hepatol 2005 Mar;20(3):332-9.

Abstract Stress, defined as an acute threat to homeostasis, evokes an adaptive or allostatic response and can have both a short- and long-term influence on the function of the gastrointestinal tract. The enteric nervous system is connected bidirectionally to the brain by parasympathetic and sympathetic pathways forming the brain-gut axis. The neural network of the brain, which generates the stress response, is called the central stress circuitry and includes the paraventricular nucleus of the hypothalamus, amygdala and periaqueductal gray. It receives input from the somatic and visceral afferent pathways and also from the visceral motor cortex including the medial prefrontal, anterior cingulate and insular cortex. The output of this central stress circuit is called the emotional motor system and includes automatic efferents, the hypothalamus-pituitary-adrenal axis and pain modulatory systems. Severe or long-term stress can induce long-term alteration in the stress response (plasticity). Corticotropin releasing factor (CRF) is a key mediator of the central stress response. Two CRF receptor subtypes, R1 and R2, have been described. They mediate increased colonic motor activity and slowed gastric emptying, respectively, in response to stress. Specific CRF receptor antagonists injected into the 0 block these visceral manifestations of stress. Circulating glucocorticoids exert an inhibitory effect on the stress response by receptors located in the medial prefrontal cortex and hippocampus. Many other neurotransmitters and neuroimmunomodulators are being evaluated. Stress increases the intestinal permeability to large antigenic molecules. It can lead to mast cell activation, degranulation and colonic mucin depletion. A reversal of small bowel water and electrolyte absorption occurs in response to stress and is mediated cholinergically. Stress also leads to increased susceptibility to colonic inflammation, which can be adaptively transferred among rats by sensitized CD4(+) lymphocytes. The association between stress and various gastrointestinal diseases, including functional bowel disorders, inflammatory bowel disease, peptic ulcer disease and gastroesophageal reflux disease, is being actively investigated. Attention to the close relation between the brain and gut has opened many therapeutic avenues for the future.

Clinical empathy as emotional labor in the patient-physician relationship.
Larson EB, Yao X
JAMA 2005 Mar 2;293(9):1100-6.

Empathy should characterize all health care professions. Despite advancement in medical technology, the healing relationship between physicians and patients remains essential to quality care. We propose that physicians consider empathy as emotional labor (ie, management of experienced and displayed emotions to present a certain image). Since the publication of Hochschild's The Managed Heart in 1983, researchers in management and organization behavior have been studying emotional labor by service workers, such as flight attendants and bill collectors. In this article, we focus on physicians as professionals who are expected to be empathic caregivers. They engage in such emotional labor through deep acting (ie, generating empathy-consistent emotional and cognitive reactions before and during empathic interactions with the patient, similar to the method-acting tradition used by some stage and screen actors), surface acting (ie, forging empathic behaviors toward the patient, absent of consistent emotional and cognitive reactions), or both. Although deep acting is preferred, physicians may rely on surface acting when immediate emotional and cognitive understanding of patients is impossible. Overall, we contend that physicians are more effective healers--and enjoy more professional satisfaction--when they engage in the process of empathy. We urge physicians first to recognize that their work has an element of emotional labor and, second, to consciously practice deep and surface acting to empathize with their patients. Medical students and residents can benefit from long-term regular training that includes conscious efforts to develop their empathic abilities. This will be valuable for both physicians and patients facing the increasingly fragmented and technological world of modern medicine.

Job stress and cardiovascular risk factors in male workers.
Gun Kang M, Baek Koh S, Suk Cha B, Ku Park J, Koo Baik S, Jin Chang S
Prev Med 2005 May;40(5):583-8.

BACKGROUND.: This study examined whether job stress (work demand and decision latitude) is associated with smoking, blood pressure, lipid level (total cholesterol, triglyceride, HDL cholesterol), and homocystein as risk factors for cardiovascular disease in Korean male workers. METHODS.: Study subjects of this study were recruited from a sample of 1,071 workers in 20 companies of W city and H counties, and they were grouped into four categories (high strain group, active group, passive group, and low strain group) based on the postulation of Karasek's Job Strain Model. Of them, we invited 160 male workers (40 people each subgroup) using a stratified sampling, and finally, 152 eligible participants were analyzed. RESULTS.: In multivariate analyses, we found that decision latitude was associated with cholesterol, triglyceride, and homocystein and that work demand was related to smoking and systolic blood pressure. Job strain (the combination of high work demand with low decision latitude) was significantly related to higher levels of homocystein after controlling for age, BMI, smoking, and social support at workplace. CONCLUSIONS.: These results indicate that job stress is associated with cardiovascular risk factors and might contribute to the development of cardiovascular disease. Some considerations for the future research were discussed.

The relationship among lower urinary tract symptoms, prostate specific antigen and erectile dysfunction in men with benign prostatic hyperplasia: results from the proscar long-term efficacy and safety study.
Paick SH, Meehan A, Lee M, Penson DF, Wessells H
J Urol 2005 Mar;173(3):903-7.

PURPOSE: We evaluated the associations among lower urinary tract symptoms, prostate specific antigen (PSA) and erectile dysfunction (ED) in men with benign prostatic enlargement enrolled in the Proscar (Merck, Whitehouse Station, New Jersey) Long-Term Efficacy and Safety Study. MATERIALS AND METHODS: The Proscar Long-Term Efficacy and Safety Study was a 4-year, randomized, double-blind, placebo controlled study that enrolled 3,040 men with moderate to severe lower urinary tract symptoms and an enlarged prostate gland. Two questions assessed ED. A logistic regression model, including the effect of patient age, was used to examine the relationships among quasi-American Urological Association Symptom Score (AUASS), PSA, and ED at baseline. Changes in ED scores from baseline to study closeout were analyzed with ANOVA. RESULTS: A total of 2,981 patients had baseline data available for analysis. Mean age was 64 years, mean quasi-AUASS was 15, mean PSA was 2.8 ng/ml and mean prostate volume was 55 cm. At baseline every 1 point increase in quasi-AUASS was associated with a 2% increased risk of ED even after controlling for age (p <0.001). At 48 months in placebo but not in finasteride treated men a 1-unit decrease in quasi-AUASS was associated with a slight but statistically significant decrease in ED. No association existed between increasing PSA and ED on baseline or longitudinal analysis. CONCLUSIONS: We found a moderately strong association between baseline quasi-AUASS and the ED rate in men with an enlarged prostate, a finding that was supported by longitudinal data in the placebo arm. The absence of a relationship between PSA and ED highlights the need for further investigation into the mechanisms of benign prostatic hyperplasia related sexual dysfunction.

Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection.
Golden MR, Whittington WL, Handsfield HH, Hughes JP, Stamm WE, Hogben M, Clark A, Malinski C, Helmers JR, Thomas KK, Holmes KK
N Engl J Med 2005 Feb 17;352(7):676-85.

BACKGROUND: Many sex partners of persons with gonorrhea or chlamydial infections are not treated, which leads to frequent reinfections and further transmission. METHODS: We randomly assigned women and heterosexual men with gonorrhea or chlamydial infection to have their partners receive expedited treatment or standard referral. Patients in the expedited-treatment group were offered medication to give to their sex partners, or if they preferred, study staff members contacted partners and provided them with medication without a clinical examination. Patients assigned to standard partner referral were advised to refer their partners for treatment and were offered assistance notifying partners. The primary outcome was persistent or recurrent gonorrhea or chlamydial infection in patients 3 to 19 weeks after treatment. RESULTS: Persistent or recurrent gonorrhea or chlamydial infection occurred in 121 of 931 patients (13 percent) assigned to standard partner referral and 92 of 929 (10 percent) assigned to expedited treatment of sexual partners (relative risk, 0.76; 95 percent confidence interval, 0.59 to 0.98). Expedited treatment was more effective than standard referral of partners in reducing persistent or recurrent infection among patients with gonorrhea (3 percent vs. 11 percent, P=0.01) than in those with chlamydial infection (11 percent vs. 13 percent, P=0.17) (P=0.05 for the comparison of treatment effects) and remained independently associated with a reduced risk of persistent or recurrent infection after adjustment for other predictors of infection at follow-up (relative risk, 0.75; 95 percent confidence interval, 0.57 to 0.97). Patients assigned to expedited treatment of sexual partners were significantly more likely than those assigned to standard referral of partners to report that all of their partners were treated and significantly less likely to report having sex with an untreated partner. CONCLUSIONS: Expedited treatment of sex partners reduces the rates of persistent or recurrent gonorrhea or chlamydial infection.

[Probable sildenafil (Viagra) induced acute hepatitis in a patient with no other risk factors.]
Balian A, Touati F, Huguenin B, Prevot S, Perlemuter G, Naveau S, Chaput JC
Gastroenterol Clin Biol 2005 Jan;29(1):89.

Help-seeking behaviour for sexual problems: the global study of sexual attitudes and behaviors.
Moreira ED Jr, Brock G, Glasser DB, Nicolosi A, Laumann EO, Paik A, Wang T, Gingell C
Int J Clin Pract 2005 Jan;59(1):6-16.

The Global Study of Sexual Attitudes and Behaviors (GSSAB) investigated various aspects of sex and relationships among 27,500 men and women aged 40-80 years. Here, we report help-seeking behaviours for sexual problems in this population. A questionnaire was administered using the accepted survey method in each country. Although almost half of all sexually active respondents had experienced at least one sexual problem, less than 19% of them (18.0% of men and 18.8% of women) had attempted to seek medical help for their problem(s). The most frequent action taken by men and women was to talk to their partner (39%). Only 9% of men and women had been asked about their sexual health by a doctor in a routine visit during the past 3 years. Although sexual problems are highly prevalent, few men and women seek medical help for these problems. Overall, men and women show similar help-seeking behaviours.

Complementary and alternative medicine in the scientific literature.
Raschetti R, Menniti-Ippolito F, Forcella E, Bianchi C
J Altern Complement Med 2005 Feb;11(1):209-12.

Objective. To analyze the frequency and typology of scientific papers on complementary and alternative medicine (CAM) published in the period 1997-2002. Methods. We performed a systematic literature search of MEDLINE((R)) in order to identify all articles dealing with CAM, in the human setting, published from January 1, 1997 to December 31, 2002. Our attention was focused on randomized controlled trials conducted on CAM and on the impact factor (IF) of the journals in which CAM articles were published. Results. During the period 1997-2002, a total of 20,209 articles about CAM were published, representing the 0.7% of the total number of MEDLINE-listed articles. Approximately 50% of CAM articles published in 1996-2002 appeared on journals with no IF. The proportion of randomized clinical trials was 7.6% of total CAM articles Conclusions. There is an upward trend in the number of CAM articles but the number of experimental studies is low and over half of articles are published in journals without an IF. We believe there is an urgent need to conduct rigorous research in the field of CAM in order to support, for the need of the public, an evidencebased approach to these therapies.

Gut feelings, intuition, and emotions: an exploratory study.
Radin DI, Schlitz MJ
J Altern Complement Med 2005 Feb;11(1):85-91.

Objective: Investigate whether the gut feelings of one person, as measured with an electrogastrogram (EGG), respond to the emotions of a distant person. Design: In a double blind protocol, EGG activity was recorded in an individual relaxing in a heavily shielded chamber while, at a distance, a second person periodically viewed the live video image of the first person along with stimuli designed to evoke positive, negative, calming, or neutral emotions. Subjects: Twenty-six (26) pairs of healthy adult volunteers. Outcome measures: EGG maximum values recorded while the distant person was exposed to emotional stimuli were compared to similar values recorded during exposure to neutral stimuli. Results: EGG maximums were significantly larger on average when the distant person was experiencing positive (p = 0.006) and negative (p = 0.0009) emotions, as compared to neutral emotions. Nonparametric bootstrap procedures were employed to evaluate these differences, and the results survive correction for multiple analyses. Conclusions: EGG activity increases in response to the emotions of a distant person, beyond the influence of ordinary sensory interactions. Relationships commonly reported between gut feelings and intuitive hunches may share a common, poorly understood, perceptive origin.

Female Sexual Dysfunction: Principles of Diagnosis and Therapy.
Pauls RN, Kleeman SD, Karram MM
Obstet Gynecol Surv 2005 Mar;60(3):196-205.

Female sexual dysfunction is a common health problem, affecting approximately 43% of women. Female sexual dysfunction is defined as disorders of libido, arousal, orgasm, and sexual pain that lead to personal distress or interpersonal difficulties. It is frequently multifactorial in etiology, with physiological and psychologic roots. Approaching female sexual dysfunction involves an open discussion with the patient, followed by a thorough physical examination and laboratory testing. Therapy consists of patient and partner education, behavior modification, and may include individualized pharmacotherapy. Ultimately, as awareness and research in the field grows, it is hoped that a better understanding of the physiology and pharmacology of the female sexual response will be achieved. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader should be able to list the classifications of female sexual dysfunction, to outline the evaluation of a woman with female sexual dysfunction, and to summarize the various therapies for female sexual dysfunction.

Efficacy of a Bivalent L1 Virus-Like Particle Vaccine in Prevention of Infection With Human Papillomavirus Types 16 and 18 in Young Women: A Randomized Trial.
Harper DM, Franco EL, Wheeler C, Ferris DG, Jenkins D, Schuind A, Zahaf T, Innis B, Naud P, Decarvalho NS, Roteli-Martins CM, Teixeira J, Blotter MM, Kom AP, Quint W, Dubin G
Obstet Gynecol Surv 2005 Mar;60(3):171-173.

This double-blind, multicenter, randomized, placebo-controlled study was conducted to assess the efficacy of a bivalent human papillomavirus (HPV)-16/18 L1 virus-like particle vaccine in preventing cervical infection with HPV-16/18. The study participants were recruited among healthy women aged 15 to 25 years from 32 healthcare facilities in Brazil, Canada, and the United States. A total of 1113 women enrolled in the study. Enrollees had 6 or fewer lifetime sexual partners, no history of cervical abnormality, and were negative for high-risk HPV types.The subjects were randomized to receive placebo injections or the vaccine that contained 20 mug each of HPV-16 and HPV-18 virus-like particles. Women received 1 0.5-mL dose of vaccine or placebo at enrollment, 1 month, and 6 months. Cervical smears were taken at 6, 12, and 18 months. In addition, participants collected self-administered cervicovaginal samples at enrollment, 6 months, and every 3 months thereafter. Serologic testing for immunogenicity was performed at 0, 1, 6, 12, and 18 months. The women kept a diary of symptoms for 1 week after each injection, and symptoms were evaluated by telephone interview 1 month after each injection. Outcome results at 27 months were available for 81 women in the vaccine group and 59 in the placebo group.Study subject data were analyzed in two different cohorts. One analysis was performed including women who received all 3 injections and who had complete follow-up data. They comprised the 'according-to-protocol' cohort (ATP). Another analysis was performed using data from the 'intention-to-treat' cohort (ITT), which consisted of all enrolled participants who had at least one dose of vaccine or placebo and had any data available for analysis.There were 560 subjects randomized to receive vaccine and 553 randomized to receive placebo. The average age was 20 years. The two groups had similar patterns of risk factors for HPV infection.There were no cases of persistent HPV-16/18 among ATP women who received the vaccine. The vaccine was 100% effective against HPV-16, HPV-18, and HPV-16/18 (P < 0.0001). The effectiveness against HPV-18 infection was not significant until 27 months. In comparison, 13 (2.1%) women in the ATP group who received placebo developed a persistent HPV-16 infection, 4 (0.6%) had persistent HPV-18, and 16 (2.6%) had persistent HPV-16/18.In the ITT cohort, there were 4 women in the vaccine group who were positive for persistent HPV-16 (0.5%: efficacy 84.5%, P < 0.0001), 1 positive for persistent HPV-18 (0.1%: efficacy 91.1%, P = 0.003) and 4 with HPV-16/18 (0.5%: efficacy 87.5%, P < .0001). In the ITT placebo group, 25 women (3.2%) were positive for persistent HPV-16, 11 (1.4%) had persistent HPV-18, and 31 (4.0%) persistent HPV-16/18.Among the 560 women who received the vaccine, 2 developed cervical abnormalities associated with HPV types 16 or 18. One had atypical squamous cells of unknown significance (ASGUS) and 1 had a low-grade squamous intraepithelial lesion (LSIL). Of the 553 women who received placebo, 27 developed cervical abnormalities, including 15 ASCUS, 14 LSIL, and 1 high-grade squamous intraepithelial lesion (HSIL). The vaccine had an efficacy of 95.2% against HPV-16 (P < 0.0001), 91.2% against HPV-18 (P = 0.003), and 92.9% against HPV-16/18 (P < 0.0001).Cervical intraepithelial neoplasia (CIN) 1 or 2 was seen in 7 women, including 1 CIN 1 in the vaccine group, and 3 each CIN 1 and CIN 2 in the placebo group.

Treatment of panic disorder.
Ham P, Waters DB, Oliver MN
Am Fam Physician 2005 Feb 15;71(4):733-9.

Panic disorder with or without agoraphobia occurs commonly in patients in primary care settings. This article assesses multiple evidence-based reviews of effective treatments for panic disorder. Antidepressant medications successfully reduce the severity of panic symptoms and eliminate panic attacks. Selective serotonin reuptake inhibitors and tricyclic antidepressants are equally effective in the treatment of panic disorder. The choice of medication is based on side effect profiles and patient preferences. Strong evidence supports the effectiveness of cognitive behavior therapy in treating panic disorder. Family physicians who are not trained in cognitive behavior therapy may refer patients with panic disorder to therapists with such training. Cognitive behavior therapy can be used alone or in combination with antidepressants to treat patients with panic disorder. Benzodiazepines are effective in treating panic disorder symptoms, but they are less effective than antidepressants and cognitive behavior therapy.

Effects of sildenafil citrate on ejaculation latency, detumescence time, and refractory period: placebo-controlled, double-blind, crossover laboratory setting study.
Ekmekcioglu O, Inci M, Demirci D, Tatlisen A
Urology 2005 Feb;65(2):347-52.

OBJECTIVES: To evaluate whether sildenafil citrate (SC) prolongs ejaculation latency and detumescence time and shortens the refractory period in a laboratory setting. METHODS: Two successive double-blind, placebo-controlled, crossover laboratory studies were performed with 30 different healthy volunteers in each study (total of 60). In the first study, the subject ingested placebo or SC. Real-time penile tumescence and rigidity monitoring and audiovisual sexual stimulation was performed. When the subject had his best erection, he applied vibratory stimulation until he ejaculated, and then audiovisual sexual stimulation was stopped. Monitoring was continued until he lost rigidity. The test was repeated with the second medication in 7 to 15 days. In the second study, another group of 30 volunteers were tested, as in the first study, and audiovisual sexual stimulation was continued for an additional hour after ejaculation. RESULTS: In the first study, the time to ejaculation with vibratory stimulation was 2.23 and 3.89 minutes (P = 0.01) and the time to minimal tip rigidity after ejaculation was 1.93 and 3.1 minutes (P <0,001) in the placebo and SC groups, respectively. In the second study, the time to ejaculation with vibratory stimulation was 2.23 and 4.91 minutes (P = 0.006), the time to best tip rigidity after ejaculation was 19.10 and 15.66 minutes (P = 0.242), and the area under the curve of tip rigidity in 3 minutes after ejaculation was 73.61 and 144.05 (P <0.001) in the placebo and SC groups, respectively. CONCLUSIONS: In this laboratory setting, SC seemed to prolong the ejaculation latency time. The detumescence time was also longer, with better quality. However, we did not show that SC shortens the refractory period after ejaculation.

Female Sexual Dysfunction in a Healthy Austrian Cohort: Prevalence and Risk Factors.
Ponholzer A, Roehlich M, Racz U, Temml C, Madersbacher S
Eur Urol 2005 Mar;47(3):366-375. Epub 2004 Dec 2.

PURPOSE: Data on prevalence and risk factors for female sexual dysfunction (FSD) are rare, particularly from Europe. Aim of our study was therefore to investigate this issue in a cohort of women undergoing a health investigation. PATIENTS AND METHODS: A consecutive series of women aged 20-80 years participating in a health-screening project in Vienna underwent a detailed health investigation and completed a 23-item questionnaire on several aspects of FSD including desire, arousal, pain and orgasmic disorders. Prevalence of FSD in different age groups and risk factors for FSD were calculated. RESULTS: A total of 703 women aged 43+/-15 years entered this study. Within the total study population, 22% reported on desire disorders, 35% on arousal disorders, and 39% on orgasmic problems, all of which increased significantly with age. Pain disorders were reported by 12.8% being most frequently in the women aged 20-39 years. In women aged 60-69 years, still 50% reported having at least "occasionally" sexual desire and 30% had more than two sexual intercourses per month. In this age group, 50% stated that a healthy sexual life is at least moderately important to them. Apart from age few risk factors for FSD were identified. Sportive activity was the only correlate to desire- and arousal disorders, psychological stress for orgasmic disorders. CONCLUSIONS: This study provides insights into age-specific changes of FSD in apparently healthy women. The importance of this subject is underlined by the high prevalence of FSD particularly in the elderly paralleled by a persisting interest in sexual activity.

The utility of tamsulosin in the management of orgasm-associated pain: a pilot analysis.
Barnas J, Parker M, Guhring P, Mulhall JP
Eur Urol 2005 Mar;47(3):361-5. Epub 2004 Dec 16.

INTRODUCTION: Orgasmic pain is an infrequently reported but distressing problem for the patients who experience it. No consensus exists as to its etiology however bladder neck/pelvic floor spasm may play a role. This analysis was conducted to assess the effect of the alpha-blocking medication, tamsulosin on post-orgasmic pain. METHODS: In a prospective, non-placebo controlled study, patients with orgasmic pain were interviewed and administered tamsulosin 0.4mg po qhs for at least 4 weeks. Outcome measures included libido, pain and continence and these were evaluated using the International Index of Erectile Function (IIEF), a visual analog scale (VAS) for pain and an incontinence scale respectively pre and post treatment. Patients were separated into groups based on etiology of the problem (radical prostatectomy, radiation therapy, and other) for statistical analysis. RESULTS: 98 patients were enrolled. Pain was located predominantly in the penis (72%), with other sites including testis, rectum and abdomen. Most patients (52%) experienced pain for less than 5minutes post-orgasm. 76/98 (77%) patients reported significant improvement in pain (>/=2 points on pain VAS) and 12/98 (12%) noted complete resolution of their pain. The VAS for pain reflected a statistically significant decrease in pain for all groups in response to tamsulosin treatment. The entire group had a decrease of 2.7 points between pre and post-treatment phases. The IIEF libido domain increased significantly (mean of 2.4 points) for all treatment groups. CONCLUSION: Tamsulosin decreases orgasmic pain intensity in patients with orgasmic pain. These data support the hypothesis that orgasmic pain is related to bladder neck and/or pelvic floor muscle spasm.

Ten-Year Historic Cohort of Quality of Life and Sexuality in Patients With Rectal Cancer.
Schmidt CE, Bestmann B, Kuchler T, Longo WE, Kremer B
Dis Colon Rectum 2005 Feb 23;.

PURPOSE: In various studies, type of surgery, age, and gender had different impact on sexuality and quality of life in patients with rectal cancer. This study was designed to investigate how sexuality and quality of life are affected by age, gender, and type of surgery. METHODS: A total of 516 patients who had undergone surgery for rectal cancer in our department from 1992 to 2002 were included. Within one year after the operation, 117 patients died. Questionnaires were sent to 373 patients 12 to 18 months after surgery. We received quality of life data from 261 patients. Comparisons were made after adjusting age, gender, and type of surgical procedure. RESULTS: For patients receiving abdominoperineal resection sexuality was most impaired. Significant differences were seen in symptom and function scales between males and females. Females reported more distress from the medical treatment insomnia, fatigue, and constipation. Both genders had impaired sexual life; however, males had significantly higher values and felt more distressed by this impairment. Younger females felt more distress through impaired sexuality. In males sexuality was impaired independent of age. Adjuvant therapy had no influence on sexuality but on quality of life one year after surgery. CONCLUSIONS: Assessing quality of life with general and specific instruments is helpful to determine whether patients improved through the treatment. The study showed that gender, age, and type of surgery influence sexuality and that quality of life after surgery for rectal cancer is impacted. Because quality of life is a predictor for complications and survival, availability of such data may help to direct supportive treatment to improve outcome.

Efficacy, safety, and treatment satisfaction of tadalafil versus placebo in patients with erectile dysfunction evaluated at tertiary-care academic centers.
Carson C, Shabsigh R, Segal S, Murphy A, Fredlund P, Kuepfer C States (TREATED-US) Study Group.
Urology 2005 Feb;65(2):353-9.

OBJECTIVES: To determine the efficacy, safety, and treatment satisfaction of tadalafil 20 mg for erectile dysfunction (ED) in patients evaluated at tertiary-care academic centers. METHODS: In this randomized, double-blind, placebo-controlled trial, patients were randomly allocated to receive fixed-dose tadalafil 20 mg (n = 146) or placebo (n = 49) for 12 weeks. Efficacy was assessed by the International Index of Erectile Function (IIEF), Sexual Encounter Profile (SEP), and Global Assessment Question (GAQ); patient and partner treatment satisfaction by the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and SEP; and safety by adverse events, laboratory values, and vital signs. RESULTS: Mean baseline IIEF erectile function (EF) domain was 12.98. Fifty-one percent of enrolled patients had severe baseline ED, and 82% had organic ED. Pre-existing, ED-associated comorbid conditions were common. When compared with patients treated with placebo, those receiving tadalafil reported significant improvement from baseline in the IIEF EF domain (P <0.001), successful penetration attempts (SEP question 2; P <0.001), successful intercourse (SEP question 3; P <0.001), and all secondary efficacy outcomes (P <0.001). Patients and their sexual partners were also significantly more satisfied with tadalafil treatment (P <0.001), including overall satisfaction (P <0.001) and length of time the treatment worked (P <0.001). Mild or moderate headache, dyspepsia, and myalgia were the most frequent treatment-emergent adverse events reported. CONCLUSIONS: Tadalafil significantly improved erectile function and patient and partner satisfaction and was well tolerated. These results were observed in a tertiary-care, academic center population with a high incidence of severe, organic ED, and comorbid medical conditions, factors known to compromise erectile function and treatment outcome.

Sildenafil citrate and vacuum constriction device combination enhances sexual satisfaction in erectile dysfunction after radical prostatectomy.
Raina R, Agarwal A, Allamaneni SS, Lakin MM, Zippe CD
Urology 2005 Feb;65(2):360-4.

OBJECTIVES: To assess the effectiveness of combining sildenafil citrate with a vacuum constriction device (VCD) in men (after radical prostatectomy) unsatisfied with the results of the VCD alone. METHODS: A total of 31 patients unsatisfied with the early use of VCD alone after radical prostatectomy (mean follow-up of 4.5 months) were instructed to take 100 mg of sildenafil 1 to 2 hours before VCD use for sexual intercourse. Patients used combination therapy for a minimum of five attempts before assessment with the abridged International Index of Erectile Function (IIEF) questionnaire and a visual analogue scale to gauge rigidity. The effect of combination therapy on the total IIEF-5 score and penile rigidity score were assessed. RESULTS: Of the 31 patients, 7 (22%) had no improvement with the addition of sildenafil with VCD and discontinued the drug, and 24 (77%) reported improved penile rigidity and sexual satisfaction. The IIEF-5 score revealed statistically significant improvement in each domain, and patients reported that sildenafil enhanced their erections 100% of the time. The penile rigidity scores on a scale of 0 to 100 with the VCD alone averaged 55% (range 23% to 85%) for the men and 59% (range 26% to 90%) for their partners. With the addition of sildenafil, it increased to 76% for the men and 82% for their partners. Of the 24 men, 7 (30%) reported a return of natural erections at 18 months using combination therapy, with 5 of 7 reporting erections sufficient for vaginal penetration. CONCLUSIONS: In this study, the addition of sildenafil with VCD improved sexual satisfaction and penile rigidity in patients unsatisfied with VCD alone after radical prostatectomy.

Impact of vaginal surgery for stress urinary incontinence on female sexual function: is the use of polypropylene mesh detrimental?
Shah SM, Bukkapatnam R, Rodriguez LV
Urology 2005 Feb;65(2):270-4.

OBJECTIVES: To evaluate prospectively the impact of a distal urethral polypropylene sling on sexual function using a validated questionnaire. Suburethral slings are currently the most common anti-incontinence surgery performed. Although the use of polypropylene is safe and effective, concern exists that the presence of the material in the vagina may adversely affect sexual function. METHODS: A total of 29 patients agreed to participate in this prospective study. The patients were evaluated with the Female Sexual Function Index, a validated, 19-item questionnaire that assesses six domains of sexual function: desire, arousal, lubrication, orgasm, satisfaction, and pain. The questionnaires were administered at 6-month intervals during the follow-up visits. RESULTS: The mean patient age was 52 years (range 38 to 72). The mean duration of follow-up was 19.4 months (range 7 to 37). No statistically significant difference was found in sexual function after placement of a distal urethral polypropylene sling. Of the 29 patients, 14% were not sexually active before or after surgery. No statistically significant difference was found between preoperative and postoperative desire, arousal, lubrication, orgasm, satisfaction, and pain. CONCLUSIONS: No change was found in overall sexual function in women undergoing placement of a mid to distal polypropylene urethral sling. Specifically, neither a deleterious effect nor statistically significant improvement was found in sexual desire, arousal, lubrication, orgasm, satisfaction, or pain compared with the preoperative baseline values.

Operative delivery and postnatal depression: a cohort study.
Patel RR, Murphy DJ, Peters TJ
BMJ 2005 Feb 25;.

OBJECTIVES: To assess the association between elective caesarean section and postnatal depression compared with planned vaginal delivery and whether emergency caesarean section or assisted vaginal delivery is associated with postnatal depression compared with spontaneous vaginal delivery. DESIGN: Prospective population based cohort study. SETTING: ALSPAC (the Avon longitudinal study of parents and children). PARTICIPANTS: 14 663 women recruited antenatally with a due date between 1 April 1991 and 31 December 1992. MAIN OUTCOME MEASURE: Edinburgh postnatal depression scale score >/=13 at eight weeks postnatal on self completed questionnaire. RESULTS: Albeit with wide confidence intervals, there was no evidence that elective caesarean section altered the odds of postnatal depression compared with planned vaginal delivery (adjusted odds ratio 1.06, 95% confidence interval 0.66 to 1.70, P=0.80). Among planned vaginal deliveries there was similarly little evidence of a difference between women who have emergency caesarean section or assisted vaginal delivery and those who have spontaneous vaginal delivery (1.17, 0.77 to 1.79, P=0.46, and 0.89, 0.68 to 1.18, P=0.42, respectively). CONCLUSIONS: There is no reason for women at risk of postnatal depression to be managed differently with regard to mode of delivery. Elective caesarean section does not protect against postnatal depression. Women who plan vaginal delivery and require emergency caesarean section or assisted vaginal delivery can be reassured that there is no reason to believe that they are at increased risk of postnatal depression.

Sexual risk behaviour of Canadian participants in the first efficacy trial of a preventive HIV-1 vaccine.
Lampinen TM, Chan K, Remis RS, Merid MF, Rusch M, Vincelette J, Logue K, Popovic V, Alary M, Schechter MT, Hogg RS
CMAJ 2005 Feb 15;172(4):479-83.

BACKGROUND: Phase I and phase II HIV-1 vaccine trials have revealed increases in risky sexual activity among study subjects during the trials, perhaps because the subjects believe that the vaccine being tested is efficacious; subjects may thus suffer harm from their participation. We evaluated the sexual behaviour of Canadian men who have sex with men (MSM) who participated in the phase III Vax004 trial of an HIV-1 vaccine. METHODS: Using self-reports of sexual behaviours during the 6 months before trial entry as a baseline, we determined changes in reported sexual behaviour after 6, 12 and 18 months of participation in the trial. RESULTS: Of 291 HIV-seronegative MSM enrolled from July to October 1999, 260 (89%) completed 18 months of follow-up, 19 (7%) experienced seroconversion, and 12 (4%) did not complete follow-up. Unprotected receptive anal intercourse during the previous 6 months with partners whose HIV-1 serostatus was positive or unknown was reported by 21% of men at enrollment and by 27% at any point during 18 months of follow-up. No increase in this behaviour from baseline was reported by participants, including among men who were motivated to enroll because of expected protection from HIV-1 infection, men who believed they had received the vaccine, men who believed that the vaccine had greater than 50% efficacy, or men who believed that they had received the vaccine and that vaccine efficacy was greater than 50%. INTERPRETATION: MSM can be successfully enrolled in HIV-1 vaccine efficacy trials without evident increases in those sexual behaviours most associated with HIV-1 risk.

Impact of sex reassignment surgery on lower urinary tract function.
Hoebeke P, Selvaggi G, Ceulemans P, Cuypere GD, T'sjoen G, Weyers S, Decaestecker K, Monstrey S
Eur Urol 2005 Mar;47(3):398-402. Epub 2004 Dec 2.

OBJECTIVE: To investigate the effects of sex reassignment surgery (SRS) on lower urinary tract function. METHODS: A questionnaire concerning voiding habits and lower urinary tract symptoms after sex reassignment surgery, was given to 24 female-to-male transsexuals (FTM) and 31 male-to-female transsexuals (MTF), who respectively underwent phalloplasty and vaginoplasty. For this study only Dutch speaking patients were selected. Also, uro-flowmetry data from 92 FTM transsexuals were reviewed. RESULTS: In general, no change in voiding patterns was observed. Post-void dribbling was reported by 79% of the FTM transsexuals, and 16% of the MTF group reported some form of incontinence. The uro-flowmetry examination showed a mean, non-significant decrease of 2ml/s in Q(max) in FTM patients. CONCLUSION: SRS can cause minor changes in urinary habits. Even if they do not result in patients seeking medical help, transsexuals should be warned about these eventual discomforts pre-operatively.

Pelvic floor exercises for treating post-micturition dribble in men with erectile dysfunction: a randomized controlled trial.
Dorey G, Speakman M, Feneley R, Swinkels A, Dunn C, Ewings P
Urol Nurs 2004 Dec;24(6):490-7, 512.

PURPOSE: The purpose of this trial was to compare the efficacy of pelvic floor muscle exercises and manometric biofeedback for post-micturition dribble (PMD) in men with erectile dysfunction. METHODS: Fifty-five men with erectile dysfunction (median age 59.2 years; range 22-78) were enrolled from a local urology clinic. Twenty-eight subjects were randomized to an intervention group and received pelvic floor muscle exercises including a strong post-void "squeeze out" pelvic floor muscle contraction, biofeedback, and suggestions for lifestyle changes. Twenty-seven control subjects were solely advised on lifestyle changes. The PMD status, anal manometry, and digital anal muscle grade were assessed at baseline, 3, and 6 months. After 3 months, the control group received the intervention with pelvic floor muscle exercises and biofeedback. Both groups were followed for an additional 3 months of home exercises. An independent assessor who was blinded to the grouping assessed the PMD status of subjects at 3 and 6 months. RESULTS: Thirty-six (65.5%) of the 55 subjects reported PMD at baseline. At 3 months, there was significant reduction in PMD after intervention (p=0.001) compared to the control subjects (p=0.102). In both groups combined after 3 months of pelvic floor muscle exercises and 3 months of home exercises, 27 (75%) subjects became asymptomatic of PMD, 3 (8.3%) improved, 5 (13.9%) dropped out, and 1 (2.8%) subject still reported PMD. PMD was not correlated to age, erectile function, anal manometric pressure, or digital anal muscle grade. CONCLUSION: Pelvic floor muscle exercises including a post-void "squeeze out" pelvic floor muscle contraction are an effective treatment for post-micturition dribble in men with erectile dysfunction.

Human pheromones and sexual attraction.
Grammer K, Fink B, Neave N
Eur J Obstet Gynecol Reprod Biol 2005 Feb 1;118(2):135-42.

Olfactory communication is very common amongst animals, and since the discovery of an accessory olfactory system in humans, possible human olfactory communication has gained considerable scientific interest. The importance of the human sense of smell has by far been underestimated in the past. Humans and other primates have been regarded as primarily 'optical animals' with highly developed powers of vision but a relatively undeveloped sense of smell. In recent years this assumption has undergone major revision. Several studies indicate that humans indeed seem to use olfactory communication and are even able to produce and perceive certain pheromones; recent studies have found that pheromones may play an important role in the behavioural and reproduction biology of humans. In this article we review the present evidence of the effect of human pheromones and discuss the role of olfactory cues in human sexual behaviour.

Different Nordic facilities for victims of sexual assault: a comparative study.
Nesvold H, Worm AM, Vala U, Agnarsdottir G
Acta Obstet Gynecol Scand 2005 Feb;84(2):177-183.

Background. Open multidisciplinary centers were operated in the mid 1990s for victims of sexual assaults in Oslo and Reykjavik. However, in Copenhagen and Helsinki forensic medical examination was only available to victims who reported directly to the police. One of the main aims of this study was to compare the effect of these different service facilities in four Nordic capitals on the victims' frequency to seek help and report sexual assaults to the police. Methods. The age and attendance profile of 380 individuals, seeking support after sexual assault, was compared for the four capitals over a period of 1 year. The circumstances and consequences of assault, frequency and time lag of reporting were also compared. Results. Open centers received several times more victims, especially in younger age groups, including more reported cases, when compared with the population at risk than forensic institutes. Victims were seen earlier for examination at forensic institutes that dealt with a more limited spectrum of sexual assaults than the open centers. The proportion of rape was higher amongst victims brought to forensic institutes whereas a higher proportion of victims received at open centers had been exposed to less violent assaults. The frequency of visits was higher at weekends, between 50% and 70% of victims reported consumption of alcohol, and one-third were attacked while sleeping. In the majority of cases only one perpetrator was involved, most often unknown or peripherally known to the victim. Conclusion. Open multidisciplinary centers receive and assist considerably more victims, reporting and not reporting sexual assaults than forensic institutes.

Erectile function: the barometer of men's health.
Mulcahy JJ
J Urol 2005 Feb;173(2):341.

[The profile of female victims of conjugal violence]
Vasseur P
Presse Med 2004 Dec 18;33(22):1566-8.

OBJECTIVE: To define the profile of female victims of conjugal violence examined in the Legal Medicine emergency unit of the Hotel-Dieu hospital in Paris. METHODS: A self-administered questionnaire with 15 questions was distributed to 100 victims. RESULTS: The 100 victims replied: 86 cases of violence took place usually in the home, 78 episodes of violence were multiple and complaints were rarely lodged after the first episodes. Mental and sexual violence were severe and unrecognized. Eighty women interviewed suffered from mental violence. In 43 cases, alcohol played a determining role in the onset of such violence. CONCLUSION: Female victims of conjugal violence do not have a specific profile. The law of silence persists, but the increase in the number of complaints from North African and African women is encouraging for the future.

[Domestic violence: what are the difficulties for practitioners? Analysis of interviews among 19 practitioners within a town-hospital care network aimed at a global approach of patients]
Francois I, Moutel G, Plu I, Fauriel I, Herve C

Presse Med 2004 Dec 18;33(22):1561-5.
OBJECTIVE: Using a qualitative approach of medical practice, the aim of this study was to specify the difficulties and pitfalls that practitioners are confronted with regarding persons suffering from domestic violence. METHODS: Nineteen practitioners agreed to participate in an assessment of their attitude towards the recognition and management of domestic violence. These practitioners were aware of the medico-social dimension of their practice. A questionnaire was proposed during an interview conducted in all participants by the same investigator. The interviews were reviewed and analysed by two assessors. In the case of discordance, a second reading was made so that a consensus could be reached. RESULTS: The interview lasted a mean of 40 minutes. The practitioners interviewed (11 men and 8 women) were 29 to 60 years old and had practiced for 6 months to 36 years. They all knew of such violence, notably through its physical impact, but this did not permit them to recognise all the forms of violence. The medico-legal tools at their disposal are not clearly understood and are often not adapted to the demands of their female patients. CONCLUSION: The notion of global management required in such cases must be developed and specified in medical training, because the recognition and management of "battered women" is a question of personal dignity.

Assessment of cognitive function of the elderly population: effects of darifenacin.
Lipton RB, Kolodner K, Wesnes K
J Urol 2005 Feb;173(2):493-8.

PURPOSE: Overactive bladder is common in the elderly population, which is susceptible to cognitive disorders and drug induced cognitive impairment. Existing overactive bladder treatments may cause adverse events, such as cognitive impairment, due to antagonism of the M1 receptor in the central nervous system. In this study we evaluated the effect of darifenacin, an M3 selective antagonist, on cognitive function in elderly volunteers without clinical dementia. MATERIALS AND METHODS: This double-blind, 3-period crossover study randomized 129 volunteers 65 years or older with no/mild cognitive impairment to receive 3 of 5 treatments, namely darifenacin controlled release (3.75, 7.5 or 15 mg once daily), darifenacin immediate-release (5 mg 3 times daily) or matching placebo for 14 days. Each treatment period was separated by 7 days of washout. Cognitive function tests were completed at baseline and at treatment end. RESULTS: For the primary end points of memory scanning sensitivity, speed of choice reaction time and word recognition sensitivity, there were no statistically significant differences for darifenacin vs placebo. There were no statistically significant differences in secondary variables except memory scanning speed, which increased in all groups relative to baseline, but improvement was greater with placebo than with 3.75 mg darifenacin. Darifenacin treatment was not associated with changes in alertness, contentment or calmness, which are likely to be clinically relevant. Darifenacin was well tolerated. CONCLUSIONS: In elderly volunteers 2 weeks of treatment with darifenacin had no effect on cognitive function compared with baseline and it was not significantly different from placebo. This may be related to its M3 receptor selectivity with negligible M1 receptor antagonism.

Sexual problems among women and men aged 40-80 y: prevalence and correlates identified in the global study of sexual attitudes and behaviors.
Seftel A
J Urol 2005 Feb;173(2):545.

Evaluation of sexual function with an international index of erectile function in subjects taking finasteride for androgenetic alopecia.
Seftel A
J Urol 2005 Feb;173(2):544.

Effect of lifestyle changes on erectile dysfunction in obese men. A randomized controlled trial.
Seftel A
J Urol 2005 Feb;173(2):544-5.

Does sildenafil combined with testosterone gel improve erectile dysfunction in hypogonadal men in whom testosterone supplement therapy alone failed?
Greenstein A, Mabjeesh NJ, Sofer M, Kaver I, Matzkin H, Chen J

J Urol 2005 Feb;173(2):530-2.
PURPOSE: We evaluated the efficacy of testosterone gel (T-gel) alone and in combination with sildenafil in hypogonadal patients with erectile dysfunction (ED). MATERIALS AND METHODS: A total of 49 hypogonadal men (mean age 60.7 years) with ED participated for a mean of 20.2 months. Blood was tested for total and bioavailable testosterone, and prostate specific antigen. Sexual function was assessed using the International Index of Erectile Function questionnaire and a global assessment question (GAQ). Men received 1% 5 gm T-gel for 6 months, and 100 mg sildenafil was added to those with a "no" response to the GAQ after 3 months on testosterone supplement. RESULTS: A total of 31 patients reported significant improvement in the sexual desire domain (from a mean +/- SD of 4.2 +/- 0.8 to 8.6 +/- 0.4) and erectile function (EF) domain (from 13.6 +/- 1.9 to 27 +/- 0.8) following treatment with testosterone supplement alone. One patient was excluded from study after urinary retention developed and 9 reported irritation at the gel application site. In spite of normalization of total and bioavailable testosterone values, and significant improvement of sexual desire domain scores, the EF of 17 men remained less than 26 or they responded "no" to the GAQ. These men received combined T-gel and sildenafil, after which all graded EF greater than 26 and responded positively to the GAQ. CONCLUSIONS: Combined treatment with sildenafil and T-gel has a beneficial effect on ED in hypogonadal patients in whom treatment with testosterone supplement alone failed.

Intima-media thickening of common carotid arteries is a risk factor for severe erectile dysfunction in men with vascular risk factors but no clinical evidence of atherosclerosis.
Bocchio M, Scarpelli P, Necozione S, Pelliccione F, Mhialca R, Spartera C, Francavilla F, Francavilla S
J Urol 2005 Feb;173(2):526-9.

PURPOSE: The association of erectile dysfunction (ED) with vascular damage in men without clinical atherosclerosis is unknown. By B-mode ultrasound we evaluated intima-media thickness (IMT) of common carotid arteries, a measure of vascular damage, in men reporting ED with or without vascular risk factors (VRFs) but no clinical atherosclerosis. MATERIALS AND METHODS: IMT of common carotid arteries was evaluated in 270 men with ED. A total of 50 men (mean age +/- SD 39.84 +/- 12.5 years) had no VRFs, 100 (mean age 47.92 +/- 10.94 years) were overweight and/or had hyperlipidemia, and 120 (mean age 53.95 +/- 9.73 years) were affected by type 2 diabetes and/or essential arterial hypertension. RESULTS: IMT was significantly lower in men with no VRFs compared to men with VRFs (p <0.05), and correlated with the severity of ED evaluated through the Sexual Health Inventory for Men (p = 0.0008). Of men with VRFs 17.7% (39 of 220) showed an IMT score indicative of vascular damage (1.00 mm or greater), while only 1 man with no VRFs had a high IMT. Men with VRFs and a high carotid IMT score demonstrated more severe ED, were older and had a higher serum level of C-reactive protein compared to men with VRFs and an IMT of less than 1.00 mm (p <0.05). A high IMT score but not an increased measure for each VRF, including aging, significantly increased the risk of severe ED (odds ratio 2.6, confidence interval 1.1 to 5.9) even after controlling for smoking and drugs associated with ED. CONCLUSIONS: ED in men with VRFs was the only clinical correlate of unrecognized atherosclerosis of common carotid arteries.

Sexually transmitted diseases: an update.
Blair M
Urol Nurs 2004 Dec;24(6):467-73.

Sexually transmitted diseases (STDs) have reached epidemic numbers in this country and represent considerable costs to the health care system. Nurses, who see clients in a variety of acute and community settings, have a unique opportunity to discuss STDs and their prevention. However, nurses must retain knowledge that is up-to-date on each of these diseases. Nurses need to take the lead in evaluating their clients' risk of acquiring STDs and tailor specific preventative techniques to the individual needs uncovered.

Urologic complications of sexual trauma among male survivors of torture.
Norredam M, Crosby S, Munarriz R, Piwowarczyk L, Grodin M
Urology 2005 Jan;65(1):28-32.

OBJECTIVES: To describe the urologic and sexual complications of male survivors of sexual torture, including prevalence, sequelae, diagnosis, and treatment. METHODS: Through chart reviews, we identified all male survivors of torture who had been treated for physical and/or psychological symptoms due to sexual trauma at the Boston Center for Refugee Health and Human Rights at Boston Medical Center between January 1, 2001 and January 1, 2002. Of the 72 men seen, 20 (28%) were survivors of sexual trauma. Our study focused on genital trauma leading to urologic and/or sexual dysfunction. Therefore, all cases of male genital trauma that had been referred to the urology department (3 of 20) were selected for this review. RESULTS: The patients presented with chronic genital and erectile pain, lower urinary tract symptoms, and sexual dysfunction. The diagnostic workup included history, physical examination, and ultrasonography. Treatment included steroid injections for chronic pain and oral erectogenic agents for sexual dysfunction. CONCLUSIONS: The apparent prevalence and severity of the physical and mental sequelae to sexual trauma make it an important area for screening when treating survivors of torture. Our study is the first of its kind to document urologic complications of sexual torture in a foreign-born U.S. cohort of tortured men, including prevalence, diagnosis, and treatment. The proposed use of steroid injections in the clinical treatment of these patients has not been previously reported.

Prevalence of female sexual dysfunction symptoms and its relationship to quality of life: a Japanese female cohort study.
Hisasue S, Kumamoto Y, Sato Y, Masumori N, Horita H, Kato R, Kobayashi K, Hashimoto K, Yamashita N, Itoh N
Urology 2005 Jan;65(1):143-8.

OBJECTIVES: To clarify the age prevalence of female sexual dysfunction and the factors that contribute to the varying frequency of sexual intercourse and satisfaction with sexual life in Japanese women. METHODS: Of 8956 participants (median age 57 years, range 17 to 88) in a Japanese female cohort study, 5042 (56.3%) responded. We evaluated 2095 women aged 30 to 69 years (median 48) who completed a questionnaire that queried about their sexual life. RESULTS: When women in their 30s were compared with those in their 60s, we found that the prevalence of the symptom of orgasmic disorder, sexual desire disorder, arousal disorder, and lubrication disorder had increased significantly from 15.2% to 32.2%, 27.7% to 57.9%, 29.7% to 57.9%, and 12.5% to 51.2%, respectively. Multivariate analysis showed that the rigidity of the partner's erection, orgasm, and arousal contributed significantly to sexual frequency and foreplay and orgasm to satisfaction with sexual life. CONCLUSIONS: The prevalence of female sexual dysfunction increased with age. The results of multivariate analysis indicated that favorable sexual function is important to maintain the opportunity for sexual intercourse in both men and women and that foreplay and orgasm are essential for satisfactory sexual life in women.

Emotional antecedents of hot flashes during daily life.
Thurston RC, Blumenthal JA, Babyak MA, Sherwood A
Psychosom Med 2005 Jan-Feb;67(1):137-46.

Objective: Hot flashes are among the most frequently reported menopausal symptoms. However, little is known about factors associated with their occurrence. Moreover, despite the wide use of self-report hot flash measures, little is known about their concordance with physiological flashes. This study evaluated emotional and behavioral antecedents of subjectively and objectively measured hot flashes during daily life. It also examined individual differences predicting concordance between objective and subjective hot flashes. Methods: Forty-two perimenopausal or postmenopausal women (mean age = 50.5 +/- 4.8 years) reporting daily hot flashes completed 2 days of ambulatory sternal skin conductance monitoring, behavioral diaries 3 times an hour, and psychometric questionnaires. Hot flashes meeting objective physiological criteria and subjectively reported flashes not meeting physiological criteria were assessed. Likelihood of hot flashes following emotions and activities were examined in a case-crossover analysis. Results: Relative to nonflash control times, objective hot flashes were more likely after increased happiness, relaxation, and feelings of control, and less likely after increased frustration, sadness, and stress. Conversely, subjective hot flashes not meeting physiological criteria were more likely after increased frustration and decreased feelings of control. Questionnaires revealed increased negative mood and negative attitudes were associated with fewer objective flashes and higher false-positive reporting rates. Conclusion: Increased positive and decreased negative emotions were associated with objective hot flashes, whereas increased negative and decreased positive emotions were associated with subjective flashes not meeting physiological criteria. The anecdotal association between negative emotions and hot flashes may be the result of self-reported flashes lacking physiological corroboration.

The Perceived Stress Questionnaire (PSQ) Reconsidered: Validation and Reference Values From Different Clinical and Healthy Adult Samples.
Fliege H, Rose M, Arck P, Walter OB, Kocalevent RD, Weber C, Klapp BF
Psychosom Med 2005 Jan-Feb;67(1):78-88.

Objective: The aim was to translate, revise, and standardize the Perceived Stress Questionnaire (PSQ) by Levenstein et al. (1993) in German. The instrument assesses subjectively experienced stress independent of a specific and objective occasion. Methods: Exploratory factor analyses and a revision of the scale content were carried out on a sample of 650 subjects (Psychosomatic Medicine patients, women after delivery, women after miscarriage, and students). Confirmatory analyses and examination of structural stability across subgroups were carried out on a second sample of 1,808 subjects (psychosomatic, tinnitus, inflammatory bowel disease patients, pregnant women, healthy adults) using linear structural equation modeling and multisample analyses. External validation included immunological measures in women who had suffered a miscarriage. Results: Four factors (worries, tension, joy, demands) emerged, with 5 items each, as compared with the 30 items of the original PSQ. The factor structure was confirmed on the second sample. Multisample analyses yielded a fair structural stability across groups. Reliability values were satisfactory. Findings suggest that three scales represent internal stress reactions, whereas the scale "demands" relates to perceived external stressors. Significant and meaningful differences between groups indicate differential validity. A higher degree of certain immunological imbalances after miscarriage (presumably linked to pregnancy loss) was found in those women who had a higher stress score. Sensitivity to change was demonstrated in two different treatment samples. Conclusion: We propose the revised PSQ as a valid and economic tool for stress research. The overall score permits comparison with results from earlier studies using the original instrument.

Perceived psychologic stress and colorectal cancer mortality: findings from the Japan collaborative cohort study.
Kojima M, Wakai K, Tokudome S, Tamakoshi K, Toyoshima H, Watanabe Y, Hayakawa N, Suzuki K, Hashimoto S, Kawado M, Suzuki S, Ito Y, Tamakoshi A
Psychosom Med 2005 Jan-Feb;67(1):72-7.

Objective: The purpose of this research was to examine the relationship between perceived psychologic stress and colorectal cancer mortality in a prospective large-scale study. Methods: Between the years 1988 and 1990, 32,153 men and 45,854 women aged 40 to 79 years were enrolled. Participants completed a self-administered questionnaire that addressed demographic, lifestyle, and psychosocial characteristics. Subjects were subsequently followed for mortality until the end of 1999. Perceived psychologic stress was assessed using the question "Do you feel stress during your daily life?" The 4 possible responses, ranging from "little or none" (1) to "extreme" (4), were dichotomized as low (1 or 2) or high (3 or 4) stress. Relative risks (RRs) with 95% confidence intervals (CIs) for colon and rectal cancer according to the perceived level of stress were estimated using Cox's proportional hazard model. Results: During the follow-up period (average, 9.6 years), 193 colon cancer deaths (96 men and 97 women) and 127 rectal cancer deaths (88 men and 39 women) were confirmed within the study group. Women who reported high stress had a 1.64-fold higher risk of colon cancer mortality (multivariate-adjusted RR, 1.64; 95% CI, 1.01-2.66) compared with those reporting low stress. There was no significant association between perceived stress and female rectal cancer or male colon and rectal cancer mortality. Conclusions: Perceived psychologic stress was weakly associated with increased mortality from colon cancer in women. No positive or inverse association was found in men. Further studies are needed to confirm our results.

Sexual function after partial cystectomy and urothelial stripping in a 32-year-old woman with radiation cystitis.
Elzevier HW, Gaarenstroom KN, Lycklama A Nyeholt AA
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan 13;.

We report a case of a 32-year-old woman who underwent a partial cystectomy to preserve sexual function. After radiotherapy for stage IB1 cervical cancer, cystectomy was indicated because of severe radiation cystitis. During this procedure we resected the upper part of the bladder followed by stripping off urothelium of the remaining bladder to spare the neurovascular bundle. Follow-up after 3 months indicated intact sexual function including orgasm. In our opinion the cystectomy procedure described in this case report is a good, novel option in women who are candidates for cystectomy because of a crippled bladder, after radiotherapy, and want to retain sexual function.

Sexual function after tension-free vaginal tape (TVT) for stress incontinence: results of a mailed questionnaire.
Elzevier HW, Venema PL, Lycklama a Nijeholt AA
Int Urogynecol J Pelvic Floor Dysfunct 2004 Sep-Oct;15(5):313-8. Epub 2004 Jun 18.

In a retrospective study we evaluated sexual function after tension-free vaginal tape (TVT) placement for urinary stress incontinence based on responses to a mailed questionnaire at least 3 months after the operation, to a maximum of 1 year. From 1999 to 2002, a sexual function questionnaire was mailed to 128 women (and their partners) who had undergone a TVT procedure for genuine urinary stress incontinence, without pelvic organ prolapse or detrusor instability. The questionnaire was returned by 96 women (75%), 69 (72%) of whom reported being sexually active. Mean frequency of intercourse did not change. Overall, 26% described improved intercourse compared to before the operation. Only one patient described worsening of intercourse after the TVT operation because of an increase in her incontinence. Overall, in this study the technique of tension-free vaginal tape as such seems to have no negative impact on sexual function. However, because of its successful outcome on incontinence, it has a positive overall effect on sexual function. The possible causes of postoperative partner discomfort require further investigation.

Acupuncture for depression: first steps toward a clinical evaluation.
Macpherson H, Thorpe L, Thomas K, Geddes D
J Altern Complement Med 2004 Dec;10(6):1083-91.

Aim of study: To explore issues that need to be addressed in the design of a clinical trial of acupuncture for people with depression. Methods: In this study we conducted a focus group with 6 volunteer participants with experiences of depression, and a prospective case series of 10 patients who received acupuncture treatment for their depression. In the case series study, 10 patients were referred by their general practitioner, and received up to 10 individualized acupuncture treatments from one of two acupuncturists. Acupuncturists recorded traditional acupuncture diagnoses and details of the treatment provided. Measures of depression (Beck Depression Inventory and the Hospital Anxiety and Depression Scale) and health status (SF-36) were taken at baseline and 10 weeks later. Changes in mean before and after scores were analyzed using the Wilcoxon signed ranks test. Adverse events were also monitored. Results: The focus group and the case series both identified considerable heterogeneity among people with depression. In the case series, only 6 patients both received treatment and completed 10-week questionnaires; however, significant improvements between before and after were found in their levels of depression (p < 0.05). Many factors, as well as the acupuncture, may have contributed to these improvements. No serious adverse events occurred. In the context of designing a clinical trial of acupuncture for depression, a series of methodological challenges is explored. Conclusion: This study highlighted the complexities of evaluating acupuncture for patients with depression. Successfully addressing the identified methodological challenges in the design of a trial will increase its relevance and impact.

An approach to teaching dermatologists about complementary medicine.
Ben-Arye E, Frenkel M, Ziv M
J Altern Complement Med 2004 Oct;10(5):899-904.

OBJECTIVES: There is increasing evidence for the extensive use of complementary and alternative medicine (CAM) among patients with dermatologic ailments amid a scarcity of information about teaching health providers on how to engage with patients who use CAM or request information about it. An approach to educating dermatologists and nurses about CAM is described in this paper. DESIGN: A course on CAM and dermatology was offered to 17 dermatologists and nurses at a dermatology department in a university hospital in Israel. The course objective was to expose participants to common methods in CAM, emphasizing the role of an evidence-based approach and patient-doctor communication relating to CAM. RESULTS: Course evaluation revealed that participants acknowledged the existence of evidence-based research as an important consideration before referring their patients to CAM. CONCLUSIONS: Teaching CAM to dermatologists and nurses using evidence-based medicine and a patient-centered approach could enable them to provide informed and balanced advice to their patients.

A personal perspective on energies in future energy medicine.
Tiller WA
J Altern Complement Med 2004 Oct;10(5):867-77.

This paper deals with the evolution of medicine from chemical medicine to energy medicine to information medicine as, first, standard electric, magnetic, and electromagnetic fields are applied to a patient and, second, as subtle energy fields are applied to the patient. Next, a brief reporting is given on our specific intention imprinting of a simple electrical device, which, when turned on in a given space, lifts the inner symmetry state of that space and tunes that space so that the specific intention, acting on the materials in that space, causes well-designed target experiments running in that space to yield results in full accord with the specific intention. A new theoretical model of nature is provided to explain these seemingly anomalous phenomena. A new perspective on what constitutes the whole person is also provided and one finds that human consciousness will become an important experimental variable in future medicine.

Acupuncture as a complex intervention: a holistic model.
Paterson C, Britten N
J Altern Complement Med 2004 Oct;10(5):791-801.

OBJECTIVES: Our understanding of acupuncture and Chinese medicine is limited by a lack of inquiry into the dynamics of the process. We used a longitudinal research design to investigate how the experience, and the effects, of a course of acupuncture evolved over time. DESIGN AND OUTCOME MEASURES: This was a longitudinal qualitative study, using a constant comparative method, informed by grounded theory. Each person was interviewed three times over 6 months. Semistructured interviews explored people's experiences of illness and treatment. Across-case and within-case analysis resulted in themes and individual vignettes. SUBJECTS AND SETTINGS: Eight (8) professional acupuncturists in seven different settings informed their patients about the study. We interviewed a consecutive sample of 23 people with chronic illness, who were having acupuncture for the first time. RESULTS: People described their experience of acupuncture in terms of the acupuncturist's diagnostic and needling skills; the therapeutic relationship; and a new understanding of the body and self as a whole being. All three of these components were imbued with holistic ideology. Treatment effects were perceived as changes in symptoms, changes in energy, and changes in personal and social identity. The vignettes showed the complexity and the individuality of the experience of acupuncture treatment. The process and outcome components were distinct but not divisible, because they were linked by complex connections. The paper depicts these results as a diagrammatic model that illustrates the components and their interconnections and the cyclical reinforcement, both positive and negative, that can occur over time. CONCLUSIONS: The holistic model of acupuncture treatment, in which "the whole being greater than the sum of the parts," has implications for service provision and for research trial design. Research trials that evaluate the needling technique, isolated from other aspects of process, will interfere with treatment outcomes. The model requires testing in different service and research settings.

Sex differences in the relationship between social support and risk for major depression: a longitudinal study of opposite-sex twin pairs.
Kendler KS, Myers J, Prescott CA
Am J Psychiatry 2005 Feb;162(2):250-6.

OBJECTIVE: Compared to men, women have larger and more intimate social networks and higher rates of major depression. Prior studies have suggested that women are more sensitive to the depressogenic effects of low social support, but most of these studies had substantial methodologic limitations. METHOD: In two interview waves at least 1 year apart, 1,057 pairs of opposite-sex dizygotic twin pairs ascertained from a population-based register were assessed. The authors predicted risk of major depression in the year before the wave 2 interview from levels of social support assessed at wave 1. RESULTS: Women reported higher levels of global social support than their twin brothers. Global social support at wave 1 predicted risk for major depression at wave 2 significantly more strongly in female than in male members of these pairs, and the same effect was seen when the analysis controlled for the history of major depression in the year prior to wave 1. Women were more sensitive than men to the depressogenic effects of low levels of social support, particularly from the co-twin, other relatives, parents, and spouses. Levels of social support did not explain the sex difference in risk for major depression. CONCLUSIONS: Emotionally supportive social relationships are substantially more protective against major depression for women than for men. While these effects cannot explain sex effects on the prevalence of major depression, they do suggest important sex differences in pathways of risk. Clarification of the nature of the causal links between low social support and depression in women is needed.

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