Newsletter – Vol. 3 No. 2

May 1, 2004

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
Dr. Irwin Goldstein

We have all survived this winter, despite the changes of weather we have all come to associate with New England. So, too, does our medical center change. While I thought by the time you were reading this e-mail our construction for the long-awaited face lift of the Center for Sexual Medicine would have been completed, we are once again in a waiting mode. Architectural plans, however, have been finalized.

I want to congratulate Dr. Ricardo Munarriz for having passed the urology specialty boards. These boards cannot be taken until the physician has been in practice for a length of time.

I also want to congratulate Dr. Abdulmaged Traish, Director of the Laboratory for Sexual Medicine Research, for having been selected Educator of the Year in the graduate sciences (again) for Excellence in Teaching at Boston University School of Medicine. It is an honor to have this outstanding educator on our faculty.

In March Boston University School of Medicine held a special event: its annual induction of members to Alpha Omega Alpha, the medical school honor society. This year’s inductees included third year medical student Aisha Traish, older daughter of Dr. Traish. Also, I was inducted this year as the faculty inductee and received my pin and certificate from my son who became a member of AWA last year as a third year medical student. This was a very special moment for our family.

Upcoming Events

This is a reminder that registration is still available for Female Sexual Dysfunction: Symptoms and Solutions on May 23, 2004, and Erectile Dysfunction and other Male Sexual Dysfunctions: Symptoms and Solutions on June 6, 2004. Both programs are free and will be run from 1:00-5:00 pm, with registration starting at 12:30 They will be held at the Holiday Inn on Grove Street in Newton, at the junction of Routes 90 and 95. Although health care clinicians are always welcome, these programs are designed for the general public. For on line registration www.bumc.bu.edu/sexualmedicine/fsdprogram or www.bumc.bu.edu/sexualmedicine/edprogram.

Sexual Medicine Education
Sue Goldstein, Coord. of Education & Development

Sexual Medicine is a relatively new entity for both physicians and patients. This means that you can play a key role as our partners in educating both health care professionals and the public in sexual health concerns.

More than likely, when your physician went to medical school, there was little or no education in the realm of sexual medicine. Rather than getting frustrated, you can help fill that void by sharing your knowledge with your help care provider, and showing him or her that there are reliable resources in the field when looking for help. Organizations such as the Sexual Medicine Society or the International Society for the Study of Women’s Sexual Health are dedicated to the scientific study of sexual medicine. The Journal of Sexual Medicine is committed to publishing the highest quality, evidence-based research in sexual function and dysfunction.

A priority for our Institute for Sexual Medicine is teaching. We do this through the sexual medicine information sessions and public seminars. We do this through lectures given by our physicians to health care professionals around the world. And we do this by lecturing to those students currently in medical school, so that they will be better-educated physicians in the future. This year, Dr. Goldstein had the opportunity to work with first year students in the gross anatomy lab, biochemistry class and introduction to clinical medicine. He lectured to second year students in endocrinology and fourth year students in advanced anatomy. There are no formal sexual medicine lecture blocks, but sexual medicine is multi-disciplinary so it is taught within other areas. In addition, students rotating through urology during their third and fourth years of medical school have the option of working in the Center for Sexual Medicine, and each year several masters students choose Dr. Goldstein or Dr. Munarriz as thesis advisor, developing an area of research within sexual medicine. Residents at our medical center in many different disciplines, including endocrinology, family medicine, gynecology, primary care and urology choose to spend time observing at the Center for Sexual Medicine.

We are doing our best to disseminate sexual medicine information and expand educational opportunities. Please help us by recognizing that sexual health should be no different than any other area of health. It should be spoken about and treated without a sense of embarrassment. Direct your physician to our website, www.bumc.bu.edu/sexualmedicine, so he or she has an opportunity to learn and help others.

Sexual Medicine Information Sessions

Sexual medicine information sessions are open to patients, the public, health care professionals and interested persons. All programs are held at Boston Medical Center, 88 E. Newton St, Boston from 7:00-9:00 pm. Upcoming programs include Sexual Dysfunction in Men on May 18, 2004, Restoring sexual function after Lupron or cancer treatment on June 22, 2004 for both men and women, and The Most Common Female Sexual Dysfunction: Low Interest on July 20, 2004. More information about our programs is available on line at www.bumc.bu.edu/sexualmedicine/informationsessions.

In February the topic of the information session was Persistent Sexual Arousal Syndrome, with lectures by Dr. Stanley Ducharme, his student Julie Johnson, and Dr. Goldstein. The condition of persistent sexual arousal is not reported frequently enough to be included in national surveys on women’s sexual health. It is unknown how often women complain of persistent arousal but it is thought to be extremely rare. The occurrence of PSAS for a woman is unrelated to demographic concerns. The arousal is unrelated to sexual excitement or desire, with little or no relief form orgasmic experience. PSAS can be triggered by sexual or non-sexual stimuli or no stimuli at all, and is generally unwanted and intrusive. It is a unique experience for each person. Long term emotional consequences of living with PSAS include disruptions in occupational, educational and social functioning, a continued sense of shame and isolation, feelings of helplessness, vulnerability and sadness, being awakened in the morning by hot flashes, and a feeling of a lack of normalcy. In order to cope with PSAS it is important to recognize that this is a couple’s issue.

There is no consensed definition for women with persistent sexual arousal. Based on patients who either presented for evaluation to the Center for Sexual Medicine or who communicated by e-mail to the Institute for Sexual Medicine, we have gained data on PSAS and propose new definitions. Persistent Sexual Arousal Syndrome/Disorder may be considered as the persistent, recurrent or continuous ability to attain or maintain sufficient sexual excitement, causing personal distress. It may be expressed as excessive subjective excitement or excessive genital (lubrication, swelling, engorgement) or other somatic responses. Some patients are better classified as having Persistent Orgasmic Syndrome/Disorder or Persistent Sexual Desire Disorder. Common features shared by women with PSAS are the torment from having lives ruled by the condition and the feeling of despair due to the lack of recognition of this condition by the medical community resulting in their having to live the rest of their lives with the PSAS-hell.

Diagnosis of the underlying PSAS pathophysiology is essential to correct patient management. It is our belief that all patients with PSAS should have a psychologic interview, medical history, physical examination, neurologic sensation testing, blood flow tests before and after arousal, arteriography if indicated and hormone blood tests. All patients should have access to ongoing psychologic care and management. We propose a new classification of PSAS based on suspected pathophysiology (causation). Neurologic-Central: The central nervous system (brain and spinal cord) is critical in regulating sexual function, especially desire, arousal and orgasm. What if there was persistent neurologic stimulation of the autonomic nerves to the clitoris, labia, vagina secondary to central nervous system pathology? For patients suspected of Neurologic-Central pathophysiology, we consider the following treatments – 1. Medications that stabilize nerve transmission and/or effect mood, 2. Local topical anesthetic agents, ice 3. Medical treatment of irritating neurolgic lesion: Physical Therapy, acupressure, pain meds, muscle relaxants 4. Hormonal milieu normalization; 5. Surgical excision of irritating neurologic lesion. Neurologic-Peripheral: The peripheral nervous system (local genital nerves: motor and sensory) is critical in regulating sexual function, especially arousal and orgasm. What if there was persistent neurologic stimulation of the autonomic nerves to the clitoris, labia, vagina secondary to local peripheral nervous system pathology? We recommend: 1. Local estrogen to external genitalia 2. Local topical anesthetic agents, ice 3. Steroid nerve blocks (repeated) 4. Medical treatment of irritating lesion 5. Hormonal milieu normalization; 6. Surgical excision of irritating lesion Pharmacologic: Sexual arousal involves release of chemicals into the genital tissue that induces genital smooth muscle relaxation. What if there was persistent pharmacologic-induced inhibition of contraction or enhanced relaxation of the clitoral, labial, vaginal smooth muscle? We recommend: discontinuing the offending medication. Vascular: Blood supply is critical to genital swelling and lubrication responses to sexual arousal. Relief from a pelvic arterial venous malformation (AVM) communicating to the arteries of the clitoris can be achieved after multiple embolization episodes. Other: Sexual arousal involves release of chemicals broken down by enzymes in the genital tissue that induce genital smooth muscle relaxation, but the enzyme could be inactive or missing.. For patients with PSAS suspected of this pathophysiology (other causes were excluded), we recommend: 1. Discontinue offending medications 2. Medications that stabilize nerve transmission and/or effect mood, 3. Local topical anesthetic agents, ice 4. Hormonal milieu normalization. We look forward to basic science and clinical research expanding our understanding and management options for PSAS patients in the future.

The March program on Sexual Dysfunction in Women was cancelled due to a snowstorm in Boston.

In April Dr. Goldstein and Nurse Terry Payton addressed the topic Better Erections with Injections. The concept that a penile erection could be initiated by injection of drugs into the erectile tissues was introduced to urologists in the spring of 1983 by Dr. Giles Brindley. We had patients on self-injection therapy 1 week later. Our nurse, Terry Payton, has been teaching patients self-injection therapy ever since, with over 5000 patients at the Center for Sexual Medicine using self-injection therapy as a successful, reliable strategy for the treatment of ED. Self-injection therapy is based on the physiologic understanding of the mechanism of penile erection. The key to self-injection therapy is that the injected medications induce sustained penile smooth muscle relaxation.

Self-injection therapy is indicated for erectile dysfunction that is unresponsive to oral agents, psychologic therapy, vacuum constrictive device therapy, and where other therapies are not considered safe or appropriate (e.g. a man who is on nitroglycerine is not a candidate for treatment by oral pill use). Typical clinical situations where a man with ED problems would consider self-injection therapy includes ED after prostate cancer treatment, ED after low spinal cord injuries, ED with multiple sclerosis, ED with Peyronie’s disease, ED with accompanying venous leak (veno-occlusive dysfunction).

A typical injection involves use of a 30 or 31 gauge insulin needle. The medication typically utilized consists of various combinations and doses of three agents: papaverine hydrochloride, phentolamine mesylate and prostaglandin E1. Prostaglandin E1 alone (Caverject, Edex) is an FDA approved therapy for ED. Individual patients usually need a series of office injections to identify which agent (s) work best for them, with the goal being to obtain a functionally rigid erection for approximately 30 – 60 minutes. The major complication is a sustained erection lasting more than 4 hours. For this situation, injection of the antedote, phenylephrine, leads to detumescence of the erection.

Oncology Connection

We have been working with Dr. Michael Krychman of Memorial Sloan Kettering Cancer Institute in New York to develop an oncology sexual health program at Boston Medical Center similar to the one at Memorial. Dr. Krychman meets with oncology patients before their cancer therapy to discuss their sexual health and the consequences of their oncologic therapy. He then meets with them after the fact to treat their sexual dysfunction. This sexual health program helps make both the patient and the oncologist aware of potential sexual health issues, making expectations realistic, and allows Dr. Krychman to reassure the patient of available sexual dysfunction therapies. Dr. Goldstein is working with Dr. Doug Faller, Director of the Cancer Center, and Dr. Michael Stone, Chairman of Oncologic Surgery at Boston Medical Center to lay the groundwork for this kind of program at BMC, especially in view of the building of the Moakley Cancer Center on the Boston University Medical Campus.

Sexual Medicine Meetings

Drs. Munarriz and Goldstein have just returned from the annual meeting of the American Urological Association held this year in San Francisco. Dr. Goldstein had an opportunity to speak on Female Sexual Dysfunction to approximately 5000 urologists and allied health professionals. This was undoubtedly the largest attendance to date at a lecture on the topic of sexual dysfunction in women. Dr. Goldstein also spoke at the meeting of the Sexual Medicine Society, held on the first day of the AUA. Dr. Suzette Sutherland presented a poster on research she conducted with Drs. Goldstein and Munarriz while she was training at the Institute for Sexual Medicine. This was the first identification of androgen receptors in the vestibular glands and the recognition that there are glands that are androgen dependent within the vestibule. Also presented at the AUA were two non-pharmaceutical company funded preference trials, one by Dr. Hartmut Porst and one by Dr. Frank Sommer, both of Germany, of head to head to head trials among the 3 PDE5 inhiibitors, sildenafil, tadalafil and vardenafil. They showed preferences of one drug over another in various categories. The conclusion is that patients should consider all 3 drugs. The AUA is the largest annual gathering of urologists in the world.

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.