Medical Meeting Reports

Sexual Function: Evaluation & Surgical Therapy

Author: Donghua Xie, MD.Ph.D.

Raymond Rosen and his colleagues (Abstract 1244) developed a new scale (Male Sexual Function) to assess the multiple components of male sexual function in clinical and research settings. In this study, draft items were developed for testing in the major domains of erectile function, orgasm and ejaculatory function, sexual desire, pain and satisfaction. Draft items were subjected to intensive qualitative investigation in focus groups in men with and without sexual dysfunction. Based on the results of qualitative testing, a final item set (7 items) was developed for quantitative testing in a large, community-based sample of middle-aged and older U.S. men. Items were selected for assessing both response and bother aspects of sexual function. The data suggests that this scale was suitable for use in both primary care and urology practice settings, and for evaluation of sexual function following pelvic surgery or with chronic illness or medications.

The sensitive nature of ED makes it difficult for patients to discuss their condition with their physicians. Most of the screening and diagnostic tools require the administration of a questionnaire which contains specific questions regarding erectile functioning. Various surveys have demonstrated the association between ED and age as well as other health conditions. Moritz Braun and his colleagues (Abstract 1257) developed a simple scoring scheme to identify the individual likelihood of erectile dysfunction, based on age, smoking habits and existing health conditions. This tool may help facilitate communication between patients and physicians. In this study, complete case records (n=4,396) from the Cologne Male Survey, a cross-sectional study investigating male sexuality by means of a validated questionnaire, were used to develop a multivariable logistic regression model for the prevalence of ED. The validated ED risk score may provide a different approach to identification of ED high-risk patients.

No objective test for quantifying sexual interest exists to date. Yoram Vardi and his colleagues (Abstract 1253) used a new psychophysical method employing P300 EEG-waves for quantifying the level of interest in sexual content in both sexes. They found that by using the combined methodology of auditory with visual stimuli it is possible to achieve significant reduction of p300 for almost any type of visual stimuli. Nevertheless, in the male population, the reported sexual interest highly correlated with the results obtained by this testing, demonstrating that this method is reliable for the purpose of measuring sexual desire. They believe that in the future this method could be applied for diagnosis of desire disorders in both sexes.

It has been recommended that at least 3 outcomes are relevant to the assessment of premature ejaculation (PE): ejaculatory latency time, ejaculatory control, and sexual satisfaction. An ideal measure would be self-administered, short, reliable, valid, and sensitive to change. Donald Patrick et al (Abstract 1246) carried out a study to evaluate the reliability and validity of 2 single-item patient-reported outcome measures (Control Over Ejaculation and Satisfaction With Sexual Intercourse) using data from a non-interventional observational study, and to assess the efficiency of the measures using evidence from a clinical trial. Outcome measures included single and multiple-item measures of Control Over Ejaculation and Satisfaction With Sexual Intercourse. Multiple-item measures included the Golombok Rust Inventory of Sexual Satisfaction (GRISS) PE subscale (4 items) and the Premature Ejaculation Questionnaire (PEQ) satisfaction subscale (4 items). Intraclass correlation coefficient (ICC) was used to assess test-retest reliability over a 2-week period. There finding demonstrated that the single-item measures of Control Over Ejaculation and Satisfaction With Sexual Intercourse were reliable, valid, and efficient measures of the key PE outcomes. This is a very encouraging scale.

Another similar study (Abstract 1245) reported a recent US, 4-week, multicenter, observational study of males ≥18 years of age (and their female partners) with and without PE (N=1587) collected data on intravaginal ejaculatory latency time (IELT) and various Patient Reported Outcomes (PROs) in order to characterize IELT and validate single-item PRO measures in these populations. Using IELT, PRO measures, and age, they identified those variables and their combinations predictive of a diagnosis of PE.They concluded that IELT combined with a small set of single-item PRO measures adequately predicted PE status. Along with subject Control Over Ejaculation, a partner measure of Satisfaction With Sexual Intercourse or Personal Distress predicted PE more strongly than did IELT. IELT alone is not an optimal predictor of PE status.

New pharmaceuticals have increased the number of patients presenting for treatment of sexual dysfunctions, including retarded ejaculation (RE) which is a reportedly difficult-to-treat dysfunction. Dr. Perelman and his colleagues (Abstract 1254) carried out a study to identify variables that could improve a practicing urologist's capacity to understand and treat RE. In this study, a five year retrospective chart review was conducted of the 80 men diagnosed as REs, who had been referred for sex therapy by their urologists. Key variables previously unexplored by their urologists were identified. The data strongly suggested that high frequency, idiosyncratic masturbation and fantasy/partner disparity predispose RE. Failure to assess these factors may account for much of the perceived difficulty in treating RE. Identifying and using counseling techniques to alter these patterns could enhance the practicing urologist's ability to improve their patient's orgasmic capacity. Once new drugs are developed to increase the ease and speed of ejaculatory latency, combination drug and sex therapy protocols may produce the best treatment outcome.

Penile prosthesis implantation remains an effective and acceptable treatment for the significant number of men who fail to respond to nonsurgical therapy. The most serious complication that can affect the use of most prosthetic devices is infection. Re-operation of penile implants was reported to carry a higher risk of infection. A salvage irrigation protocol has been proven to rescue patients with clinically infected IPPs. During revision surgery for non-infectious reasons, early results have shown that washing out the implant space at the time of revision surgery and utilizing antibiotic coated replacement prosthesis lowers subsequent infection rates. Gerard Henry and his colleagues (Abstract 1262) investigated whether longer follow up and a larger group of patients would show the continued benefit of decreased infections using the revision washout. Results of combining complete implant removal and modified salvage protocol indicate a markedly decreased incidence of infection in penile prosthesis patients undergoing revision for non-infectious reasons. One draw back from this study was the the difficulty involved in removing the reservoir on occasion.

In another study, Steven Wilson and his colleagues (Abstract 1264) reported the first large single surgical team experience with this type of coating. In this study, retrospective chart review of IPP infections was conducted in all 467 patients receiving InhibiZone implants. The InhibiZone coated AMS IPP showed statistically significant reduction of infection for virgin implants, diabetics & revisions with washout when compared to our previously published series of non coated prosthetics. This finding is very exciting, even though there was still relative higher infection rate in the revisions. The amount of antibiotic used to coat the outside of the InhibiZone penile prosthesis is less than a single oral pill, which is potentially enough to lower infection rates in primary surgeries but not enough for the established biofilm found in secondary cases. We still need larger scale and longer follow-up to furtherly observe the effect.

Proximal corporal perforation during prosthesis dilatation is common during reinsertion of implants after a previous prosthesis has been removed for infection. The surgical fields have been altered, the erectile tissue replaced by fibrosis and the proximal corpora are scarred and stenotic. Steven Wilson and his colleagues (Abstract 1263) describe a new method of correction that does not use graft material and does not require repair of the perforation. On the perforated side, a suture sling of non-absorbable suture was constructed slinging the rear tip extender (RTE) to normal corporal tissue lateral or proximal to the corporotomy. The cylinders were inserted, the corporotomies were closed, the prosthesis inflated and the sling tied after the guide strings had been snugged on the glans penis. The theory is that the RTE sling keeps the end of the cylinder out of the perforation and the damage fibroses. They concluded that RTE suture sling is an effective, easy solution to proximal corporal perforation.

Priapism is a pathologic condition of a penile erection that persists beyond or is unrelated to sexual stimulation. Hemodynamically, it can be separated into two distinct types: ischemic (veno-occlusive) and nonischemic (arterial). Ischemic priapism is the more common form characterized clinically by the absence of cavernous blood flow. Pardeep Kumar and his colleagues (Abstract 1271) reported a long term follow up for 27 patients with ischemic priapism. Patients with ischemic priapism who have failed conservative management traditionally go on to have shunt surgery. The outcome in these patients is usually poor with resulting severe cavernosal smooth muscle fibrosis, penile shortening, and long term erectile dysfunction. In this study, they assessed the long term results of immediate penile prosthesis implantation thereby treating the inevitable ED early and preventing excessive shortening. There finding demonstrated that the patient satisfaction was high and complications were low.