Catrina C. Crisp

Clitoral Size and Location in Relation to Sexual Function Using Pelvic MRI

INTRODUCTION The female sexual response is dynamic; anatomic mechanisms may ease or enhance the intensity of orgasm. AIM The aim of this study is to evaluate the clitoral size and location with regard to female sexual function. METHODS This cross-sectional TriHealth Institutional Board Review approved study compared 10 sexually active women with anorgasmia to 20 orgasmic women matched by age and body mass index (BMI). Data included demographics, sexual history, serum hormone levels, Prolapse/Incontinence Sexual Questionnaire-12 (PISQ-12), Female Sexual Function Index (FSFI), Body Exposure during Sexual Activity Questionnaire (BESAQ), and Short Form Health Survey-12. All subjects underwent pelvic magnetic resonance imaging (MRI) without contrast; measurements of the clitoris were calculated. MAIN OUTCOME MEASURES Our primary outcomes were clitoral size and location as measured by noncontrast MRI imaging in sagittal, coronal, and axial planes. RESULTS Thirty premenopausal women completed the study. The mean age was 32 years (standard deviation [SD] 7), mean BMI 25 (SD 4). The majority was white (90%) and married (61%). Total PISQ-12 (P < 0.001) and total FSFI (P < 0.001) were higher for orgasmic subjects, indicating better sexual function. On MRI, the area of the clitoral glans in coronal view was significantly smaller for the anorgasmic group (P = 0.005). A larger distance from the clitoral glans (51 vs. 45 mm, P = 0.049) and body (29 vs. 21 mm, P = 0.008) to the vaginal lumen was found in the anorgasmic subjects. For the entire sample, larger distance between the clitoris and the vagina correlated with poorer scores on the PISQ-12 (r = -0.44, P = 0.02), FSFI (r = -0.43, P = 0.02), and BESAQ (r = -0.37, P = 0.04). CONCLUSION Women with anorgasmia possessed a smaller clitoral glans and clitoral components farther from the vaginal lumen than women with normal orgasmic function.

Robotic virtual reality simulation plus standard robotic orientation versus standard robotic orientation alone: a randomized controlled trial.

Objective The objective of this study was to compare the effect of virtual reality simulation training plus robotic orientation versus robotic orientation alone on performance of surgical tasks using an inanimate model. Methods Surgical resident physicians were enrolled in this assessor-blinded randomized controlled trial. Residents were randomized to receive either (1) robotic virtual reality simulation training plus standard robotic orientation or (2) standard robotic orientation alone. Performance of surgical tasks was assessed at baseline and after the intervention. Nine of 33 modules from the da Vinci Skills Simulator were chosen. Experts in robotic surgery evaluated each resident’s videotaped performance of the inanimate model using the Global Rating Scale (GRS) and Objective Structured Assessment of Technical Skills—modified for robotic-assisted surgery (rOSATS). Results Nine resident physicians were enrolled in the simulation group and 9 in the control group. As a whole, participants improved their total time, time to incision, and suture time from baseline to repeat testing on the inanimate model (P = 0.001, 0.003, <0.001, respectively). Both groups improved their GRS and rOSATS scores significantly (both P < 0.001); however, the GRS overall pass rate was higher in the simulation group compared with the control group (89% vs 44%, P = 0.066). Conclusions Standard robotic orientation and/or robotic virtual reality simulation improve surgical skills on an inanimate model, although this may be a function of the initial “practice” on the inanimate model and repeat testing of a known task. However, robotic virtual reality simulation training increases GRS pass rates consistent with improved robotic technical skills learned in a virtual reality environment.

Impact of physical therapy on quality of life and function after vaginal reconstructive surgery.

Objectives Although pelvic floor physical therapy (PFPT) can be beneficial for complaints after vaginal reconstructive surgery, it is not routinely offered to all patients. We sought to evaluate the role of perioperative PFPT in improving quality of life and function after prolapse repairs. Methods This randomized controlled trial compared PFPT to standard care after vaginal reconstructive surgery. The intervention group received PFPT 2 weeks preoperatively and 2, 4, 6, 8, and 12 weeks postoperatively, as well as a physician assessment. Control subjects underwent a physician’s assessment alone at the same time points postoperatively. Both groups completed pelvic organ prolapse quantification examinations, intravaginal electromyography (EMG), voiding diaries, and validated questionnaires at baseline and 12 weeks. The primary outcome was change in the World Health Organization Quality of Life-BREF scale after surgery. Results Forty-nine women completed the study: 24 women in the PFPT group and 25 women in the control group. At 12 weeks, condition-specific questionnaires improved for the entire sample, confirming effectiveness of surgery. Nevertheless, no significant differences were noted between the groups despite therapy with PFPT. However, intravaginal EMG measures were notably affected by the intervention. The PFPT group showed significantly lower averages across all measurements of rest, indicating positive impact on muscle function. Pearson correlations revealed associations with better scores on the World Health Organization Quality of Life-BREF physical domain and greater EMG relaxation, supporting effects from PFPT on quality of life. Conclusions Pelvic symptoms improved in all subjects after vaginal reconstructive surgery. Whereas PFPT did not result in detectable subjective differences in this short-term study, superior muscular function suggested benefit from the intervention.

Histologic and Cytologic Effects of Vaginal Estrogen in Women With Pelvic Organ Prolapse: A Randomized Controlled Trial

Objective This study aimed to evaluate the histologic and cytologic effects of preoperative vaginal estrogen in women with atrophic vaginitis and pelvic organ prolapse. Methods Forty-two women with atrophic vaginitis and stage greater than or equal to 2 prolapse were enrolled in this assessor-blinded randomized controlled trial comparing daily vaginal estrogen cream use for 2 to 12 weeks preoperatively versus no intervention. Data were analyzed using t test and analysis of variance. Results Of these 42 women, 22 received treatment and 20 were controls. After a mean 7 (3) weeks of use, the vaginal maturity index increased 15.5% in the treatment group and declined 1.5% in the control group (P < 0.001). The vaginal epithelial thickness was 339 (96) &mgr;m in the treatment group compared to 302 (119) &mgr;m (P = 0.275) in the controls. Conclusions Preoperative vaginal estrogen application for 2 to 12 weeks restores vaginal cytology to premenopausal levels, but does not increase vaginal epithelial thickness in women with prolapse.

Innervation and Histology of the Clitoral–Urethal Complex: A Cross-Sectional Cadaver Study

INTRODUCTION Despite its central role in sexual function, we lack a description of the nerve distribution and histology for the central components of the clitoris. AIM This study aims to characterize microscopic anatomy of the clitoral-urethral complex (CUC) and aid our understanding of sexual sensation METHODS The CUC was excised from three female fresh-frozen cadavers en bloc and prepared in 5-μm longitudinal sections with hematoxylin and eosin and S100 immunohistochemistry for neural elements. Approximately 20 sections were obtained from each specimen. On low power microscopy, the 30 most innervated fields on each section were identified. On high power, the total number of nerves per field was quantified, then was averaged. The histologic characteristics of each clitoral component were described. Two investigators evaluated all specimens. MAIN OUTCOME MEASURES Descriptives of large (≥3 fibers) and small nerves based on location in the CUC. RESULTS Nerve quantification revealed the glans to be the most populated by small nerves (52.1, standard deviation [SD] 26.2). As slices through each specimen moved caudad toward the urethra, the number of small nerves dramatically decreased from 40.4 (SD 10.8) in the body and 29.8 (SD 8.8) (superior CUC) near the bulb to 23.7 (SD 9.8) in the middle CUC and 20.5 (SD 10.4) (inferior CUC) near the urethra. Although the variation in small nerves was striking, large nerves were somewhat uniform and comprised a minority of the overall quantity. Neuroanatomy was consistent for all cadaver specimens. CONCLUSIONS Our study provided a description of the nerve distribution throughout the central CUC. Increased density of small nerves in the glans suggests this is the location of heightened sensation. Decreasing quantity of nerves in segments closer to the urethra may indicate these zones are less important for sexual sensation. Knowledge of human clitoral innervation is important for understanding the complexities of the female sexual response cycle.

Is Female Sexual Dysfunction Related to Personality and Coping? An Exploratory Study

Introduction Sexual disorders impact up to 43% of women. However, the relationship between sexual dysfunction and psychological variables such as personality traits and coping mechanisms is not well understood. Aim To examine personality domains and coping strategies utilized by women with sexual dysfunction in a clinical sample. Methods Patients seeking care for female sexual dysfunction (FSD) from a sexual medicine specialist were identified using International Classification of Diseases, Ninth Revision codes. Packets containing informed consent, Female Sexual Function Index (FSFI), Female Sexual Distress Scale-Revised (FSDS-R), Ten Item Personality Index (TIPI), and Brief COPE were mailed to subjects. Main Outcome Measures Correlations among FSFI, FSDS-R, TIPI, and Brief COPE. Results Of 79 eligible subjects, 50 (63.2%) returned completed questionnaires. The mean age was 40 years (standard deviation 14). Total FSFI and FSDS-R scores confirmed FSD. Correlations between the FSFI and TIPI illustrated trends with the domain of extraversion, suggesting better function in those exhibiting more of this trait (r = 0.285, P = 0.079). Similarly, FSDS-R scores correlated with openness to experience (r = −0.305, P = 0.037) and approached significance for extraversion (r = −0.258, P = 0.080), indicating lower distress in such personality types. When assessing the Brief COPE, use of emotional support, a positive coping strategy, correlated with better orgasm (r = 0.303, P = 0.048) and higher satisfaction (r = 0.331, P = 0.03). Finally, when evaluating TIPI with COPE scores, several significant associations were noted, establishing that personality may influence these adaptive behaviors. Conclusion Many notable relationships between sexual function, personality, and coping are presented. These support a role for consideration of psychological variables when evaluating women presenting for sexual dysfunction. Crisp CC, Vaccaro CM, Pancholy A, Kleeman S, Fellner AN, and Pauls R. Is female sexual dysfunction related to personality and coping? An exploratory study. Sex Med 2013;1:69–75.

Patient-controlled versus scheduled, nurse-administered analgesia following vaginal reconstructive surgery: a randomized trial

OBJECTIVE To determine whether patient-controlled analgesia or scheduled intravenous analgesia provides superior pain relief and satisfaction with pain control after vaginal reconstructive surgery. STUDY DESIGN Fifty-nine women scheduled for vaginal reconstructive surgery were enrolled in this randomized trial. Operative procedures and postoperative orders were standardized. Visual analog scales for pain and satisfaction with pain control were recorded during the hospital stay and 2 weeks after surgery. RESULTS Patients receiving patient-controlled analgesia had less pain on postoperative day 1, 25 mm vs 39 mm, on visual analog scales (P = .007). Although this group used twice as much hydromorphone (3.57 mg vs 1.48 mg, P < .001), there was no difference in side effects, length of hospital stay, or complications. For the sample overall, larger amounts of narcotic used correlated with higher pain scores (r = 0.364, P = .009) and worse satisfaction scores (r = -0.348, P = .012). CONCLUSION In patients undergoing vaginal surgery, patient-controlled analgesia offers superior pain relief on postoperative day 1 when compared with scheduled, nurse-administered hydromorphone.

The Influence of Personality and Coping on Female Sexual Function: A Population Survey

INTRODUCTION Female sexual dysfunction (FSD) is a common disorder with limited data investigating relationships with psychological influences, such as personality traits and coping mechanisms. AIM To investigate the relationship and impact of personality traits and coping strategies on female sexual function. METHODS A web-based survey was distributed to a sample of women representative of the areas demographic distribution. MAIN OUTCOME MEASURES Participants completed the Female Sexual Function Index (FSFI), the Ten Item Personality Index (TIPI), and the Brief COPE. RESULTS Five hundred twenty-six females responded. The mean total FSFI score was 24.56 (SD 6.77) with lowest scores in the desire domain. Personality scores were similar to published normative values. Subjects displaying stronger tendencies for introversion (r = 0.246, P < 0.001), not being open to new experiences (r = 0.159, P = 0.008), and emotional instability (r = 0.244, P < 0.001) were found to have significantly worse sexual function. Conscientiousness was significantly associated with better desire, orgasm, satisfaction, and total FSFI score (P = 0.029, P = 0.002, P = 0.005, P = 0.003). Moreover, the utilization of negative coping strategies such as self-blame, self-distraction, and behavioral disengagement, significantly correlated with poor sexual function (r = -0.298, P < 0.001, r = -0.360, P < 0.001, r = -0.398, P < 0.001, respectively). CONCLUSION Personality and coping are linked to sexual function with introversion, not being open to new experiences, emotional instability, and the utilization of negative coping strategies being significantly associated with poor sexual function. Women presenting with sexual function complaints may need further evaluation of their personality and coping strategies in order to mitigate any negative impact of these tendencies.

Effects of dexamethasone on quality of recovery following vaginal surgery: a randomized trial

OBJECTIVE Dexamethasone is a corticosteroid with minimal side effects that may improve quality of recovery. We sought to evaluate standard use of this medication prior to vaginal reconstructive surgery. STUDY DESIGN This was a double-blind, randomized, placebo-controlled trial of women undergoing vaginal reconstructive surgery for pelvic organ prolapse. Patients scheduled for an intraperitoneal vaginal vault suspension, with general anesthesia and an overnight stay, were enrolled. The intervention arm received dexamethasone 60 minutes prior to surgery, and controls received placebo. Postoperative pain medications, antiemetics, and voiding trials were standardized. Our primary outcome was the difference in Quality of Recovery (QoR-40) scores on postoperative day 1. Secondary measures included Postoperative Nausea and Vomiting Intensity scores, and visual analog scales for nausea/vomiting, and pain. Our power calculation demonstrated 31 subjects in each group would be necessary to document difference in QoR-40 scores; to allow for attrition, a goal of 74 subjects was set. RESULTS Seventy-four women were enrolled and randomized. Two withdrew, 9 were excluded, and 63 were analyzed (36 placebo, 27 dexamethasone). The mean age was 63 years. No significant differences were noted among demographics other than American Society for Anesthesiologists class; there were greater numbers of dexamethasone subjects that were class 3 (5 vs 11; P = .030). Postoperatively, more patients in the placebo group required promethazine as a rescue antiemetic for control of their nausea/vomiting (11 vs 2; P = .029). Placebo subjects also failed their voiding trials more frequently, which remained following a logistic regression controlling for suburethral sling (30 vs 15; P = .037). Regarding the QoR-40 following surgery, the emotional state domain declined less in dexamethasone patients (-14.3, interquartile range [IQR], 16.8 vs -4.6, IQR, 20.1; P = .042), indicating better symptoms. Whereas pain scales were similar, the visual analog scales for nausea/vomiting was lower in dexamethasone subjects (0.7; IQR, 4.1 vs 0.4; IQR, 1.4; P = .042). Postoperative Nausea and Vomiting Intensity scores were not significantly different; nevertheless, twice as many placebo subjects had severe range symptoms (4 vs 2; P = .47). No adverse effects from the dexamethasone were noted. CONCLUSION Use of dexamethasone prior to vaginal reconstructive surgery was associated with less nausea/vomiting and need for antiemetics as well as greater success with voiding trials. Furthermore, quality of recovery was enhanced, suggesting use of dexamethasone should be considered for these patients.

Acupuncture in Premenopausal Women With Hypoactive Sexual Desire Disorder: A Prospective Cohort Pilot Study

Introduction Female sexual dysfunction affects up to 43% of women in the United States and hypoactive sexual desire disorder (HSDD) is the most common type; however, we lack treatment options showing improvement for this condition. Aims To investigate whether acupuncture therapy could improve HSDD. Methods Premenopausal women with a primary diagnosis of HSDD were included in a single-arm prospective pilot study that was approved by the institutional review board. After providing informed consent, subjects completed validated questionnaires. Participants underwent 25-minute twice-weekly acupuncture sessions for 5 weeks with one certified acupuncturist. Questionnaires were completed again 6 weeks after onset of treatment. Main Outcome Measures Based on a statistically significant change in the desire domain of the Female Sexual Function Index from 2.0 (at baseline) to 2.4 (after intervention with a specialist) in our population of patients diagnosed with HSDD, a sample of 13 was determined, with 90% power and α 0.05. Results Fifteen women were enrolled and 13 completed the study. Mean age was 36.9 ± 11.4 years. Most were white (n = 9, 60%), heterosexual (n = 15, 100%), and non-smokers (n = 14, 93%). Most were sexually active more than four times per month (n = 8, 53%) and none had a history of sexual abuse (n = 15, 100%). Participants received a mean acupuncture needle application of 17 ± 2 at each session. Sexual function improved after intervention, particularly desire (2.1 ± 0.6 to 3.3 ± 1.2, P < .0001), arousal (P < .0001), lubrication (P = .03), and orgasm (P = .005). Conclusion In this cohort of premenopausal women with HSDD, 5 weeks of acupuncture therapy was associated with significant improvements in sexual function, particularly desire. This supports a role for acupuncture as a therapeutic option for women with low desire.