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Objective The objective of the study was to asses ocular findings' prevalence in children with primary congenital heart disease (CHD). Patients and methods This is a prospective cross-sectional study of children with CHD treated at a specialized center in the South of Brazil between 2013 and 2015. They underwent a complete ocular examination, including measurement of visual acuity, refraction test, external motility, anterior and posterior biomicroscopy, and binocular indirect fundoscopy with retinal photographs. Two experienced examiners independently assessed fundus findings: one at the time of examination and image capture, while the other assessed only the captured images. Results Of a total of 146 children examined, 124 were included in this analysis (16% loss). Seventy children were male (55.5%). The average age was 9.3 years (minimum 1 month and maximum 15 years). Caucasians race were 81.2%, African Descendants race were 11.1%, and others were 7.7%. About 57.1% had already had heart surgery. About 14.8% had visual acuity below 0.6 and 2.8% below 0.1. Strabismus was found in 7.4% and cataracts in 1.7%. Retinal alterations were recognized in 13.5%, of which 4.8% were related to vascular narrowing or dilation and/or abnormal arteriovenous crossing; 7.14% were related to increased vascular tortuosity, while 1.6% were related to active toxoplasmic chorioretinitis lesions. Concomitant abnormalities in ocular motility, biomicroscopy, or ophthalmoscopy were detected in 24% of the cases. Conclusion Children under the age of 15 years old with primary CHD have a high prevalence of ocular alterations, with external ocular and retinal manifestations, with higher occurrence rate among cyanotic cases. This leads us to strongly recommend the performance of a complete ophthalmological examination in such cases.

PURPOSE Laser-evoked potentials (LEPs) are useful neurophysiological tools for investigating the A-delta sensory peripheral fibers and the central nociceptive pathway. The current investigation aims to obtain normative values of LEPs via pudendal nerve stimulation in healthy adult volunteers. METHODS Laser-evoked potentials were recorded in 16 men and 22 women, 22 to 75 years of age, using neodymium and yttrium and aluminum and perovskite laser bilateral stimulation to the pudendal nerve-supplied skin and the dorsal surface of the hands and feet. We assessed the perceptive threshold, latency, and amplitude of the N1 component and main vertex N2-P2 complex. The relationship between gender, age, height, and site of stimulation was statistically analyzed. RESULTS Both in men and in women, laser perceptive threshold increased from genitalia to foot and from hand to foot (P ≤ 0.001). N1 and N2-P2 latencies progressively increased from pudendal area to hand to foot (P ≤ 0.008). N1 and N2-P2 complex LEP amplitudes progressively decreased from hand to genitalia to foot (P ≤ 0.04). The latencies of N1 component and N2-P2 complex of LEPs correlated with body height, whereas the amplitude of the N2-P2 complex correlated negatively with age; no correlations were observed between the latencies and amplitudes with gender. CONCLUSIONS This study provides normative data on pudendal LEPs versus hand and foot LEPs. Incorporation of pudendal LEPs into clinical practice could provide a valuable neurophysiological tool for the study of pelvic pain syndromes.

Background. Ophthalmic findings in mycosis fungoides (MF) can be highly variable. It seems that the prevalence of ophthalmic findings could be much more common than previously assumed. Objective. To present case series examined in the last 12 months, together with a literature review. Methods. Symptomatic patients with biopsy-proven mycosis fungoides were examined ophthalmologically in a 12-month period. The medical records of affected patients were reviewed. Results. Eight patients were examined. Of these, 75% were male, all were Caucasian, and average age was 58.2 years. Blepharitis (50.0%), thickened eyelids (37.5%), and flaking (25.0%) were the most prevalent findings. Conclusion. Incidence of MF affecting the eyes and surrounding structures may be greater than estimated. Early case management offers means to reduce difficulties experienced with later diagnosis. Regular monitoring by an ophthalmologist is justified, including that of asymptomatic cases.

Uncomplicated recurrent urinary tract infections (rUTIs) are common among reproductive-aged women. We aimed to assess the prevalence and predictors of sexual dysfunction (FSD) in a cohort of women with rUTIs and compare their psychometric scores to those of matched controls. Data from 147 rUTIs women and 150 healthy controls were analysed. Participants completed the International Prostatic Symptoms Score (IPSS), the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (SDS). Descriptive statistics and logistic regression models tested prevalence and predictors of distressful FSD. Women with rUTIs had lower FSFI scores (p

Erectile dysfunction (ED) has been well recognized as a marker of increased cardiovascular risk for more than 15 years, especially in younger men. Early detection of ED represents an opportunity to intervene to decrease the risk of future cardiovascular events and limit the progression of ED severity. Evidence suggests there is a window of opportunity of 3 to 5 years from the onset of ED to subsequent cardiovascular events. This opportunity is usually missed if the onus is placed on the patient to seek care for his sexual problems. Unfortunately, these clear messages have not been incorporated into routine cardiovascular care. The reasons for these disparities within specialties are discussed in this article, in addition to management algorithms. Lifestyle modification is usually recommended as the first-line treatment to correct ED and lessen cardiovascular risk, but evidence suggests that this might be effective only in men without established cardiovascular comorbidities. In men with type 2 diabetes mellitus and established cardiovascular disease, lifestyle modification alone is unlikely to be effective. Cardiovascular medications are often associated with sexual dysfunction but changes in medication are more likely to be beneficial in men with milder recent-onset ED. A balanced view must be taken related to medication adverse events, taking into account optimal management of established cardiovascular disease. Testosterone deficiency has been associated with different metabolic disorders, especially metabolic syndrome and type 2 diabetes mellitus. Testosterone deficiency syndrome has been associated with an independent burden on sexual function globally and increased cardiovascular and all-cause mortality. Testosterone replacement therapy has been shown to improve multiple aspects of sexual function and, in some studies, has been associated with a decrease in mortality, especially in men with type 2 diabetes mellitus. Recent studies have suggested that phosphodiesterase type 5 inhibitors, the first-line medications to treat ED, could decrease cardiovascular and all-cause mortality, through multiple mechanisms, predominantly related to improved endothelial function.Copyright (C) 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Introduction: The diagnosis, treatment, and survivorship of cancer have a profound effect on the quality of life and psychological well-being of men and women. Indeed, the perturbation of sexual function because of neoplasm has far-reaching implications. Aims: To explore the prevalence, pathophysiology, and treatment of sexual issues in persons with cancer and offer evidence-based recommendations regarding optimal prevention and treatment strategies. Methods: A committee of multidisciplinary specialists was formed as part of the larger International Sexual Medicine Consultation working with urologic and sexual medicine societies over a 1-year period to review the result of chronic-illness management on sexual function and satisfaction. The aims, goals, data collection techniques, and report format were defined by a central committee. Main Outcomes Measures: Expert consensus was based on evidence-based medical and psychosocial literature review, extensive group discussion, and an open presentation with a substantial discussion period. Results: This summary evaluates contemporary literature concerning the prevalence, pathophysiology, and psychological impact of cancer diagnosis and treatment on sexual dysfunction. Evidence-based recommendations and guidelines for evaluation and management are presented. Conclusion: The diagnosis and treatment of cancer have a significant negative impact on sexual function and satisfaction. Comprehension of baseline sexual function, role of psychological supports, and available treatment options could attenuate the heavy burden of decreased sexual function. Copyright (C) 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Vulvar pain is challenging for patients and healthcare providers. It can be acute, recurrent, chronic, and neuropathic with or without premenstrual flares. Patients may present with a variety of symptoms such as pain, burning, itching, irritation, soreness, and patterns continuous or intermittent localized or generalized). Some critically differential aspects are summarized in Box 10.1.

Vulvar pain is a very common problem that affects women of all age groups. Too often, women endure pain and sexual dysfunction for years without an adequate definitive diagnosis. They are desperate for help, looking for every type of medical and alternative treatment and regularly self-treat, wasting a lot of money a year in disappointing/frustrating consultations, anti-yeast creams, and other over-the-counter treatments.

Pregnancy is a special period in a woman’s life. The childbirth involves significant physical, hormonal, psychological, social, and cultural changes that may influence her own sexuality as well as the health of the couple’s sexual relationship.

Pain during intercourse (coital pain or “dyspareunia”) has been recently included under the new genito-pelvic pain/penetration disorder (GPPPD). With patients, “pain during intercourse” is the best wording to ease communication. GPPPD is a sexual disorder with a multifactorial etiology. It can be elicited at the entrance of the vagina (“introital dyspareunia”), deep in the vagina (“deep dyspareunia”), or both. In its comprehensive wording, it should include pain during anal intercourse (when women like/practice it) and clitoral pain during penetration and/or at orgasm. Leading etiologies are different among premenopausal and postmenopausal women. In premenopausal subjects, the most frequent biological etiologies of introital dyspareunia are vulvar vestibulitis/provoked vestibulodynia, with recurrent candida infections and/or an hyperactive pelvic floor in the background, and painful outcomes of delivery (either because of episiotomy/rraphy, or traumatic deliveries). Endometriosis, chronic pelvic pain, and pelvic inflammatory disease are leading contributors of deep dyspareunia in premenopausal subjects.

Physicians and healthcare providers (HCPs) can contribute to vulvar pain with different pathophysiologic pathways and responsibilities. They seem to be often unaware of a dramatic truth, valid in every field of medicine: doctors can be cofactors in the pathogenesis of a disease (Graziottin 2006; Norian and Stratton 2008; Esparaz et al. 2015). Specifically, HCPs may contribute to cause vulvar pain, acting as

Background: Optic disc is a region with a complex vascular stratification, with components from the posterior ciliary arteries and central retinal artery. Nonarteritic anterior ischemic optic neuropathy (NA-AION) and papilledema can produce disc edema and visual fields defects. Optical coherence tomography angiography (OCTA) can aid in the rapid differentiation of cases when signals overlap. Objective: The purpose of this systematic review is to discuss the current information concerning the signs in OCTA that eventually could help to differentiate these situations and analyze the best diagnostic evidence. Methods: A systematic search was conducted in the MEDLINE ("Medical Literature Analysis and Retrieval System Online") via Pubmed; Embase, Scopus, Web of Science, Google Scholar, BVS databases, in addition to a manual search on studies published, from inception until July 2019, with no language restriction. Results: Of the 20935 articles identified, eleven were included. Different methodologies, sample characteristics, types of equipment, potential artifacts, segmentation errors were the main arguments against formal meta-analysis. Conclusion: The main differentiation of papilledema from NA-AION is the vascular dropout. Density values in both retina and optic nerve head images were significantly lower in NA-AION. These vascular changes appears to precede detectable structural or visual field damage.

Introduction Erectile dysfunction (ED) impacts on both members of the couple. Female partners of men with ED are more likely to report reduced sexual quality of life than women whose partners do not have ED. Aim To assess vardenafil efficacy in men with ED and determine the effects of treatment on their female partner's sexual quality of life. Methods Study participants comprised men aged 18–64 years with ED and their female partners. Eligible men had ED of ≥6 months' duration and a female partner who was motivated to support their ED treatment. Eligible women had a total Female Sexual Function Index score >23.55, indicating absence of significant sexual dysfunction. Following a 4-week screening period, men were randomized to treatment with vardenafil 10 mg or placebo, which could be titrated to 20 or 5 mg after 4 weeks. Main Outcomes Measures Primary efficacy variables were question 3 of the Sexual Encounter Profile questionnaire (SEP3) and the quality-of-life domain of the modified Sexual Life Quality Questionnaire (mSLQQ-QOL). Results The intent-to-treat population included 343 couples, with 168 and 175 men receiving vardenafil or placebo, respectively. Vardenafil treatment significantly improved both erection maintenance and the female partners' sexual quality of life. Least squares (LS) mean SEP3 overall success rates after 12 weeks of treatment were 9.5 (baseline) vs. 67.2 (week 12) and 12.4 (baseline) vs. 24.2 (week 12) in the vardenafil and placebo groups, respectively (P Conclusions Vardenafil treatment of men with ED improved both their erectile function and the sexual quality of life of their female partners.

Chronic pain has been recognized as a major worldwide health care problem. Today, medical experts and health agencies agree that chronic pain should be treated with the same priority as the disease that caused it, and patients should receive adequate pain relief. To achieve good analgesia, patient adherence to a prescribed pain treatment is of high importance. Patients with chronic pain often do not use their medication as prescribed, but change the frequency of intake. This can result in poor treatment outcomes and may necessitate additional emergency treatment, which increases the overall costs. Factors that influence adherence include knowledge of the disease, realistic treatment expectations, perceived benefit from treatment, side effects, depression, dosing frequency, and attitudes of relatives/significant others toward opioids. Addressing all these factors should ensure a good treatment outcome. Good adherence to pain therapy is associated with improved efficacy in pain relief and quality of life. Opioids have become an integral part of the treatment of moderate to severe chronic noncancer pain. They may cause unpleasant side effects such as nausea, vomiting, and constipation. Patients should be informed adequately about side effects, which should be treated pro-actively to foster adherence to treatment. Signs of tolerance, hyperalgesia, and drug abuse should be monitored as these may occur in some patients. An individualized treatment algorithm with a clear treatment goal and regular treatment reassessment is key for successful treatment. Long-acting opioids offer sustained pain relief over 24 hours with manageable side effects—they simplify treatment thereby supporting treatment adherence.

Woman's sexuality encompasses sexual identity, sexual function, and sexual relationships. It is modulated throughout life by life and reproduction-related events, health, relationships, and sociocultural variables. The aging process and menopause are two potent contributors to female sexual dysfunction. The earlier the menopause, the more severe and complex the impact on sexuality is. The younger the woman, the less she realizes the different key goals of her life cycle (falling in love, having a satisfying sexual life, forming a stable couple, getting married, having a family) and the more pervasive the consequences on her sexual identity, sexual function, and sexual relationship can be. Premature menopause is an amplified paradigm of the complex impact menopause can have on women's and couple's sexuality. This paper will focus on biologically based sexual issues, namely desire, arousal, orgasm, and pain disorders, as well as key questions encountered in infertility. The concepts of "symptom inducer" and "symptom carrier" will also be addressed.

Introduction Insufficient documentation exists regarding the prevalence of hypoactive sexual desire disorder (HSDD) in surgically menopausal (SM) women in European countries. Women who have undergone hysterectomy and bilateral oophorectomy experience a loss of ovarian hormones. Inclusion of these women in an epidemiological study provided the opportunity to study biological and cultural impacts on sexual function. Aim The aim of this study was to compare the prevalence of HSDD among SM women in France, Germany, Italy, and the United Kingdom, as well as the relationship between low sexual desire and sexual activity or behavior, and sexual or partner relationship satisfaction. Methods Cross-sectional survey of a convenience sample of 427 SM women aged 20–70 years. Main Outcome Measures The desire domain of the Profile of Female Sexual Function (PFSF) to identify women with low sexual desire, Personal Distress Scale (PDS) to measure distress caused by low sexual desire, and a sexual activities measure. Women with low sexual desire who were distressed were classified as having HSDD. Results SM women having low sexual desire ranged from 35% (United Kingdom) to 44% (Italy); of these women, 16% (Germany) to 56% (France) were distressed because of their low sexual desire. Overall, SM women classified with HSDD ranged from 7% (Germany) to 22% (France). A strong positive correlation was observed between sexual desire and arousal, orgasm, and sexual pleasure in all countries ( P Conclusions A similar percentage of SM women with low sexual desire were found across countries suggesting the role of biological factors (i.e., losing ovarian hormones) in determining sexual desire. Differences in the percentage of SM women with HSDD suggest a role for cultural factors in determining how low sexual desire is perceived. Graziottin A, Koochaki PE, Rodenberg CA, and Dennerstein L. The prevalence of hypoactive sexual desire disorder in surgically menopausal women: An epidemiological study of women in four European countries. J Sex Med 2009;6:2143–2153.

Objective: To provide an expert review of the clinical management of hypoactive sexual desire disorder. Method: The importance of diagnosing and providing therapeutic management for hypoactive sexual desire disorder will be explained with a case scenario which is resolved by drawing on original trial publications and meta-analyses published in English. Results: Hypoactive sexual desire disorder (HSDD) is highly prevalent (9-16%) and has a strong impact on the quality of life of both women and their partners. Medical and sexual history, physical and laboratory examinations as well as validated questionnaires will help us make an accurate diagnosis. Treatment should begin by focusing on lifestyle and psychosexual therapy. Women randomized to oestrogen-testosterone transdermal patch combination or testosterone transdermal patch alone reported significantly increased frequency of satisfying sexual activity (p < 0.05). Hormonal treatment with oestrogen and testosterone or with testosterone alone should be personalised, as should follow-up. Conclusions: Guidelines for the medical management of hypoactive sexual desire disorder are now available and this starts by understanding the importance of this disorder and knowing that accurate diagnosis and treatment options exist.

Mast cells play a key role in many sexual pain disorders including interstitial cystitis (IC), provoked vestibulodynia (PVD), and endometriosis. Mast cells are ubiquitous, present in virtually all organs and vascularized tissue where they work to modulate the immune response. In addition, mast cells are present in, and recruited to, sites of inflammation, where they orchestrate key steps in the inflammatory response. Granules released by mast cells contain angiogenic, proinflammatory, and neurotrophic factors. These granules are heterogenous and different substances are released depending on the type, location, and timing of the damaging event or agent. When persistently up-regulated, mast cells maintain chronic inflammation, leading to a shift between nociceptive and neuropathic pain. This chapter reviews the biochemical complexity of mast cells to illustrate their role in sexual pain disorders.

Background and Objective Botulinum neurotoxin (BoNT), now commonly used for reducing muscular spasms in other neuromuscular disorders, is now increasingly proposed also for treating pelvic floor disorders, including chronic pelvic pain syndromes, vaginismus, vulvodynia and vulvar vestibulitis syndrome. To provide up-to-date information on these advances we reviewed the literature about Bunt injections for pain and spasms related to pelvic floor disorders. Methods We conducted a Medline search using the terms botulinum neurotoxin, pelvic floor disorders, levator ani myalgia, vaginismus, vulvar vestibulitis , vulvodynia, dyspareunia, interstitial cystitis, recurrent cystitis, and postcoital cystitis. We sought information on the indications and techniques used for Bunt treatment for pelvic floor dysfunctions, and related pain syndromes in women. Results Our search identified 12 studies for review (including a randomized controlled trial) showing that Bunt effectively reduces pain in chronic genital pain syndromes associated with pelvic floor spasm. Before Bunt trials, patients with idiopathic lifelong vaginismus and dyspareunia, associated with hyperactive pelvic floor muscles, had no effective treatment options. Bunt injected under electromyographic (EMG) guidance in pelvic floor muscles improves vaginismus, helping to restore a normal sexual life. Bunt injections also seem to improve vulvodynia and vulvar vestibulitis. Though some patients need periodic injections, in about 65% of affected women BoNT achieves permanent benefit. Conclusions These encouraging evidence-based results suggest that BoNT injected intramuscularly should extend treatment options for women with lifelong or acquired pelvic floor disorders and genital pain.

Dyspareunia and vaginismus are sexual pain disorders that partially overlap and are neglected in clinical practice. The etiology of sexual pain disorders is multifactorial. Pain may be perceived at vaginal entry (introital dyspareunia) or deep in the pelvis (deep dyspareunia). It may be lifelong, acquired, generalized, or situational and cause personal and interpersonal distress. Dyspareunia has a solid biological etiology. Comorbidity is frequent with lower urinary tract symptoms, sex-associated and recurrent cystitis, vulvodynia, recurrent Candida infections, vaginal dryness, obstructive constipation, myalgia of the levator ani, endometriosis, and disorders of desire and arousal disorders. Vaginismus has a psychosexual etiology with a variable myogenic component. Dyspareunia and vaginismus affect the patient on many levels: sexual, medical, emotional, and relational. The aim of the paper is to share with physicians the key steps of a focused clinical history and physical examination for a comprehensive diagnosis and effective multimodal treatment of sexual pain disorders.

Somatic symptoms characterized by arthralgias, bodily aches and pains, musculoskeletal pain and joint pain have been investigated in a number of menopause and depression studies. Although depression is one of the most common causes of bodily aches and pains, and arthralgias, these same symptoms are also commonly associated with a natural menopause, surgical menopause and menopause induced by chemotherapy in breast cancer treatment. Somatic symptoms in the absence of definitive medical diagnoses result in these patients receiving various diagnoses and labels--'medically unexplained symptoms', 'worried well', as well as various Diagnostic and Statistical Manual of Mental Disorders (4th edition) somatoform diagnoses. Osteoarthritis and joint pain increase in prevalence from premenopausal- to menopausal-aged women with hormonal change implicated in their etiology. The current research on the relationships among menopause, depression, nociceptive mechanisms, perception and pain in the distressed midlife patient is discussed. The amelioration and management of pain symptoms in the menopausal and postmenopausal woman, with or without comorbid depression, have been elusive and difficult problems for clinicians. Familiarity with the differential diagnosis, pathophysiology and evidence-based treatment for such patients is crucial to their proper care.

Introduction The complex condition of the menopause is experienced by all women going through the physical and emotional changes associated with ovarian sexual hormones loss. It may impact directly on their physical and mental health. Aim The complexity of this condition makes it necessary to accumulate large bodies of data to define the patterns and trends in its evaluable manifestations. To this end, large amounts of data were collected on women from France, Germany, Italy, and the United Kingdom, via the Women's International Survey on Health and Sexuality. Main Outcome Measures The key measures within the survey were the Profile of Female of Sexual Function© (PFSF©) and the Personal Distress Scale© (PDS©). Results The survey yielded 2,467 responders aged between 20 and 70, capturing women with surgical and natural menopausal status and those with premenopausal status. In the four EU countries studied, sexual activity decreases by age. An increase in female sexual dysfunction (FSD), particularly loss of sexual desire, is directly correlated with increasing age. However, the distress associated with loss of sexual desire is inversely correlated with age. Cultural and context-dependent factors modulate the percentage of any FSD in the different European countries. This is exemplified in the significant intercountry variation observed in the percentage of low desire in women aged 20–49, with normal ovarian function. However, when women undergo surgical menopause, with concomitant loss of their sexual hormones, the culture-related differences are blunted. Conclusions The findings of this survey have implications for the understanding of hypoactive sexual desire disorder (HSDD), not only the way it should be assessed in clinical practice, but also the most appropriate means for its treatment. Testosterone deficiency is a significant cause of HSDD, and new therapies have been investigated which offer considerable potential to address this hormonal etiology. Graziottin A. Prevalence and evaluation of sexual health problems—HSDD in Europe.

The menstrual cycle is characterised by cyclical fluctuations in oestrogens, progesterone and androgens. Changes in hormone levels in the premenstrual phase with the decline in progesterone trigger a physiological reaction which culminates in menstruation. This process is accompanied in many women by various symptoms such as pelvic pain, headache, mood disorders and gastrointestinal discomfort. The aim of this article was to summarise the latest findings on the physiology and pathophysiology of menstruation and review the impact of shortening the hormone-free interval (HFI) on the health and wellbeing of women.Menstruation can be viewed as an inflammatory event in which local and systemic effects produce symptoms in genital and extragenital regions of the body. The mast cells are the main mediator of this reaction. In women using hormonal contraceptives, menstrual bleeding is not biologically necessary and it may be advantageous to maintain more stable levels of oestrogens, progesterone and androgens throughout the cycle. New combined oral contraceptives (COCs) have been formulated with a progressively shorter HFI (24/4 and 26/2) than traditional 21/7 pills, with the rationale of reducing hormone withdrawal- associated symptoms. Several studies have shown the beneficial effects of these regimens, which reduce the inflammatory exposure of the female organism and thus have the capacity to increase the quality of life of women. A combination of estradiol valerate (E2V) and dienogest (DNG) is administered on the shortest 26/2 regimen. This regimen has a broad evidence base from randomised controlled trials that have examined the impact of E2V/DNG on symptoms and quality of life.Shortening the HFI reduces the occurrence of bleeding-related inflammatory processes and subsequent physical and mental symptoms. The shortest interval with evidence of reproductive and sexual health benefits is provided by a 26/2 regimen.

Purpose The Authors present their results using laparoscopic prostatectomy in the treatment of large benign prostatic hyperplasia (BPH). Materials and methods Between March 1999 and March 2005, 60 patients were submitted to laparoscopic prostatectomy with vascular control for large BPH. The demographic, operative period and outcome data were recorded. Results The average prostate weight was 144.50±41.74gm. Mean operative time was 138.48±23.38minutes and estimated blood loss of 330.98±149.52ml. No patient required transfusions or conversion to open surgery. Post operative complications included one case of septicemia and three cases of prolonged ileum. The most frequent long-term complication was retrograde ejaculation, presented in all patients after 6 months of follow-up. The erectile function was preserved in all those patients who were potent before surgery. No urinary incontinence was reported by patients. Conclusions The results demonstrate that resection of large prostatic adenomas can be performed with a laparoscopic approach. The patients had a shorter hospital stay and early return to normal activity.

Introduction Although increasing age is a primary determinant of reduced sexual function in older women, hormonal changes may be significant contributors to female (and couples’) sexual dysfunction. Aim To analyze the most relevant biological, psychosexual, and/or contextual factors that influence changes in women's sexuality during and after menopause. Methods A Postmenopausal FSD Roundtable consisting of multidicsiplinary international experts was convened to review specific issues related to postmenopausal women and sexual dysfunction. Main Outcome Measure Expert opinion was based on a review of evidence‐based medical literature, presentation, and internal discussion. Results Menopause is associated with physiological and psychological changes that influence sexuality: the primary biological change is a decrease in circulating estrogen levels. Estrogen deficiency initially accounts for irregular menstruation and diminished vaginal lubrication. Continual estrogen loss is associated with changes in the vascular, muscular, and urogenital systems, and also alterations in mood, sleep, and cognitive functioning, influencing sexual function both directly and indirectly. The age‐dependent decline in testosterone and androgen function, starting in the early 20s, may precipitate or exacerbate aspects of female sexual dysfunction; these effects are most pronounced following bilateral ovariectomy and consequent loss of 50% or more total testosterone. The contribution of progestogens to sexual health and variability in the effects of specific progestogens are being increasingly appreciated. Comorbidities, influenced by loss of sexual hormones, between mood and desire disorders and urogenital and sexual pain disorders are common and remain frequently overlooked in clinical practice. Physical and psychosexual changes may contribute to lower self‐esteem, and diminished sexual responsiveness and sexual desire. Nonhormonal factors that affect sexuality are health status and current medication use, changes in or dissatisfaction with partner, partner's health and/or sexual problems, and socioeconomic status. Conclusion Determination of the best way to provide optimal management of sexual dysfunction associated with menopause requires additional controlled studies. Graziottin A, and Leiblum SR. Biological and psychosocial pathophysiology of female sexual dysfunction during the menopausal transition. J Sex Med 2005;2(suppl 3):133–145.

An epidemic of fear and distrust has infected women (and physicians) after publication of the Women's Health Initiative (WHI). The overinflated negative data emerging from the oestroprogestinic arm of WHI have frightened women and gave rise to the most difficult emotions to cope with. Keywords such as cancer, death and hormones combined together, have potentiated an avoidant attitude towards hormonal therapy (HT) driven more emotionally than rationally. This negative aura has not been dissipated by the positive data from the oestrogen-only arm of WHI. This paper will discuss: women's different emotional reactions to and coping strategies for HT-related fear after WHI; the communication skills physicians should use in focusing on positive messages emerging from WHI; predictors of current HT use; the meaning of the higher use of HT in postmenopausal highly-educated women and women gynaecologists; the importance of increasing healthy life-styles as a taking of responsibility towards aging by every woman; shifting from passivity to active sharing of the decision making process with the caring physician; and the use of an individually tailored HT, when appropriate, as part of an active strategy in the pursuit of a longer health expectancy.

Vulvar vestibulitis (VV) is a heterogeneous, multifactorial, and multisystemic vulvar disease. It is the leading cause of dyspareunia in the fertile age. Etiologic, biological, and psychosexual factors may be divided into predisposing, precipitating, and maintaining factors. Among the biological factors, the increased presence and hyperactivity of the mast cells may be induced by different agonist stimuli, infectious or mechanical (ie, coital, hormonal, chemical, physical, nervous). The upregulation of the local inflammatory response and the mast cell’s increased production of nerve growth factor (NGF) are emerging as the bridging factors that contribute to the shift from nociceptive to neuropathic pain. NGF is responsible for the neuronal sprouting and increased proliferation of pain fibers, leading to hyperalgesia and allodynia. The defensive myalgic contraction of the pelvic floor contributes to the pathophysiology of pain. Psychosexual factors may concur with the clinical picture. Treatment should address predisposing, precipitating, and maintaining factors, with a multimodal individually tailored treatment.

Purpose: Using an animal model we studied the long-term effects of ovariectomy and simulated birth trauma in the development of apoptosis as well as the urodynamic, histological and ultrastructural findings 9 months after such procedures.Materials and Methods: A total of 24 pregnant Sprague-Dawley female rats were used. Immediately after delivery 14 animals underwent vaginal ballooning and ovariectomy, while the remaining 10 served as controls. At 9 months the animals underwent urodynamic evaluation, which included the urethral pressure profile. The rats were then sacrificed and urogenital tissue was obtained for immunostaining using terminal deoxynucleotidyl transferase mediated deoxyuridine triphosphate nick end-labeling, histomorphometry evaluation and electron microscopy.Results: Immunostaining demonstrated a significant increase in the apoptotic index in the urethra of castrated/ballooning rats with a predominance in the submucosa layer. Maximum urethral closure pressure was significantly lower in th...

Objective To assess the effectiveness of the association of 2 specific strains, Lactobacillus fermentum LF10 (DSM 19187) and Lactobacillus acidophilus LA02 (DSM 21717), specifically formulated in slow-release effervescent tablets, in patients with recurrent vulvovaginal candidiasis. Study design The study was a clinical trial of 58 women diagnosed with recurrent VVC (≥4 culture-confirmed episodes in a 12-mo period). All patients were given 200 mg of fluconazole orally as an induction dose for 3 alternate days during the first treatment week. Afterward, the patients were given a new product formulated in slow-release vaginal tablets containing at least 0.4 billion live cells of each of lactobacillus L. fermentum LF10 and L. acidophilus LA02 (first phase of the prophylactic period), on alternate days for 10 consecutive nights. Patients who were still free of symptoms were given 1 vaginal tablet every week for the next 10 weeks (second phase of the prophylactic period). Patients asymptomatic after the total duration of the observation phase (7 mo) were considered as responders. Results During the second 10-week prophylactic phase, 49 of 57 (86.0%) patients remained free of clinical recurrence, whereas symptomatic VVC occurred in 8 patients (14.0%). During the 7-month follow-up, 42 patients of 49 (85.7%) were symptom free at the end of the protocol, whereas clinical recurrences occurred in 7 women (14.3%). Overall, 42 of 58 women enrolled in the study (72.4%) experienced no clinical recurrence throughout the 7-month observation phase (responders). Conclusions This study strengthens the evidence supporting the use of specific lactobacilli with well-demonstrated activities associated with the creation and maintenance of a vaginal biofilm that hinders the persistence of an infection caused by Candida.

To assess the cross-cultural differences in women's perception of premature ejaculation (PE).A total of 1463 sexually active women from 3 different countries—Mexico, South Korea, and Italy—reporting being or having been in a relationship with a man who suffers from PE were included in the study. A mix of self-constructed questions and questions taken from validated instruments were used, including the Female Sexual Function Index, the Female Sexual Distress Scale, and the Relationship Assessment Scale.Significant differences in importance of ejaculatory control and the degree of distress caused by PE were detected between the 3 countries (P.001 for both). Lack of control was the most commonly reported reason for distress for Mexico, short latency for Italy, and lack of control for South Korea. Mexico reported the highest rates of previous relationship breakups due to PE (28.9%), whereas Italian women reported the lowest relationship satisfaction and South Korean women the highest.It is important to get a better understanding of which sexual issues are important for individuals across different cultures, and whether the same aspects of the problem are considered distressing. This can have implications on nosology, on types of treatments offered, and hence, the likelihood of their efficiency when a couple's sexual perspective is carefully considered.

Inflammatory and neuroinflammatory processes are increasingly recognized as critical pathophysiologic steps in the development of multiple chronic diseases and in the etiology of persistent pain and depression. Mast cells are immune cells now viewed as cellular sensors in inflammation and immunity. When stimulated, mast cells release an array of mediators to orchestrate an inflammatory response. These mediators can directly initiate tissue responses on resident cells, and may also regulate the activity of other immune cells, including central microglia. New evidence supports the involvement of peripheral and central mast cells in the development of pain processes as well as in the transition from acute, to chronic and neuropathic pain. That behavioral and endocrine states can increase the number and activation of peripheral and brain mast cells suggests that mast cells represent the immune cells that peripherally and centrally coordinate inflammatory processes in neuropsychiatric diseases such as depression and anxiety which are associated with chronic pelvic pain. Given that increasing evidence supports the activated mast cell as a director of common inflammatory pathways/mechanisms contributing to chronic and neuropathic pelvic pain and comorbid neuropsychiatric diseases, mast cells may be considered a viable target for the multifactorial management of both pain and depression.

Depression is often associated with local and/or systemic diseases. Chronic inflammation, pain and depression are a clinical triad increasingly recognized as co-morbid. Peripheral and central inflammation can alter neuronal activity, thereby contributing to the psych emotional and somatic symptoms of depression. Preliminary evidence suggests that mast cells direct the immune pathways mediating this triad. Chronic pelvic pain in women could be a paradigm of the triad, and of considerable clinical relevance. Mast cells are immune cells which contribute to and modulate inflammation and immunity. Upon stimulation mast cells release an array of mediators, cytokines, and growth factors to orchestrate an inflammatory response. These mediators can directly initiate tissue responses on resident cells, and may also regulate the activity of other immune cell functions, including central nervous system immune cells like microglia. Mast cell mediators can interact also with neurons, either alone or in concert with other immune cells. New evidence supports the involvement of peripheral and central mast cells in the development of pain processes, in the transition from acute, nociceptive to chronic and neuropathic pain and in the depressive states associated with them. A significant increase of pro-inflammatory cytokines is evident in depression associated with chronic diseases. Marked increases of tissue mast cells and pro-inflammatory cytokines have been documented in disorders associated with chronic pelvic pain presenting as well with significant affective comorbidities (anxiety and depression). Mast cells could be thus considered as a target of therapeutic approaches which aim to reduce inflammation and the chronicization of pain. The present review analyzes current evidence on co-morbidity between depression with peripheral and central inflammation associated with chronic pelvic pain in women. The analysis will briefly focus on key mechanisms of inflammation and role of mast cells as a common denominator of depression and chronic pain. The goal is to offer mental health professionals a biologicallyoriented contribution in the pathophysiologic reading of co-morbidities between depression and chronic pelvic pain in women. Results underline the increasing evidence supporting a role of inflammatory pathways/mechanisms, orchestrated by activated mast cells, as common denominators contributing to co-morbidity between depression and chronic pelvic pain in women.

Cervical dystonia is seldom associated with other focal dystonias. A patient with coexisting cervical dystonia and primary vaginismus led us to conjecture that primary vaginismus might be a form of dystonia. A 32-year-old woman suffered from idiopathic right laterocollis. We recorded polymyography of the neck muscles, median nerve somatosensory evoked potentials (SEPs) and upper limb motor evoked potentials (MEPs). At age 38 the patient complained of introital pain during intercourse, vulvar pain and erythema diagnosed as type IV vaginismus complicated by vestibulitis. She also reported mild constipation...

OBJECTIVE To obtain data on correlates of climacteric symptoms in women around menopause attending menopause clinics in Italy. METHODS Since 1997 a large cross sectional study has been conducted on the characteristics of women around menopause attending a network of first level menopause outpatient's clinics in Italy. A total of 66,501 (mean age 54.4 years) women are considered in the present paper. RESULTS The odds ratios of moderate and severe hot flashes/night sweats were lower in more educated women and (for severe symptoms only) in women reporting regular physical activity. Depression, difficulty to sleep, forgetfulness and irritability tended to be less frequent in more educated women and (depression only) in women reporting regular physical activity. Parous women reported more frequently these symptoms. CONCLUSIONS This large study confirms in Southern European population that low education, body mass index and low physical activity are associated with climacteric symptoms. Parous women are at greater risk of psychological symptoms.

h Abstract Objective. The study aimed to assess the effect of palmitoylethanolamide + transpolydatin combination in patients with vestibulodynia undergoing transcutaneous electrical nerve stimulation (TENS) therapy and to confirm the effectiveness of TENS also in a domiciliary protocol. The study is based on the premise that palmitoylethanolamide + transpolydatin combination may contribute to a down-regulation of mast cell hyperactivity, which is believed to be responsible for the proliferation and sprouting of vestibular pain fibers and the associated hyperalgesia and allodynia. Materials and Methods. Twenty women with vestibulodynia were randomly assigned to receive oral palmitoylethanolamide (PEA) 400 mg and transpolydatin 40 mg or placebo, twice daily for 60 days. All patients underwent TENS therapy in a self-administered home protocol. Visual analogue scale (VAS), Marinoff score for dyspareunia, and current perception threshold obtained from the vulvar vestibule were assessed at baseline and at the end of treatment. Results. The patients received a mean of 26.7 TENS sessions. All scores in the 2 groups improved significantly, although the level of improvement was similar between the groups (VAS,pG .57;dyspareunia,pG.38). Nevertheless, the analysis of regression of symptoms related to the duration of disease revealed the therapy to be more effective when PEA + transpolydatin is included in cases with more recent disease onset, as compared with the placebo group (PEA: VAS, p G .01; dyspareunia, p G .01) (placebo: VAS, p = nonsignificant; dyspareunia, p = nonsignificant). Conclusions. This study confirms that TENS is of significant benefit in the management of vestibulodynia, also in a home environment. PEA + transpolydatin can be a value-added treatment adjunct when the onset of vestibulodynia is more recent or when the disease relapses. h

Introduction The relational impact of male and female sexual dysfunction, and specifically premature ejaculation (PE), is an important consideration. Published findings are consistent in identifying the negative psychosocial impact of PE on the man. However, the effect of PE on the female partner, especially in relation to her sexual functioning, has been less well studied. Aim Provide an overview of the impact of PE on the man, the woman, and the couple. Methods Review of relevant literature. Results Female partners of men with PE report significantly greater sexual problems, with reduced satisfaction, increased distress and interpersonal difficulty, and more orgasmic problems than partners of non-PE men. Both men with PE and their partners feel control over ejaculation is the central issue in PE. For both, the lack of control leads to dissatisfaction, a feeling that something is missing from the relationship, and an impaired sense of intimacy. If left untreated, the situation can lead to increased irritability, interpersonal difficulties, and deepening of an emotional divide. Conclusions When treating a man with PE, the partner's participation should be encouraged to enable the physician to fully understand the extent of the problem, and consider other relevant factors, from her perspective. Identifying the best approach for the couple requires consultation with each person individually and together. In clinical practice, treatments for PE are likely to include a combination of pharmacological, psychological, sexological, and/or behavioral approaches for both the man and his partner. It is important that physicians regard PE as the couple's problem and endeavor to include the partner in its management where possible.

Vulvodynia is a complex syndrome of vulvar pain with sexual dysfunction and psychological disability. Its etiology remains elusive but several lines of investigation support a neuropathic etiopathogenesis for the disease. The manifestation of vulvodynia may be caused by more than one factor and may vary in each patient.

Premature menopause, that is, menopause – spontaneous or iatrogenic – occurring at or before the age of 40 years, affects sexual identity, sexual function and sexual relationships. The woman's health, wellbeing and achievement of life's goals may be variably impaired. Factors modulating the individual's sexual outcome after premature menopause include: etiological heterogeneity of premature menopause and associated medical and sexual comorbidities; psychosexual vulnerability to premature menopause and associated infertility in survivors of childhood and adolescent cancers; impact of premature menopause on women's sexual identity, sexual function – particularly the biological basis of desire, arousal, orgasm and vaginal receptivity – and sexual relationships; partner-related factors; fertility issues; and preventive/therapeutic measures. Hormone therapy is indicated but long-term safety data are lacking. An interdisciplinary medical and psychosexual approach comprises appropriate counseling, fertility protection, when feasible, individualized hormone therapy and specific psychosexual treatment(s). Further research on fertility protection and the safety of long-term hormone therapy after premature menopause is needed.

The assessment and then treatment of a change in libido, or a change in the desire to partake in sexual activity, during the menopausal transition and beyond has been a challenging and elusive area of clinical research. This is partly due to the multidimensional nature of female sexuality, the difficulties of measuring testosterone in women in a reliable and accurate manner, and the complexity of the neurobiology and neurobehavior of female sexual desire. In addition, there is a lack of evidence for diagnostic specificity of low free testosterone levels for the symptom of low libido in women for whom there are no confounding interpersonal or psychological factors; although, in the symptomatic population of surgically or naturally menopausal women, a low level of free testosterone often accompanies a complaint of reduced desire/libido. The randomized clinical trial research on testosterone replacement for naturally and/or surgically menopausal women with sexual dysfunction has been criticized for a high placebo response rate, supraphysiological replacement levels of testosterone, the perception of modest clinical outcome when measuring objective data such as the frequency of sexual intercourse relative to placebo, and the unknown safety of long-term testosterone replacement in the estrogen-replete surgically or naturally menopausal woman. A careful review of current evidence from randomized, controlled trials lends support to the value of the replacement of testosterone in the estrogen-replete menopausal woman for whom libido and desire has declined. The issue of long-term safety remains to be answered. Multifactorial nature of female sexuality The assessment and then treatment of a change in libido, or a change in the desire to partake in sexual activity, during the menopausal transition and beyond has been a challenging and elusive area of clinical research. There is a lack of evidence for the diagnostic specificity of low free testosterone levels for the symptom of low libido in the women for whom there are no confounding interpersonal or psychological factors; although, in the symptomatic population of surgically or naturally menopausal women, a low level of free testosterone often accompanies a complaint of reduced desire/libido [1–6]. Female sexuality is dependent on biological, psychosexual, sociocultural and context-related factors [7–9]. As a consequence, any movement or change in any of these realms may increase or decrease a woman’s perception of her drive or motivation to participate in sexual activity. The presence of any chronic medical illness such as diabetes, pulmonary or cardiovascular problems, or depression will in many instances impact a woman’s sexuality concurrent with changes related to age [10,11]. The length of the relationship with a partner, as well as aging, has been demonstrated to impact sexual interest and frequency of sexual activity [12,13]. The menopause has been shown to have an incremental effect on a woman’s sexuality, separate from the change brought about by aging [14]. The quality of her intimate relationship and the degree to which she feels empowered in it have been demonstrated to affect sexual desire [15]. The culture in which she lives has been shown to affect frequency of sexual intercourse [16]. The degree of stress she is under, as well as her general wellbeing, has also been shown to affect her libido. A recent longitudinal study demonstrated that higher stress lowers wellbeing, resulting in a decrease in sexual arousal, enjoyment, orgasm and desire [17]. In addition, the balance between sexual inhibition and sexual excitement may be unique to each woman and may change according to her circumstances, along with any other change she may have with regard to these opposing forces [18]. Thus, the treatment of any woman distressed by a change in desire at midlife and beyond is driven by many factors. The clinician’s task is to elucidate which one or more of these many variables changed in her life, concurrent with her change in sexual desire, and then to determine whether or not these changes are related to her change in sexual desire.

Objective The aim of this paper is to describe the aetiology, diagnosis and prognosis of female sexual dysfunction (FSD), so as to increase the physician's competence in the management of women with these problems. Method A literature review of the most relevant publications was undertaken evaluating each sexual dysfunction. Results The aetiology of FSD is multifactorial. The most important causes include biological, psychosexual and contextual factors. When assessing FSD, the clinical history should assess if: (a) the disorder is generalized or situational; (b) the disorder is lifelong or acquired after months or years of satisfying sexual intercourse; (c) the level of distress is mild, moderate, or severe in terms of the impact of FSD on personal life; and (d) the leading aetiologies. To diagnose a sexual dysfunction, it is crucial to ask specifically about sexual function and avoid a collusion of silence that is all too common. A structured clinical history, selected investigations and physical examination are fundamental to diagnosis. Conclusions A structured multidisciplinary, integrative approach is fundamental to the evaluation and management of FSD.

Introduction Genital Human Papillomavirus (HPV) infection is the most commonly occurring sexually transmitted viral infection in humans. HPV is a wide family of DNA viruses, which may cause benign skin and mucosal tumors (genital, anal, or oral warts), intraepithelial neoplasias, and/or malignant cancers in different organs. Women are more susceptible to the oncogenic effect of HPVs, mostly at the genital site on the uterine cervix. Aims This review analyzes the impact of: (i) genital warts (GWs) and their treatment; (ii) HPV-related genital, oral, and anal precancerous lesions on women's sexual function. Methods A Medline search was carried out. Search terms were HPV, GWs, intraepithelial neoplasia, cervical cancer, anal cancer, oral cancer, epidemiology, HPV risk factors, sexual dysfunctions, desire disorders, arousal disorders, dyspareunia, vulvar vestibulitis, vulvodynia, orgasmic difficulties, sexual repertoire, couple sexual problems, depression, anxiety, pap smear, screening program, therapy, and vaccines. Main Outcome Measures Sexual consequences of HPV infection in women, specifically GWs and intraepithelial HPV-related neoplasia. Results Psychosexual vulnerability increases with number of recurrences of HPV infections. Depression, anxiety, and anger are the emotions most frequently reported. However, to date, there is no conclusive evidence of a specific correlation between HPV infection and a specific female sexual disorder. The relationship between HPV and vulvar vestibulitis/vulvodynia-related dyspareunia seems not to be direct. Counseling problems, the role of anti-HPV vaccine, and the concept of the high-risk partner are discussed. The reader is offered a practical approach with clinically relevant recommendations that may prove useful in his/her daily practice when dealing with HPV-infected women and couples. Conclusion The evidence of psychosexual consequences of HPV-related GWs and intraepithelial lesions is limited. Specific research on the sexual impact of GWs and intraepithelial HPV-related lesion in women is urgently needed. Graziottin A, and Serafini A. HPV infection in women: Psychosexual impact of genital warts and intraepithelial lesions. J Sex Med 2009;6:633–645.

Physical intimacy in a relationship is a dynamic process in which sexual motivation is the willingness to behave sexually with a partner [1]. This intimacy can be perceived as too frightening and can increase anxiety for some women to an overwhelming point of sexual avoidance [2]. Sexual desire and arousal is complex in women [3] and many factors can cause or contribute to sexual aversion disorder (SAD).

To evaluate female sexual dysfunction (FSD) in women with interstitial cystitis (IC) versus a control group. Specific areas of FSD in women with IC have not been reported.A mailed survey was sent to 5000 randomly selected women from the United States (controls) and 407 women with IC from a large referral center (cases). The Female Sexual Distress Scale and questions about sexual function, desire, orgasm, and pain were included. The Student t test was used to compare the mean values, and the chi-square test was used to compare the proportions between the cases and controls.During adolescence (the start of menstruation through age 18), having had intercourse, levels of sexual desire, and orgasm frequency did not differ significantly between the cases and controls. However, a significantly greater proportion of cases reported fear of pain (P = 0.018) and pain with intercourse (P = 0.001). In adulthood, a significantly greater proportion of cases reported having pelvic pain, fear of pain during intercourse, and dyspareunia (P0.001 for all). Furthermore, after the diagnosis of IC, the number of cases reporting moderate to high desire (P0.001) and orgasm frequently and very frequently declined significantly (P0.001). The mean value of the Female Sexual Distress Scale was greater among established IC cases (18.5 +/- 14.3) compared with controls (8.3 +/- 10.2; P0.001). A score of 15 or greater on the Female Sexual Distress Scale has been associated with sexual distress.Women with IC have significantly more FSD and sexual distress than women without IC. Additional study is needed to explore the multiple factors contributing to FSD in IC.

To assess overactive bladder (OAB) prevalence, associated factors and implications in a young population.An independent population-based study was carried out. A self-applicative questionnaire covering urinary symptoms, coping strategies, quality of life and treatment seeking behavior was developed.A total of 848 subjects between 15 and 55 years completed the questionnaire. The overall prevalence of OAB was 18.9%. Women were significantly more affected than men (p = 0.001). All age groups were equally affected (p = 0.152). Subjects with OAB reported significant impairment on household chores (p = 0.009), physical activities (p = 0.016), sleep (p0.001), work (p0.001), social life (p0.001) and sexual life (p0.001). In addition, OAB individuals present higher prevalence of depression (p = 0.036), anxiety (p0.001), shame (p0.001) and tiredness (p0.001) OAB was independently associated to sexual life impairment (OR = 3.36, 95% CI=1.20-9.39). Only 27.5% of OAB subjects sought for medical counseling.OAB is a highly prevalent condition, even in such a young population. It affects both genders, yet it is more frequently observed in women. OAB is an important health condition, with serious impact on quality of life and sexual function. A large percentual of individuals remain unrecognized, under treated and consequently suffer for long periods of time.

OBJECTIVE To discuss assessment and management of sexual dysfunctions associated with premature menopause. DESIGN Literature review plus clinical observations. RESULTS Studies on assessment and management of sexual dysfunctions associated with premature menopause are minimal. Premature menopause affects sexual identity, sexual function, and sexual relationship. Major modulating factors include etiology, life cycle stage, factors personal to the woman, and family and societal influences. Loss of ovarian function in adolescence may delay psychosexual maturity via psychological and biological mechanisms. Maternity becomes impossible, unless ovodonation is feasible, accepted, and legally available. Loss of sexual desire, subjective and genital arousal, and orgasm may be highly distressing. Reduction of sex hormones and psychological reactions of both partners to the prematurity and infertility are etiologically important. Estrogen therapy is usually indicated, but long-term safety data in this population are lacking. Testosterone therapy, also lacking in safety data and mainly investigational, may be needed to restore sexual arousability. Presence, age, and sexual health of the partner, having children, and quality of intimacy in previous and present relationships modulate coping attitudes and clinical outcome. CONCLUSIONS An interdisciplinary medical and psychosexual approach comprises individualized hormone therapy and specific psychosexual treatment(s). Research into optimal management of sexual dysfunction with premature menopause is urgently needed.

Introduction Existing definitions of women's sexual disorders are based mainly on genitally focused events in a linear sequence model (desire, arousal and orgasm). Aim To revise definitions based on an alternative model reflecting women's reasons/incentives for sexual activity beyond any initial awareness of sexual desire. Methods An International Definitions Committee of 13 experts from seven countries repeatedly communicated, proposed new definitions and presented at the 2nd International Consultation on Sexual Medicine in Paris July 2003. Main Outcome Measure Expert opinions/recommendations are based on a process that involved review of evidence-based medical literature, extensive internal committee discussion, informal testing and re-testing of drafted definitions in various clinical settings, public presentation and deliberation. Results Women have many reasons/incentives for sexual activity. Desire may be experienced once sexual stimuli have triggered arousal. Arousal and desire co-occur and reinforce each other. Women's subjective arousal may be minimally influenced by genital congestion. An absence of desire any time during the sexual experience designates disorder. Arousal disorder subtypes are proposed that separate an absence of subjective arousal from all types of sexual stimulation, from an absence of subjective arousal when the only stimulus is genital. A new arousal disorder has provisionally been suggested, namely that of persistent genital arousal. Orgasm disorder is limited to absence of orgasm despite high subjective arousal. Dyspareunia includes partial painful vaginal entry attempts as well as pain with intercourse. Variable reflex muscle tightening around the vagina and an absence of abnormal physical findings are noted in the definition of vaginismus. Women's sexuality is highly contextual and descriptors are recommended re past psychosexual development, current context, as well as medical status. Diagnosing sexual disorders need not imply intrinsic dysfunction of the woman's own sex response system. Conclusions The International Definitions Committee has recommended a number of fundamental changes to the existing definitions of women's sexual disorders.

Vulvar vestibulitis syndrome (VVS) is a heterogeneous, multisystemic, and multifactorial disease and is one of the leading causes of dyspareunia in fertile women. As a multisystemic disease, it involves the mucous structure of the vulvar vestibule and the immune, muscular, vascular, and nervous systems, including pain fibers and centers. As a multifactorial disease, its etiology is complex, involving biological, psychosexual, and relational factors. In this article, we discuss the progression of the disease and the impact of an often lengthy delay between the onset of symptoms and a correct diagnosis. Moreover, despite documented improvements from available treatments, VVS becomes a chronic disease unless it is diagnosed early and an integrated, pathophysiologically oriented treatment is offered in an experienced center. Health care providers would therefore benefit from approaching the condition within a pain management framework focused on the woman's chronic pain, the impact on the couple's relationship, and any associated psychological sequelae.

Tissue lesion mechanisms provoked by sepsis include the infectious process, inflammation, and cellular energy deficit. We chose to test fructose-1,6-bisphosphate (FBP) because of its possible anti-inflammatory and antimicrobial actions. Wistar rats were used and divided into three experimental groups: a control group (n=10), in which a capsule was introduced into the peritoneum of the animals; a septic group (n=10), in which a capsule containing non-sterile fecal matter was introduced together with Escherichia coli (1.5 x 10(9)CFU); and a septic group treated with FBP 500 mg/kg (n=10). The blood cell tests revealed that levels of leukocytes increased significantly in the septic group when compared to both the septic group treated with FBP and the control group. The blood cultures were 100% positive in both the septic group and the septic group treated with bisphosphorylated sugar. The antibiogram only revealed an inhibitory halo in the case of the antibiotic ampicillin, there was no such indication for FBP. The anti-inflammatory power of FBP remained at 60% for 5 h in the rats that received the carrageenan injection. What is more, the sugar reduced the levels of ionic calcium in relation to the control group. This data proves the validity of using FBP in the treatment of sepsis, possibly due to its anti-inflammatory rather than antimicrobial action.

Libido is a comprehensive and yet elusive word that indicates basic human mental states--and their biological counterparts--involved in the beginning of sexual behavior. It has three main roots: biological, motivational-affective and cognitive. All these dimensions may be variably affected in the post menopause, contributing to a progressive decrease of sexual drive that parallels the process of aging. Loss of estrogens and, specifically, of androgens deprives female libido of major biological fuel. The effect of this loss is pervading, affecting the central nervous system, the sensory organs that are the major windows to environmental sexual stimuli and the quality of sexual response, central, peripheral non-genital and genital. Prolactin increase may further inhibit libido. Arousal disorders, dyspareunia, orgasmic difficulties, dissatisfaction, both physical and emotional, may contribute to a secondary loss of libido. Depression, anxiety and chronic stress, may interfere with central and peripheral pathways of the sexual response, reducing the quality of sexual function mostly in its motivational root. Relational conflicts and/or marital delusions and partner-specific problems, erectile deficit first, may contribute to the fading of sexual drive in the post-menopausal years. Well tailored HRT, including androgens in selected cases, may reduce the biological causes of loss of libido. A comprehensive treatment requires a balanced evaluation between biological and psychodynamic factors.