Newsletter – Vol. 2, No. 3

August 1, 2003

The Institute for Sexual Medicine, composed of the Center for Sexual Medicine and Laboratory for Sexual Medicine Research, is dedicated to the diagnosis and treatment of patients with sexual health problems. This is achieved through the pursuit of multidisciplinary basic science and clinical research, training and education of health care professionals, and the promotion of the exchange of scientific information.

Message from our Center Director
Irwin Goldstein, MD

I am pleased to announce that as we complete our first year operating under the name Institute for Sexual Medicine at Boston University School of Medicine, we are celebrating our twenty-fifth year as a sexual medicine clinic. Look for little ways in which we will be celebrating this milestone.

We have bid a fond farewell to Dr. Soo Woong Kim, who spent two productive years in the Laboratory for Sexual Medicine (see story on the Korean connection). We wish him luck in his future endeavors.

We have had a PhD student working in our lab for several years, but next month our clinical ranks will swell to include our first psychology PhD student, Lisa Scepkowski. Hers will be a fresh face in the Center for Sexual Medicine in September.

When you check in for your appointment you will see that we have once again rearranged the reception area to accommodate our patients. Pam and Laurie are now more accessible to everyone. We hope you will enjoy the new check in procedures.

Sex Therapy Information on Ejaculation Problems
Dr. Stanley Ducharme

When does an ejaculation problem become a disorder? This is a subjective question and is based on the level of distress that is experienced by the man or his partner. Typically, ejaculatory disorders fall into two categories. These are: delayed ejaculation and early ejaculation. This column will explore some of the psychological factors related to these two distinct male dysfunctions.

In the vast majority of cases, the most effective treatment for ejaculatory dysfunction is a combination of biologic and psychologic therapy that addresses both the emotional and physical aspects of the problem. The psychological definition of delayed ejaculation refers to the inability to have an ejaculation during sexual intercourse. Interestingly enough, ejaculatory issues are rarely defined as a dysfunction if they occur only during masturbation. As a result, an important diagnostic question for sex therapists is the context in which the problem occurs. Does this difficulty happen with self-stimulation, with all partners or with specific partners? Problems of delayed ejaculation tend to be somewhat rare and not well understood by psychologists and sex therapists. In spite of the lack of information regarding delayed ejaculation, the most successful approach, for sex therapists, is to engage both members of the couple into addressing the problem. Thus, ejaculatory dysfunction is always perceived as a couple’s issue.

Ejaculatory problems can have a devastating affect on self-esteem and on the quality of a relationship. In some cases, delayed ejaculation may have existed for years prior to treatment. Thus, resentments and a sense of frustration often accompany an ejaculation problem. It is also important to address these issues in addition to the sex therapy whenever possible. Traditional behavioral sex therapy for delayed ejaculation is as follows: the man begins by masturbating, then starts intercourse when he is almost ready to ejaculate; the procedure continues with the man beginning intercourse earlier and earlier. The partner may assist the man to masturbate and maintains a supportive and encouraging attitude. Sensitivity may be improved with the use of androgens such as testosterone or by using a vibrator.

In contrast to delayed ejaculation, early ejaculation difficulties are much more common and frequently seen in sexual medicine clinics. By definition, early ejaculation is an ejaculation that occurs before it is desired. A significant amount of distress from the man or his partner typically accompanies an early ejaculation. The man experiences a sense of helplessness in controlling his ejaculation. Psychologists and sex therapists tend to view ejaculatory control as a skill that is mastered via masturbation during adolescence and early adulthood. As a result, most men ejaculate early when they are young and inexperienced. As they develop, latency of ejaculation increases although not always to the satisfaction of the man and his partner. In addition to early sexual experiences, attitudes toward sexuality as well as cultural and religious beliefs all play a role in sexual development and ejaculatory control. For example, when a boy is young he may feel rushed (his parents are going to walk in), religious conflicts (his religion frowns on masturbation) or guilt regarding self pleasuring. Such circumstances may provide the groundwork for future problems leading to early ejaculation. In other cases, these early messages may lead to other areas of conflict and distress regarding sexual functioning.

A combined urologic and psychological treatment plan is often advised and has the best chance of success. In such cases, both the medical issues are addressed as well as the emotional and relationship issues that may be contributing factors. Besides medication from the urologist, sex therapy includes learning a behavioral approach. If possible and for best results, the partner is encouraged to become involved from the beginning. Unfortunately however, there is often much anger and resentment on the part of the partner. When such frustration is involved the woman may not want to be involved in treatment. She may conceptualize this problem as a dysfunction that the husband must address individually. Such attitudes can unfortunately often sabotage the success of the treatment unknowingly reinforce the continuation of the sexual dysfunction.

In the right circumstances and with ongoing motivation ejaculation disorders can be overcome. The most important lesson to be learned by men and their partners is that there is hope and there are therapies that can help resolve the distress of ejaculatory difficulties.

Sexual Medicine Information Sessions

Upcoming sexual medicine information sessions are open to patients, the public, health care professionals and interested persons. All programs are held at Boston Medical Center, 80 E. Newton St, Boston, usually in conference room C-D, from 7:00-9:00 pm. There will be no August sexual medicine information session as so many people are on vacation. On September 16 the topic under discussion will be Improving sexual function with Androgen Therapy. This is for both men and women. The October 21 program is Treating Peyronie’s Disease.

Dr. Irwin Goldstein presented the educational lecture Renewing Your Sex Life After Childbirth. Women’s sexual function reflects both her psychological sociocultural, interpersonal influences as well as her biologic influences including the health of her gynecologic, urologic, endocrinologic, cardiovascular and central and peripheral nervous systems. One of the most common complaints of the over 1350 women evaluated at the Center for Sexual Medicine since 1998 has been persistent or consistent sexual dysfunction since childbirth. Post-childbirth sexual complaints include: loss of desire, decreased frequency of sexual activity, painful intercourse, diminished sexual responsiveness, difficulty achieving orgasm, decreased genital sensation, decreased genital arousal and new onset pudendal neuropathy (often associated with a forceps delivery).

A recent 2002 publication examined the post-natal sexual health of 122 married Nigerian women via questionnaire. After childbirth the frequency of sexual intercourse decreased, sexual satisfaction decreased and sexual dysfunction increased. Multiple sexual problems were present in 95% of the women at 6 weeks post-partum and 51% at 6 months post-partum, including loss of sexual desire, painful penetration, painful intercourse, difficulty achieving orgasm, lack of vaginal lubrication, vaginal tightness, lack of vaginal muscle tone and irritation or bleeding after sex. Women who had instrumental vaginal delivery, perineal trauma and/or pre-pregnancy dyspareunia were more likely to experience dyspareunia at 3 months post-partum.

One possible biologic explanation for the high prevalence of sexual dysfunction after childbirth relates to consistent and persistent sex steroid hormonal changes, especially in androgens, which have been found in the mother after the childbirth. Recent research has shown that sex steroids are critical for sexual activity. Based on animal research, sex steroid hormone deficiency states are associated with atrophy of the clitoris and vagina, changes in the androgen and estrogen receptors, diminished ability to relax vaginal smooth muscle and diminished vaginal blood flow and lubrication. It is postulated that in women with sexual dysfunction certain critical adrenal enzymes involved in sex steroid synthesis become inactive for unknown reasons; in particular the enzyme 17-20 lyase enzyme becomes inactive after childbirth. It has been shown that progesterone, which is dramatically elevated during pregnancy, acts to inhibit this enzyme.

The first management strategy for sexual dysfunction is “identification of the sexual dysfunction”, by psychologic interview, history (medical, sexual and psychosocial), physical examination, genital sensory and blood flow testing and blood testing. This is followed by “education” of the patient (and the partner) by reviewing the initial psychologic and biologic findings, and educating the patient (and the partner) as to anatomy, physiology and pathophysiology. The first treatment strategy is to undergo “modification of reversible factors” by sexual therapy, medication changes, hormone therapy, lifestyle change and corrective surgery when appropriate. The second treatment strategy is to undergo “first-line therapy” by vacuum clitoris device, oral and/or topical vasodilator therapy. One key diagnostic strategy for women with sexual dysfunction after childbirth has been to record sex steroid blood levels. If sex steroid levels are abnormal, based on symptoms and needs, individualized hormone therapy with dehydroepiandrosterone, androstenedione or testosterone may be indicated as treatment. Follow-up blood tests every 3 months are suggested. A woman should only take what sex steroids she needs at the lowest dose to maintain the “optimal” level of hormones in her body.

Attendees in June were treated to two educational lectures on the topic Ejaculation Problems: Too Fast, Too Slow or Not at All, one by Dr. Munarriz and one by Dr. Ducharme. You will find Dr. Ducharme’s information under the sex therapy section. According to Dr. Munarriz, the most common sexual dysfunction for men is ejaculatory disorder, including rapid or premature ejaculation (75%), delayed (8%), no ejaculation and retrograde ejaculation.

Premature ejaculation disorder, if the man ejaculates within 1 minute of penetration, may be lifelong or acquired, global or situational, biogenic, psychogenic or mixed. Objective assessment is made by number of thrusts (no data on normal) and intra-vaginal latency time (average intercourse lasts 4-7 minutes. If you have premature ejaculation there is a 91% chance that a first degree relative will also have it. SSRI’s as a first line treatment may be used before intercourse or taken every night. This treatment works better if rapid ejaculation is acquired. The anti-depressant with Sildenafil (Viagra™) is significantly better than the SSRI alone. If that doesn’t work a local anesthetic should be added to the regimen. A combination of an anti-depressant, local anesthetic and Sildenafil is effective in 97% of the time. If that still is not effective the patient may use intracavernosal injection. Fast acting SSRI’s specifically for rapid ejaculation are currently in development. .

Delayed ejaculation carries with it issues of inability to achieve orgasm and infertility, and can be affected by anti-depressants or agents which act centrally, anti-hypertensives and alcohol abuse. It is important to evaluate if this is a psychological problem, but a physical assessment must be made as well. A common cause is pudendal neuropathy, caused by a crush to the perineum. Situational delayed ejaculation is probably psychologic; generalized is probably biologic. Buproprion may be used but it is not all that effective. Check first for reversible causes. Research is still needed in this area.

The education lectures for Women Without Orgasm: Now or Not Ever were given by Dr. Stan Ducharme and Dr. Irwin Goldstein. Dr. Ducharme explained that female orgasmic dysfunction is defined as a persistent or recurring difficulty, delay or inability to attain orgasm following sufficient stimulation and arousal which causes personal distress. Orgasms vary from woman to woman, varying in the type or intensity of stimulation that triggers them. Psychologists believe that there is a subjective experience that accompanies an orgasm based on factors such as feelings toward the partner, level of comfort, feelings of trust, etc.
A woman’s ability to achieve an orgasm is based on both her physiology as well as her emotional well-being. The psychological issues that affect the ability of a woman to achieve orgasm include emotional, physical or sexual abuse, early psychological trauma, a history of poor relationships, substance abuse, depression, anxiety or psychiatric disorders. The woman’s emotional responses to her sexual dysfunction including inadequacy, sadness, feelings of loss, frustration, anger and a sense of failure often intensify and contribute to the orgasmic difficulties. Various psychotropic medications may also inhibit the woman’s ability to have an orgasm. It is not uncommon for sexual activity to serve as a trigger for emotionally painful experiences in a woman’s past. The partner’s sexual functioning is another factor affecting the woman’s ability to have an orgasm. For heterosexual women, these may include a man’s sexual performance such as early ejaculation, erectile dysfunction, low libido of partner and pressure on the woman to be orgasmic. Men often blame themselves for a woman’s sexual difficulties and question their own attractiveness and desirability, which only adds to the pressure being experienced by the woman.

Treatment for a woman’s orgasmic difficulties often involves a combined medical and psychological approach. In addition to androgen therapy that may be prescribed by the urologist, the sex therapist may utilize a cognitive behavioral approach. The goals of cognitive behavioral sex therapy are to promote an attitude shift, encourage relaxation and reduce anxiety. Relaxation training is done at home on a daily basis along with directed masturbation. The procedure includes a period of education and information followed by visual and kinesthetic self-exploration of the woman’s body. Often, a vibrator is used in self-exploration. The therapist should also address relationship issues.

Dr. Goldstein started by explaining that biology is the foundation for good health and intact biologic processes such as appropriate nerves, blood supply and hormones, are important for sexual functioning. During orgasm, several physiological changes are noted including increases in heart rate, blood pressure, breathing rate, vaginal and clitoral blood flow and rhythmic muscular contractions in the vagina, uterus, anal sphincter. Orgasm is a neurologic reflex, therefore intact sensory nerves are needed in the labia, clitoris and genital area. To help diagnose patients with orgasmic disorders, patients should undergo “quantitative sensory testing”. Quantitative sensory testing is based on administration of quantified stimuli, usually of vibration or temperature, in a controlled way tot he genital area. Quantitative sensory testing is repeatable and, therefore, a valid descriptor of the sensory state. The subject defines the sensory threshold by indicating the onset of perceived sensation. Age-corrected normograms for thresholds of vibratory and thermal sensations for the clitoris and vagina are published. Many women with orgasm problems have abnormal quantitative sensory testing of the labia and clitoris.

Researchers are showing that the nerves involved in transmitting sensory information to the spinal cord (sacral roots S 2, 3, and 4 – the pudendal nerve) are sensitive to the level of sex steroids in your body. Sex steroid hormones are critical for sexual function and help make the genital sensory nerves sensitive. Androgens are as natural to women as estrogens.

There are several reasons for women who come to our clinic with the complaint of lack of orgasm. Hysterectomy may damage nerves to the deep inside portion of the vagina. If the cervix is removed, the ability to achieve an internal orgasm may be lost. Six months after childbirth 15% of women have persistent orgasm problems. Antidepressant medications may cause orgasm problems especially SSRI’s. Oral contraceptive pills (OCP) are used by 70 million women worldwide. The OCP stops ovarian testosterone synthesis and increases the level of sex steroid binding globulin that binds to testosterone rendering much of the circulating testosterone inactive. Low bioavailable or free testosterone values may be a cause of diminished sensation in the genitals leading to difficulty with orgasm and a loss of sexual interest. Women on the OCP may also have pain because the vestibular glands near the hymen require testosterone to remain healthy.

An evaluation for lack of orgasm includes a psychological evaluation, sexual and medical history, physical exam, quantitative sensory testing, and blood tests in which as many of the 10 steroids as possible are measured. An individual plan for each patient is developed. DHEA and testosterone may be prescribed as double blind placebo-controlled tests for safety and efficacy have been published for both. EROS therapy (a device applying vacuum intermittently to the clitoris) helps makes the sensory nerves to the clitoris more sensitive. For pain, physical therapy to learn relaxation and contraction has been found to be helpful. You CAN do something about your sexual problem.

For more detailed summaries of these presentations, please refer to our website, http.www.bumc.bu.edu/sexualmedicine.

The Korean Connection

Here in the Laboratory for Sexual Medicine at the Institute for Sexual Medicine we have enjoyed a long tradition of collaboration with a number of leading medical institutions in South Korea. Through the collaborative efforts of the past several years, the Institute has developed intimate relationships with the leaders in the field of Sexual Medicine in South Korea. Our latest colleague is Soo Woong Kim, MD, PhD, Assistant Professor of Urology at Seoul National University, home of South Korea’s most prestigious medical school. In Korea, Dr. Kim has pursued an academic career and is an authority in the fields of Andrology and Sexual Dysfunction.

In 2001, Dr. Kim came to us on sabbatical and has feverishly worked in a number of areas in male and female sexual dysfunction. Most recently, he concluded his work on the development of a new, in vivo, hormonally intact, female rat model through which we will be able to further investigate female sexual physiology. Other recent research accomplishments by Dr. Kim include an investigation into the importance of the NO-cGMP pathway in vaginal hemodynamics and a comparison of surgical and medical castration on erectile dysfunction in an animal model.

One of the greatest assets in biomedical research is to have researchers who are able to bridge the gap between science and medicine. The role of academic clinicians in this capacity is critical and is greatly responsible for broadening the scope and improving the quality of health care here in the United States and around the world. The wealth of clinical knowledge, in conjunction with research experiences and ambitions of academicians like Dr. Kim, comprises a kind of investigative savvy that is priceless in terms of maintaining progress in research. Sadly (for us), Dr. Kim will return to his post at Seoul National University in July of this year. As we celebrate two fruitful years of collaborative research, we wish for his safe return and look forward to continued cooperation in future research endeavors.

Comment on FSD at the AUA

The annual meeting of the American Urologic Association in Chicago attracted over 15,000 attendees from around the world to discuss the latest advances in the diagnosis and treatment of urologic disorders. In addition to the State-Of-The-Art-Lectures, Society Meetings, and Postgraduate Courses, a total of 1877 abstracts (podiums, posters, videos), were presented over a period of 5 days.

Despite the high prevalence of female sexual dysfunction (43%), minimal attention was devoted to this exciting and emerging field. Female Sexual dysfunction (FSD) was not presented in any of the state-of-the-art lectures with the exception of brief comments by Dr. Morley in his presentation entitle “Androgen deficiency in the aging male and female”. On Saturday 29th, The Meeting of The Sexual Medicine Society of North America took place. The program was exciting, innovative, but again only 15 minutes were dedicated to female sexual dysfunction. Dr Irwin Goldstein’s presentation summarized the Boston University School of Medicine surgical experience in the management of female sexual dysfunction.

The AUA sponsored 8 postgraduate courses in Sexual Medicine, 6 courses in male sexual dysfunction, one in female sexual dysfunction (taught by a former Institute fellow) and one in both (taught by the Institute faculty). The course entitled “Advances in Sexual Medicine for Men and Women: Expanding the Role of the Urologist” briefly summarized the available data on the epidemiology, anatomy, pathophysiology, diagnosis and management of female sexual dysfunction.

Approximately 20 posters and podiums on female sexual dysfunction, which represent approximately 1.06% of the total abstracts, were presented. Well-designed, random-sample, community-based epidemiologic investigations of women with sexual dysfunction are limited, but several posters/podiums expanded the available data on the prevalence of FSD. These investigations confirmed the high prevalence of FSD in all age groups and the importance of developing appropriate diagnostic and therapeutic tools. Only six basic science studies concerning the physiology and pathophysiology of female sexual function were presented. Dr. Park (a former Institute fellow) in an elegant study showed that hyperglycemia causes alteration on vaginal blood flow and structure. More importantly, insulin-treated rats had similar histologic and hemodynamic findings. Traish et al. (Institute faculty) suggested that androstenediol modulates NOS and Arginase activity via an androgenic-dependent mechanism in the rabbit vagina. Interestingly, the rabbit vagina expresses a novel binding protein for androstenediol. Kim et al. (Institute faculty) suggested that the NO-cGMP pathway plays a more important role than previously reported. Dr. Hale and colleagues showed that apomorphine-induced genital vasocongestive arousal responses are hormonal dependent. Their work also suggest that androgens module arousal responses through genomic and non-genomic mechanisms.

Clinical studies by Dr. Solonia and colleagues (a former Institute fellow) reported that oxytocyn fluctuates throughout the menstrual cycle in healthy premenopausal women and that correlates with vaginal lubrication. Berman et al. (a former Institute fellow) presented the results of a placebo-controlled, double-blind trial of sildenafil citrate in women with sexual arousal disorder. The study showed that sildenafil is efficacious and well tolerated in women with sexual arousal disorders without concomitant sexual desired disorder. More importantly, the authors highlighted the need for correct identification of women with primary FSAD in order to maximize the efficacy of sildenafil in the management of FSD. Dasgupta et al. showed that sildenafil improved certain symptoms in patients with MS. Interestingly they also concluded that neurogenic FSD cannot be addressed by this treatment alone.

Hopefully, as this emerging field grows in acceptance in the urologic community, the number of scientific presentations will fill the paucity of data concerning the anatomy, physiology, and pathophysiology of sexual function in women.

Upcoming Events

In recognition of twenty-five years of healthcare in the field of sexual medicine at the Center for Sexual Medicine, Boston University School of Medicine will be honoring the faculty of the Institute for Sexual Medicine with a reception in September at the Boston University Medical Campus. Following the reception there will be a private dinner in celebration.

Donations

Tax deductible gifts may be made to the Institute for Sexual Medicine. Please make check payable to Boston Medical Center/Irwin Goldstein, MD, write ‘ISM donation’ on the memo line and mail to Jerie McGrath, Boston Medical Center, Department of Urology W607, 700 Albany Street, Boston, Massachusetts 02118.