Newsletter – Vol. 3 No. 4

December 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

This has been a productive fall in the Institute for Sexual Medicine, with well-deserved recognition being given to some of our faculty and staff. Dr. Stanley Ducharme recently received an award for his contributions in the area of sexual health for people with spinal cord injury. It was presented by an organization of psychologists and social workers affiliated with Paralyzed Veteran’s of America. Sue Goldstein, Coordinator of Education and Development, was presented with an honorary membership to the International Society for Sexual Medicine in recognition for her work with The Journal of Sexual Medicine on behalf of the society. In addition, Sue and I were each presented with the Distinguished Service Award by the International Society for the Study of Women’s Sexual Health. I am also pleased to announce that our IRB Consultant, Linda Frattura, has completed and earned certification as a Certified Clinical Research Professional (CCRP).

While we are still awaiting construction within our space, you may notice some modifications we are in currently undergoing to make our facility more comfortable for both our patients and staff. We appreciate your patience during this time.

Upcoming Events

Plans are currently underway for CME courses in Female Sexual Dysfunction for health care providers. Updated information about the seminar will be posted on our website as soon as it is available.

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 The Most Common Female Sexual Dysfunction: Low Interest on January 11, 2005 and Sexual Dysfunction in Men on February 15, 2005. Please check our website to confirm, as dates and topics are occasionally changed. Summaries of recent programs are listed here: for more detailed information please refer to the Institute for Sexual Medicine website https://www.bumc.bu.edu/sexualmedicine/informationsessions.

The Implant Story: Men Surviving ED was presented in September by Dr. Ricardo Munarriz. Introduced in the 1970’s, implants are considered a third line therapy for erectile dysfunction. There are 3 types of penile prosthesis: malleable, two-piece and three-piece devices. The advantages of the malleable are that this single component surgery takes only 30 minutes to place in a man whose penile erectile tissue is not scarred. The disadvantage is that the patient appears to have a rigid penis all the time. It is often utilized as a temporary implant in patients who have severe scarring. Six months following surgical insertion, the malleable implant is removed and the three piece inflatable may be placed.

The advantages of the two-piece inflatable prosthesis are that the surgery is relatively easy to place, the device consists of only two components, provides good rigidity and is easy to use. The disadvantage is that the erection is less rigid in the erect state and less flaccid in the baseline state compared to a three-piece prosthesis.

The three-piece inflatable prosthesis is the gold standard of implants. It is made up of 2 cylinders placed in the erection chambers, a reservoir placed near the bladder, and a pump placed inside the scrotum. The girth of the cylinders is greater than in the two-piece. This type of implant is the most commonly utilized as it is the most cosmetic.

All implant surgery is performed through a 2 cm incision in the scrotum, and takes less than an hour normally. Infection, the major complication, occurs in 1 – 3% of cases. In that case the surgeon may either remove the implant, replacing it once the penis has healed, or perform a salvage procedure, which is successful in 70% of cases. Penile implant complications include: implanting an undersized prosthesis, developing a malfunctioning prosthesis, experiencing an anesthetic complication and having inappropriate patient expectations. The new protheses are extremely reliable, allowing for many years of satisfactory sexual relations.

Sexual Pain in Women was the program for October 5, 2004. It is believed that 14,000,000 women in the US are affected by sexual pain. Sexual pain occurs in 16% of women. If the person has a partner, it is important that the partner participate in the therapy. While the physician can treat many aspects, the mechanics of actually having intercourse is something that can be addressed with both the patient and the partner. Physical Therapist Holly Herman spoke about the gamut of pain and showed some of the tools she uses with patients who have pain with or after penetration. Sensors can be attached to muscles for biofeedback, allowing for strategies to increase strength in weak pelvic floor muscles or decreasing tone in tight muscles. A TENS unit can block the pain by sending a light touch to the same place as the pain. One problem could be that the mechanics of trying to have intercourse do not work properly (the hip doesn’t open up for instance). Patients can use dilators of gradual sizes to learn to relax, especially utilized after surgical removal of inflamed vestibular glands. Dilators are otten used in conjunction with biofeedback to enable more efficient muscle stretching. If the muscles are weak, one cannot attain orgasm, so increasing muscle strength can make intimacy more pleasurable. On average most people learn to do things on their own at home within 3 weeks, with intercourse anywhere from 3 months post surgery to a year.

Dr. Goldstein explained that while there are psychology/ relationship issues with pain, his focus would be on the biologic causes. One common location for sexual pain is in the vestibule, the opening to the vagina, bound by the labia minora. In the vestibule there are minor vestibular glands that are likely dependent on androgens (testosterone) for structure and function. While a questionnaire can ask people about sexual function and distress, a genital exam is required for dyspareunia or vaginismus. The physician should first inspect the region closely with surgical loupes for magnification. Examine should then proceed with Q-tip testing. A single digital exam can also help localize pathology.

There are many different areas in the vestibule that can cause pain, and patients may have one or several of these areas of pain. The clitoris is covered by a retractable prepuce. In women with scarring of the prepuce, skin secretions, smegma, can collect under the prepuce, or a fungal infection (balanitis) may develop. Other problems include a tumor (fibroepithelioma) , sebaceous cyst or neuroma. An inflamed urethral meatus can cause pain. The Skene’s glands near the meatus can be blocked and irritated, and the vagina can prolapse without the estrogen support. The labia majora can have dermatitis conditions such as lichens sclerosis. Bartholin’s glands may develop into painful Bartholin’s cysts. Low sex steroid (estrogen, progesterone, androgen) hormone states can lead to atrophy with labia minora fusing to labia majora. Treatments vary according to the problem.

The lecture for the November program Sexual Dysfunction in Men was given by Dr. Munarriz. He explained that problems with sexual response in men can include desire, arousal, orgasm or ejaculation. While premature ejaculation is the most common problem, erectile dysfunction is the most common complaint among men presenting to our clinic. Traditionally considered a psychological condition, there are biologic causes as well. Other ejaculatory problems include delayed ejaculation which could be the result of spinal cord injury, certain medications, alcohol abuse or psychological issues; anejaculation which is the condition whereby a man is unable to ejaculate; retrograde ejaculation from medication or as a result of the surgical procedure TURP; and problem diminished ejaculatory volume. Treatments for premature ejaculation include the use of lidocaine, SSRI’s in conjunction with a PDE5 inhibitor.

Risk factors for erectile dysfunction include anything that is associated with hardening of the arteries. Each cardiovascular risk factor increases the risk of ED. Alternatively, ED may be a result of perineal trauma from bike riding (more than 3 hours/week increases the risk of ED) or a blow to the perineum.

The physician should help the patient with ED by first modifying any reversible causes, such as increasing exercise or lowering cholesterol. It is important to remember that whatever is happening to the arteries in your penis is also happening to the arteries in your heart. A major reason for arousal problems is hypogonadism, implying that testosterone levels are low. Testosterone can modulate erectile function and orgasmic function, as well as improve sexual desire and the quality of erections. First line ED therapies include PDE5 inhibitors and the vacuum constrictive device.. PDE5 inhibitors will manage most patients with mild to moderate ED. While sildenafil (Viagra) is the gold standard, the patient should also try vardenafil (Levitra) and tadalafil (Cialis). Second line therapies include intracavernosal self-injection of combination therapy or pre-mixed products and intraurethral pharmacotherapy. The penile prosthesis is a very effective third line therapy.

Sexual Medicine Meetings

This fall our faculty has been busy attending international meetings on sexual medicine. The International Society for Sexual Medicine met in October in Buenos Aires, Argentina. Drs. Goldstein, Kim, Munarriz and Traish were all on the faculty of the meeting. One week later Drs. Goldstein, Munarriz and Traish attended the annual meeting of the International Society for the Study of Women’s Sexual Health in Atlanta, Georgia where they again each made presentations.

Attending these world congresses allows our faculty to learn what is happening in the field in other institutions, and engage in dialogue with other experts so that they are able to continue state of the art care for you, the patient, as well as cutting edge research which will eventually translate into even better therapies.

Editorial

You may occasionally hear about the medicalization of sexual dysfunction. What this means is that the drug companies are promoting a disease state so that they may sell their drugs where a need does not really exist. We at the Institute for Sexual Medicine are well aware that a need does exist, that sexual dysfunction has biologic etiologies as well as psychologic and relationship ramifications. While journalists put their energies into criticizing the drug industry the government is taking their cue from the journalists and reducing funding in the area of sexual medicine research. The government feels it is the responsibility of industry, namely the drug companies, to fund research in this area. While those companies are happy to fund studies that show their drugs are better or faster or stronger, there is little money available for academic research centers to learn the physiology of sexual function, particularly at this time in the woman. Facilities such as ours depend more and more on the good graces of benefactors, especially patients. Donations to the Institute for Sexual Medicine are put into a dedicated fund to be used strictly for research purposes. If your life has been made better from treatment, remember others who are still distressed and consider making a donation to sexual medicine research.

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.