Position paper: Management of men complaining of a small penis despite an actually normal size.

INTRODUCTION: With the worldwide increase in penile augmentation procedures and claims of devices designed to elongate the penis, it becomes crucial to study the scientific basis of such procedures or devices, as well as the management of a complaint of a small penis in men with a normal penile size. AIM: The aim of this work is to study the scientific basis of opting to penile augmentation procedures and to develop guidelines based on the best available evidence for the management of men complaining of a small penis despite an actually normal size. METHODS: We reviewed the literature and evaluated the evidence about what the normal penile size is, what patients complaining of a small penis usually suffer from, benefits vs. complications of surgery, penile stretching or traction devices, and outcome with patient education and counseling. Repeated presentation and detailed discussions within the Standard Committee of the International Society for Sexual Medicine were performed. MAIN OUTCOME MEASURE: Recommendations are based on the evaluation of evidence-based medical literature, widespread standards committee discussion, public presentation, and debate. RESULTS: We propose a practical approach for evaluating and counseling patients complaining of a small-sized penis. CONCLUSIONS: Based on the current status of science, penile lengthening procedure surgery is still considered experimental and should only be limited to special circumstances within research or university institutions with supervising ethics committees.

Psychological and interpersonal dimensions of sexual function and dysfunction.

INTRODUCTION: Sex therapy techniques comprise behavioural and cognitive as well as psychodynamic and educational interventions, like reading ('bibliotherapy'), videotapes and illustrations of anatomical models. Contemporary approaches focus on desire, pleasure and satisfaction. DISCUSSION: It is important to assess medical and biological factors involved in the genesis of sexual dysfunctions. Sex therapy techniques were developed by Masters and Johnson, and their premise was to eliminate 'performance anxiety' by emphasising the undemanding nature of the sexual relation. New methods were introduced, like Internet-administered techniques, and 'mindfulness therapy', and they proved to be effective. CONCLUSIONS: Psychological treatments have some relieving effects on sexual dysfunction, but for studies of the outcomes it is difficult to meet the requirements of evidence-based medicine.

Psychological and interpersonal dimensions of sexual function and dysfunction.

INTRODUCTION: There are limited outcome data on the etiology and efficacy of psychological interventions for male and female sexual dysfunction as well as the role of innovative combined treatment paradigms. AIM: This study aimed to highlight the salient psychological and interpersonal issues contributing to sexual health and dysfunction, to offer an etiological model for understanding the evolution and maintenance of sexual symptoms, and to offer recommendations for clinical management and research. METHODS: This study reviewed the current literature on the psychological and interpersonal issues contributing to male and female sexual dysfunction. MAIN OUTCOME MEASURE: This study provides expert opinion based on a comprehensive review of the medical and psychological literature, widespread internal committee discussion, public presentation, and debate. RESULTS: Medical and psychological therapies for sexual dysfunctions should address the intricate biopsychosocial influences of the patient, the partner, and the couple. The biopsychosocial model provides an integrated paradigm for understanding and treating sexual dysfunction. CONCLUSIONS: There is need for collaboration between healthcare practitioners from different disciplines in the evaluation, treatment, and education issues surrounding sexual dysfunction. In many cases, neither psychotherapy alone nor medical intervention alone is sufficient for the lasting resolution of sexual problems. The assessment of male, female, and couples' sexual dysfunction should ideally include inquiry about predisposing, precipitating, maintaining, and contextual factors. Research is needed to identify efficacious combined and/or integrated treatments for sexual dysfunction.

Is physical examination required before prescribing hormones to patients with gender dysphoria?

INTRODUCTION: A genital examination can have psychologic effects on a patient, particularly when the source of their sexual medicine complaint is a body part. How necessary is a physical exam before prescribing hormones in cases of gender dsyphoria? METHODS: Five people with expertise and/or interest in the area of gender dysphoria and endocrinology were asked to contribute their opinions. MAIN OUTCOME MEASURE: To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine. RESULTS: Of the five experts writing on the topic, one believes that a physical examination should always be performed before prescribing hormones for gender dysphoria, one believes it is not a prerequisite, and three believe a physical examination is recommended, but is not necessary in cases where the patient objects despite an explanation of the purpose of the exam. As long as this was documented, it would not present a medicolegal problem. CONCLUSIONS: It is not clear whether or not a physical examination must be performed on all gender dsyphoric patients before prescribing hormones; however, an examination would be helpful in revealing a significant health management issue.

The relationship between sexual activity and urinary incontinence in older women.

OBJECTIVES: To determine whether continence status is associated with sexual activity in older women. DESIGN: Cross-sectional postal survey. SETTING: Random selection from a list of respondents to a Canada Post survey. PARTICIPANTS: Community-dwelling women aged 55 to 95. MEASUREMENTS: The International Consultation on Incontinence Questionnaire Short Form measured the presence, severity, and type of incontinence. Sexual activity and marital status were assessed using single close-ended questions. The Medical Outcomes Study 12-item Short-Form Health Survey was used to query physical and mental health status. RESULTS: Data from 2,361 women (mean age 71) were available for analysis. Thirty-nine percent reported urinary incontinence (UI), and 27% were sexually active. UI was associated with sexual activity in crude logistic analyses (odds ratio (OR)=0.82, 95% confidence interval (CI)=0.68-0.98) but not in multivariate models adjusted for physical and mental health. Marital status and age were the strongest predictors of sexual activity (OR 8.94, 95% CI=6.89-11.60 for married women; OR=3.09, 95% CI=2.57-3.73 for age

Efficacy and tolerability of vardenafil in men with mild depression and erectile dysfunction: the depression-related improvement with vardenafil for erectile response study.

OBJECTIVE: Erectile dysfunction and depression are highly associated. Previous studies have shown benefits of phosphodiesterase-5 inhibitor treatment for erectile dysfunction associated with antidepressant therapy or subsyndromal depression. The present study assessed the safety and efficacy of vardenafil in men with erectile dysfunction and untreated mild depression. METHOD: In this 12-week, multicenter, randomized, flexible-dose, parallel-group, double-blind study, 280 men with erectile dysfunction for at least 6 months and untreated mild major depression received placebo or vardenafil, 10 mg/day, for 4 weeks, with the option to titrate to 5 mg/day or 20 mg/day after each of two consecutive 4-week intervals. Endpoints included International Index of Erectile Function erectile function domain and 17-item Hamilton Depression Rating Scale (HAM-D) scores. RESULTS: Vardenafil produced statistically significant and clinically meaningful improvement in all erectile function parameters. The International Index of Erectile Function erectile function domain score was 22.9 with vardenafil compared to 14.9 with placebo. The HAM-D score was lower in the vardenafil group (7.9) than in the placebo group (10.1). Treatment with vardenafil was the most important predictor for return to normal erectile function. Improvement in International Index of Erectile Function erectile function domain score was the most important predictor of remission in depressive symptoms. CONCLUSIONS: Vardenafil was well tolerated and highly efficacious in men with erectile dysfunction and untreated mild major depression. Significant improvements in erectile function and depression were observed in patients treated with vardenafil versus placebo. Erectile dysfunction treatment should be considered a component of therapy for men with depression and erectile dysfunction.

Guidelines for the pharmacotherapy of premature ejaculation.

In the 1960s, premature ejaculation was considered a learned behaviour that had to be treated by behavioural therapy, such as the so-called stop-start technique. The efficacy of this method was questioned. Physicians have always looked for medication that could delay ejaculation. Many studies, controlled and open label, have now clearly shown that rapid ejaculation can be treated quickly and effectively with clomipramine and SSRIs. This article describes the guidelines for the pharmacological treatment of premature ejaculation. These guidelines were developed to ensure that medication are used when clear indications are present.