Male delayed orgasm and anorgasmia: a practical guide for sexual medicine providers.

Delayed orgasm (DO) is defined as increased latency of orgasm despite adequate sexual stimulation and desire. Anorgasmia (AO) is characterized as the absence of orgasm. Etiologies of DO/AO include medication-induced, psychogenic, endocrine, and genitopelvic dysesthesia. Given the multifactorial complex nature of this disorder, a thorough history and physical examination represent the most critical components of patient evaluation in the clinical setting. Treating DO/AO can be challenging due to the lack of standardized FDA-approved pharmacotherapies. There is no standardized treatment plan for DO/AO, though common treatments plans are often multidisciplinary and may include adjustment of offending medications and sex therapy. In this review, we summarize the etiology, diagnosis, and treatment of DO/AO.

Lumbar endoscopic spine surgery for persistent genital arousal disorder/genitopelvic dysesthesia resulting from lumbosacral annular tear-induced sacral radiculopathy.

BACKGROUND: Persistent genital arousal disorder/genitopelvic dysesthesia (PGAD/GPD) is characterized by distressing, abnormal genitopelvic sensations, especially unwanted arousal. In a subgroup of patients with PGAD/GPD, cauda equina Tarlov cyst-induced sacral radiculopathy has been reported to trigger the disorder. In our evaluation of lumbosacral magnetic resonance images in patients with PGAD/GPD and suspected sacral radiculopathy, some had no Tarlov cysts but showed lumbosacral disc annular tear pathology. AIM: The aims were 2-fold: (1) to utilize a novel multidisciplinary step-care management algorithm designed to identify a subgroup of patients with PGAD/GPD and lumbosacral annular tear-induced sacral radiculopathy who could benefit from lumbar endoscopic spine surgery (LESS) and (2) to evaluate long-term safety and efficacy of LESS. METHODS: Clinical data were collected on patients with PGAD/GPD who underwent LESS between 2016 and 2020 with at least 1-year follow-up. LESS was indicated because all had lumbosacral annular tear-induced sacral radiculopathy confirmed by our multidisciplinary management algorithm that included the following: step A, a detailed psychosocial and medical history; step B, noninvasive assessments for sacral radiculopathy; step C, targeted diagnostic transforaminal epidural spinal injections resulting in a temporary, clinically significant reduction of PGAD/GPD symptoms; and step D, surgical intervention with LESS and postoperative follow-up. OUTCOMES: Treatment outcome was based on the validated Patient Global Impression of Improvement, measured at postoperative intervals. RESULTS: Our cohort included 15 cisgendered women and 5 cisgendered men (mean ± SD age, 40.3 ± 16.8 years) with PGAD/GPD who fulfilled the criteria of lumbosacral annular tear-induced sacral radiculopathy based on our multidisciplinary management algorithm. Patients were followed for an average of 20 months (range, 12-37) post-LESS. Lumbosacral annular tear pathology was identified at multiple levels, the most common being L4-L5 and L5-S1. Twenty-two LESS procedures were performed in 20 patients. Overall, 80% (16/20) reported improvement on the Patient Global Impression of Improvement; 65% (13/20) reported improvement as much better or very much better. All patients were discharged the same day. There were no surgical complications. CLINICAL IMPLICATIONS: Among the many recognized triggers for PGAD/GPD, this subgroup exhibited lumbosacral annular tear-induced sacral radiculopathy and experienced long-term alleviation of symptoms by LESS. STRENGTHS AND LIMITATIONS: Strengths include long-term post-surgical follow-up and demonstration that LESS effectively treats patients with PGAD/GPD who have lumbosacral annular tear-induced sacral radiculopathy, as established by a multidisciplinary step-care management algorithm. Limitations include the small study cohort and the unavailability of a clinical measure specific for PGAD/GPD. CONCLUSION: LESS is safe and effective in treating patients with PGAD/GPD who are diagnosed with lumbosacral annular tear-induced sacral radiculopathy.

How many nerve fibers innervate the human glans clitoris: a histomorphometric evaluation of the dorsal nerve of the clitoris.

INTRODUCTION: It is frequently quoted in mainstream media that the clitoris has "8000 nerve endings." However, no study has yet quantified the number of nerve fibers (axons) innervating the human clitoris. The dorsal nerves of the clitoris (DNCs) are the primary source of sensation and somatic clitoral innervation. Therefore, reporting the number of axons in the DNCs is an important step in our understanding of clitoral innervation and sexual response with implications for many fields of medical practice. The purpose of this study is to quantify the mean number of axons in the human DNCs and to report the approximate mean number of nerve fibers that innervate the human glans clitoris. METHODS: DNC samples were obtained from 7 transmasculine patients undergoing gender-affirming phalloplasty surgery. At the time of nerve coaptation, a small excess of the DNC (5 mm) was collected for analysis at the proximal level of the clitoral body, just distal of the emergence of the DNCs from underneath the pubic symphysis. Samples were placed into 3% glutaraldehyde fixative, postfixed in 1% osmium tetroxide, and serially dehydrated in ethanol and toluene. Samples were then embedded in araldite, sectioned on an ultramicrotome into 1-µm cross sections, and counterstained with 1% toluidine blue. Histomorphometric evaluation was performed at 1000x magnification with a Leitz Laborlux S microscope and image analysis software (Clemex Vision Professional) to obtain an axon counts. Descriptive statistics were performed to yield a mean and standard deviation of the number of axons in the DNCs. Assuming anatomic symmetry between bilateral DNCs, mean total number of somatic nerve fibers innervating the human glans clitoris was obtained by doubling the mean count of the DNCs. RESULTS: Seven sample DNCs were collected. Of those, 5 were analyzed as 2 did not have sufficient nerve tissue present. The mean number of nerve fibers in the human DNCs was 5140 (SD = 218.4). The mean number of myelinated nerve fibers innervating the human clitoris was 10,281 (SD = 436.8). CONCLUSION: This study is the first to report the number of axons in the human DNC, at a mean 5140. Given the bilateral nature of clitoral innervation and symmetry of anatomic structures, the approximate mean number of myelinated axons that innervate the human glans clitoris is 10,280. When the uncaptured unmyelinated fibers and contributions from the cavernosal innervation are accounted for, it is clear that far Moree than 8000 axons innervate the human clitoris.

The clinical management of testosterone replacement therapy in postmenopausal women with hypoactive sexual desire disorder: a review.

As women age, there is an overall decrease in androgen production due to decline of ovarian and adrenal function during menopause. Androgens have been demonstrated to play an important role in sexual motivation in women. As a result, many postmenopausal women experience Female Sexual Dysfunction (FSD) which are a group of disorders that pertain to sexual arousal, desire, orgasm, and pain. A prevalent manifestation of FSD is Hypoactive Sexual Desire Disorder (HSDD) or the absence of sexual fantasies, thoughts, and/or desire for or receptivity to sexual activity. There is gaining interest in the use of Testosterone Replacement Therapy (TRT) for the treatment of HSDD in postmenopausal women. This article reviews the literature on the relationship of androgen decline and HSDD, describes our methodology for evaluation, diagnosis of HSDD, and the use of TRT in treating postmenopausal women with HSDD. Our results conclude that testosterone is a vital hormone in women in maintaining sexual health and function. TRT is an effective treatment option for postmenopausal people with HSDD. There is still limited data on the effectiveness in premenopausal people with HSDD. Further research in the strengths and weaknesses for the long-term effect of TRT in women of all ages is needed.

Managing Female Sexual Pain.

Female sexual pain disorder or genito-pelvic pain/penetration disorder (GPPPD), previously known as dyspareunia, is defined as persistent or recurrent symptoms with one or more of the following for at least 6 months: marked vulvovaginal or pelvic pain during penetrative intercourse or penetration attempts, marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of penetration, and marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration. In this review, we discuss etiology, diagnosis, and treatment for common disorders that cause GPPD.

The History of Urology at the Minneapolis Veterans Affairs Health Care System.

OBJECTIVE: The Section of Urology at the Minneapolis Veteran's Affairs (VA) Medical Center has a long history of contributions to Urology including the Gleason Score, Fuhrman Grading system, testicular tumor marker development and the birth of Endourology. The objective of this manuscript is to compile and present the Urologic history of the Minneapolis VA. METHODS: The Urologic literature and institutional records originating from the Minneapolis VA Medical Center from 1946-2017 were reviewed and presented herein. RESULTS: The Minneapolis VA Health Care System originated in 1921 and currently employs 5 Urologist who serve over 16,000 veterans per year. Historic achievements from the Minneapolis VA Section of Urology include the development of the Veteran's Affairs Cooperative Research Group (VACURG) which was instrumental to development of the Gleason grading system for prostate cancer in 1965. Additional urologic oncology achievements originating from the Minneapolis VA Section of Urology included the development of the diagnostic utility of tumor markers in testis cancer in 1976 and The Fuhrman Grading System in 1982. Perhaps the greatest contribution to the field of Urology was the birth of Endourology at the Minneapolis VA in the late 1970s under the direction of Dr. Paul Lange. Currently the Minneapolis VA is a premier center for Evidence Based Urology by housing Cochrane Urology and the U.S. Grading of Recommendations Assessment, Development and Evaluation network (US GRADE). CONCLUSION: Since 1946, the section of Urology at the Minneapolis VA has contributed basic science, clinical technique and evidence based medicine to the field of Urology while providing care to the nation's veterans.

Unilateral proptosis as initial presenting sign of prostate cancer in a 45-year-old man.

We describe the case of 45-year-old man presented with a 3-month history of progressive unilateral proptosis, voiding symptoms, and a 20-pound weight loss. Imaging showed a large brain mass as well as significant extra cranial involvement. He was diagnosed with metastatic prostatic adenocarcinoma and underwent craniotomy, androgen deprivation therapy, and chemotherapy.

Azoospermia in a Male with Klippel-Feil Anomaly.

Müllerian-duct aplasia, renal agenesis, and cervical somite dysplasia (MURCS) is a rare genetic disorder. Previously thought to be exclusive in females, there have now been a small number of case reports describing a male analogue. We describe a patient with obstructive azoospermia and Klippel-Feil anomaly.