Mels F. van Driel

Male sexuality after cancer treatment - needs for information and support : testicular cancer compared to malignant lymphoma

Testicular cancer (TC) as well as malignant lymphoma (ML), both have nowadays an excellent prognosis. However, both types of cancer may be diagnosed at young adulthood and patients may experience sexual concerns. In this article the need for information and support concerning sexuality will be explored, and the traumatic impact of cancer diagnosis with respect to this will be considered. A total of 264 patients with testicular cancer, median age 36 (S.D. 9.7) years, and 50 patients with malignant lymphoma, median age 42 (S.D. 11.7) years returned a questionnaire concerning sexual functioning; four items assessed the need for information or support concerning sexuality, at diagnosis and at follow-up. It appeared that more than half of the patients with testicular cancer reported a lack of information and support concerning sexuality during treatment; 67% of them still had a need for information at follow-up. These rates were significantly lower for patients with malignant lymphoma. Especially patients with testicular cancer who suffered sexual dysfunction reported extremely high needs for information and support. According to these findings it can be concluded that more attention should be paid to the doctor-patient communication with respect to sexual concerns in general, and especially where it concerns patients with testicular cancer.

Long-term results of an individualized, multifaceted, and multidisciplinary therapeutic approach to provoked vestibulodynia.

INTRODUCTION Although it is highly recommended to use a multifaceted approach to treat provoked vestibulodynia (PVD), the large majority of treatment studies on PVD used a one-dimensional approach. AIM To evaluate the long-term treatment outcome of a multifaceted approach to vulvar pain, sexual functioning, sexually related personal distress, and relational sexual satisfaction in women with PVD. METHODS Retrospective questionnaire survey 3-7 years after treatment. MAIN OUTCOME MEASURES Sexual functioning, sexually related personal distress, and relational sexual satisfaction were measured using the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS), and the Dutch Relationship Questionnaire (NRV), respectively. An additional questionnaire assessed socio-demographic variables, intercourse resumption, and the level to which the women would recommend the treatment to other women with PVD. Post-treatment vulvar pain scores were obtained using a visual analog scale (VAS). Pretreatment scores were reported in retrospect on a separate VAS. RESULTS The questionnaires were completed by 64 out of 70 women (91%). Mean follow-up was 5 years (range 3-7). Comparison of the mean pretreatment and post-treatment VAS scores showed a significant reduction in vulvar pain. Pain reduction was reported by 52 women (81%), whereas no change and pain increase were reported by 7 women (11%) and 5 women (8%), respectively. Post-treatment, 80% of the women had resumed intercourse. Only 5 women (8%) reported completely pain-free intercourse. Comparisons with age-related FSFI and FSDS Dutch norm data showed that scores for sexual functioning in the study group were significantly lower, while scores for sexually related personal distress were significantly higher. There were no significant differences in relational sexual satisfaction ratings between the study group and the NRV Dutch norm data. CONCLUSION These retrospective data on long-term treatment outcome support the hypothesis that a multifaceted approach to PVD can lead to substantial improvements in vulvar pain and the resumption of intercourse.

Endourological management of ureteral obstruction after renal transplantation

PURPOSE We evaluated endourological treatment of ureteral obstruction after renal transplantation. MATERIALS AND METHODS Between January 1986 and December 1993, 582 kidney transplantations were performed at our center, and ureteral obstruction was suspected in 31 cases (5.3%). RESULTS Initial treatment consisted of retrograde placement of an internal stent in 6 patients and percutaneous nephrostomy in 25. Due to upper tract dilatation obstruction could not be diagnosed in 3 patients, and rejection was the cause of decreasing renal function. Obstruction was temporary in 8 of the remaining 28 patients, including 6 in whom a Double-J stent was introduced in a retrograde manner without anesthesia. In the other 2 patients was well as the 20 with definitive obstruction, cannulation of the transplant orifice without anesthesia was unsuccessful and percutaneous nephrostomy drainage was necessary. Even with general anesthesia a guide wire could not be passed along the stricture in a retrograde or antegrade fashion in 7 of the 20 patients with definitive obstruction and open surgery was performed. The remaining 13 patients underwent dilation with (9) or without (4) diathermic incision. All 4 patients treated with dilation only had recurrent obstruction, while 9 treated with dilation and incision had no recurrence after a minimum followup of 27 months (mean 58). CONCLUSIONS Modern endourological procedures have replaced open reconstructive surgery in the majority of patients with ureteral obstruction after renal transplantation.

The place of female sexual dysfunction in the urological practice: results of a Dutch survey.

INTRODUCTION Female sexual dysfunction (FSD) is a highly prevalent and often underestimated problem. There is a strong association between urological complaints and FSD. AIMS The purpose of this survey was to evaluate how Dutch urologists address FSD in their daily practice. METHODS We performed an anonymous survey study. A 17-item anonymous questionnaire was mailed to all 405 registered members of the Dutch Urology Association (urologists and residents in urology). MAIN OUTCOME MEASURES The survey results. RESULTS. One hundred eighty-six complete surveys of eligible respondents were returned (45.9% response rate). Ten respondents (5.5%) stated that they ask each female patient for sexual function; 87.1% stated that they ask for sexual function when a patient complains about lower abdominal pain (87.2%), incontinence (75.8%), urgency or frequency (70.5%), or urinary tract infections (65.8%). Many respondents (40.3%) do not think that FSD is meaningful in a urological practice. The majority of respondents (91%) underestimate the frequency of FSD in a urological clinic. Respondents who believe the frequency of FSD to be at least 30% tend to ask more often for sexual function than the rest of the group (P = 0.08). CONCLUSION Overall, many urologists do not consistently ask each female patient for sexual function and underestimate the prevalence of FSD. For the majority of the members of the Dutch Urological Association, FSD is not part of routine urological practice. There is, therefore, a need for better implementation of education and training at both undergraduate and postgraduate levels.

The treatment of sleep-related painful erections

INTRODUCTION As specialists in male genital problems, urologists and sexologists will most likely to be involved in the treatment of males presenting with sleep-related painful erections (SRPEs). This means that this phenomenon needs to be recognized by urologists and sexologists, and that they should have knowledge of the current diagnostic and therapeutic approaches. Aim. To review the literature on SRPE and to find the best pharmacological treatment. Methods. Four personal clinical observations from two clinics and 29 other cases with SRPE found in PubMed were analyzed, especially regarding the results of pharmacological treatment. MAIN OUTCOME MEASURES The results of pharmacological treatment. RESULTS Many of the various treatments proved to be ineffective and only a few showed efficacy for a few weeks or months. The only effective drugs in the long term were baclofen, clonazepam, and clozapine. CONCLUSIONS Until now, the phenomenon of SRPE is not well understood. The rarity of the published cases undoubtedly does not reflect the actual occurrence of SRPE. Controlled double-blind pharmacological trials are needed, and long-term follow-up including polysomnography coupled with nocturnal penile tumescence and rigidity monitoring may provide further information about SRPE.

Female Sexual Abuse Evaluation in the Urological Practice: Results of a Dutch Survey

INTRODUCTION There is a strong association between urological complaints and a history of sexual abuse, especially in females. It is not known whether urologists integrate these facts in their daily practice. AIM To evaluate whether Dutch urologists address the issues of sexual abuse in their female patients and to evaluate their perception of sexual abuse prevalences. METHODS A five-item anonymous questionnaire was mailed to all 405 registered members of the Dutch Urology Association (urologists and residents). MAIN OUTCOME MEASURES The results of the survey. RESULTS One hundred eighty-six surveys of eligible respondents were returned (45.9% response rate). A total of 68.8% stated that they always ask their female patients about sexual abuse before doing the physical examination. Overall, 79.3% said to do so when a patient has certain urological complaints: 77.6% in case of lower abdominal pain, 62.1% in urgency or frequency, 41.4% in incontinence, 29.3% in urinary tract infections, and 3.4% in hematuria. The majority of the respondents (74.3%) estimated the frequency of sexual abuse in their urological clinic to be equal or less than 10%. CONCLUSION Nearly 70% of the responding Dutch urologists and residents ask their female patients about possible sexual abuse. They estimate the frequency of sexual abuse in their female patients to be equal or less than 10%.

Prevalence of Sexual Abuse among Patients Seeking General Urological Care

INTRODUCTION Sexual abuse (SA) history can be found in the backgrounds of an important fraction of men (8-10%) and women (12-25%). Until now there are no data about this prevalence within a urological patient population. AIM To establish the prevalence of SA among men and women visiting a urological outpatient clinic and to assess their opinion on screening for SA by urologists. METHODS A questionnaire to identify SA was translated into Dutch, English, and Turkish, and was adjusted for use in men. These questionnaires were anonymously distributed among 1,016 adult patients attending the urological outpatient clinic. MAIN OUTCOME MEASURE The self-reported prevalence of SA. Secondary outcome measures were data about the assailant, victims age at the time of the abuse, if the abuse was disclosed to the urologist, if the urologist had asked for SA, and patient opinions on standard screening for SA in urological care. RESULTS A total of 878 questionnaires were returned, giving a total response rate of 86.4% (878/1,016). Thirty-three patients refused to participate. This resulted in 845 filled-out questionnaires suited for analysis (845/1,016 = 83.2%). There were more male (75.7%) than female respondents (21.8%); 2.1% (13/624) and 13.0% (21/161) of the male and female respondents reported a history of SA, respectively. Almost 42% reported a stranger as assailant. In nearly 90%, the SA took place before adulthood: 56.2% in childhood and 31.2% in adolescence. Fifteen percent of the respondents with SA had it disclosed to their urologist. More than 70% of the abused respondents considered the idea to screen for SA in urological practice to be a good one. CONCLUSIONS The prevalence of SA in patients seeking urological care in the Netherlands is 2.1% for men and 13.0% for women.

Sleep-Related Erections Throughout the Ages

INTRODUCTION The occurrence of sleep-related erections (SREs) has been known since antiquity. AIM To highlight historical, theological, and sexual medicine-related aspects of SREs throughout the ages. METHODS Review of old medical books on male sexual functioning and review of scientific medical and theological articles on SREs from about 1900 on. RESULTS The cyclic character of SREs was first noted by German researchers in the forties of the 20th century. However, already before the beginning of the Christian era, one knew that men had erections and ejaculations during sleep. In the Middle Ages, SREs were generally considered to be rebellious manifestations of the male body, while it seemed to disobey its owner and showed up its perverted and sinful side. From the fifteenth to the end of the 17th century, severe erectile dysfunction (ED) was ground for divorce. The ecclesiastical court records show that if necessary, the members of the jury sat at the defendants bedside at night to be able to judge any SREs occurring. Since the 17th century, SREs were considered to be part of masturbation, which could cause many ailments and diseases. Psychoanalyst Stekel acknowledged in 1920 that a morning erection, the last SRE, is a naturally occurring phenomenon in healthy men from infancy to old age. Today, some scientists assume that SREs protect the integrity of the penile cavernous bodies. CONCLUSIONS Throughout the ages, philosophers, theologians, physicians, members of ecclesial law courts, psychoanalysts, psychiatrists, sexologists, physiologists, and urologists have shown interest in SREs. Obviously, the observations and testing of SREs have a long history, from antiquity to modern sleep labs, in men and in women, in newborns and old adults, by penis rings with sharp spikes to fancy strain gauge devices. Despite all these efforts, the mechanisms leading to SREs and its function are however not yet completely understood.

Erectile dysfunction with chemotherapy

Sickle Cell Trust, 14 Milverton Crescent, Kingston 6, Jamaica (e-mail: grserjeant@cwjamaica.com) cavernosal injection with papaverine/ phentolamine. All measurements were done before orchidectomy (and additional chemotherapy), and at 6 months and 12 months thereafter. Sexual function was assessed by questionnaire at all time points. At 12 months, a visual erotic stimulation test was done to measure ability to achieve penile erection during sexual arousal. Different types of sexual dysfunction were associated with plasma testosterone and gonadotropins, at all time points. No decreased cavernosal PFV was found in the chemotherapy group (median change in PFV 11·1 [minimum 23·5, maximum 26·2] cm/s vs controls 6·1 [ 29·1, 36·3] cm/s) at all time-lapses. Repeated measurements showed increase in PFV, suggesting psychological inhibition to play a part. In patients with Raynaud’s disease (30%), cavernosal PFV was not diminished compared with those without symptoms. Compared with controls, libido loss and erectile dysfunction were more reported by chemotherapytreated men. However, 1 year after treatment most patients reported normal libido, and visual erotic stimulation resulted in a rigid erection in nearly all patients, even in those with chemotherapy-induced Leydig cell insufficiency. Sexual morbidity is high after diagnosis of testicular cancer. However, sexual recovery can be expected within time, and a single measurement of sexual function directly after chemotherapy may not be indicative of long-term outcome. In duplex-cavernosometry, psychological inhibition may play a significant part, especially in patients with cancer of uncertain prognosis. At first, an association between symptoms of angiopathy and erectile dysfunction was found, but this could not be established by duplex survey. Contrary to Chatterjee’s suggestions, our studies suggest that chemotherapy-induced hormonal and vascular changes do not play a determining part in postchemotherapy sexual dysfunction.

SEXUAL MEDICINE HISTORYSleep Related Erections Throughout the Ages

INTRODUCTION The occurrence of sleep-related erections (SREs) has been known since antiquity. AIM To highlight historical, theological, and sexual medicine-related aspects of SREs throughout the ages. METHODS Review of old medical books on male sexual functioning and review of scientific medical and theological articles on SREs from about 1900 on. RESULTS The cyclic character of SREs was first noted by German researchers in the forties of the 20th century. However, already before the beginning of the Christian era, one knew that men had erections and ejaculations during sleep. In the Middle Ages, SREs were generally considered to be rebellious manifestations of the male body, while it seemed to disobey its owner and showed up its perverted and sinful side. From the fifteenth to the end of the 17th century, severe erectile dysfunction (ED) was ground for divorce. The ecclesiastical court records show that if necessary, the members of the jury sat at the defendants bedside at night to be able to judge any SREs occurring. Since the 17th century, SREs were considered to be part of masturbation, which could cause many ailments and diseases. Psychoanalyst Stekel acknowledged in 1920 that a morning erection, the last SRE, is a naturally occurring phenomenon in healthy men from infancy to old age. Today, some scientists assume that SREs protect the integrity of the penile cavernous bodies. CONCLUSIONS Throughout the ages, philosophers, theologians, physicians, members of ecclesial law courts, psychoanalysts, psychiatrists, sexologists, physiologists, and urologists have shown interest in SREs. Obviously, the observations and testing of SREs have a long history, from antiquity to modern sleep labs, in men and in women, in newborns and old adults, by penis rings with sharp spikes to fancy strain gauge devices. Despite all these efforts, the mechanisms leading to SREs and its function are however not yet completely understood.