The Link Between Sexual Health and Urology

Table of Contents

This essay examines several important sexual health issues with a focus on the patient arena where urologists care for women: the treatment of distressing sexual symptoms associated with stress urinary incontinence (SUI), treatment of the frustrated SUI patient who mistakenly expects incontinence surgery to restore loss of genital sensation and orgasm, the impact of urinary leakage with sexual activity, and where to refer patients with sexual dysfunction beyond the ken of urologic therapy. Sexual function is an important component of overall health: 43% of women report sexual dysfunction versus 28% of men, with these problems tending to become more prevalent with age. According to the POPPrO trial, 30% of women with symptoms of genital prolapse experience a variety of sexual issues, particularly lower libido.

At the time of symptom presentation, the best step initially is a non-invasive assessment followed by conservative therapy. Conservative therapy options for symptomatic SUI and urgency urinary incontinence (UUI) that impose minimal inconvenience on the patient are pelvic floor muscle exercises with or without biofeedback or electrical nerve stimulation and behavioral or physical therapy with success likely for two-thirds of patients opening a discussion of urinary incontinence surgery for one-third. Hem 10-year data indicate single incision mini-slings may be inappropriate for treating SUI in women to engage in vigorous physical activity or sexual activity. If stress SUI is associated with profound sexual symptomatology, then non-treatment may be the best option for the frustrated SUI patient allowing post-coital voiding to empty the posterior urethra in order to minimize the urodynamic effects of concomitant coital incontinence within the anatomical confines of a dry vaginal area.

Definition and Scope of Sexual Health

The WHO definition (2002) of sexual health is a conscious and developmental approach to the exercise of human sexuality, implying respect for and protection of human rights, absence of coercion or violence in sexual relations, and freedom from diseases. Sexual health presupposes the possibility of a satisfying and safe sexual life without coercion, discrimination, or violence. For individuals, physical, emotional, psychological, and intellectual well-being are important and intimate parts of the whole. Freedoms, rights, and protections of the individual contribute to sexual health, and the repression of sexuality can lead to serious violations of human rights.

Sexual health is present even when the wish to have children or to discover processes to conceive them is absent. Accepting and respecting sexuality is an integral part of the rights and duties of being human. The rights related to sexual health also apply to individuals (such as transgender individuals, whose gender identity does not coincide with the gender assigned to them at birth), couples, or others engaged in relationships, as sexual orientation and the identification of gender or state of health may change over time. Adults have the right to the sexual health of the individual, informed and responsible, in harmony with the constitution. Satisfactory sexual health is also possible for the elderly. All people and peoples are entitled to the recognition, respect, and protection of all rights related to sexual health. Sexual health education processes, recognizing that each one must start from their values and from the importance of the family, the partner, and the community, according to birth and social change, allow young people to acquire a rich, sequentially delayed, and responsible behavior process with regard to sexual health, beginning to strengthen their relationships.

Overview of Urology and Its Relationship to Sexual Health

Urology, a surgical specialty that focuses on diseases of the male and female urinary tracts and the male reproductive system, plays a significant role in the sexual health of both genders. In men, urology’s inherent role in sexual health extends to erectile dysfunction, ejaculatory and penile problems, infertility, and urogenital infections. Urologists also aid women with sexual dysfunction. This chapter is devoted to understanding the unique relationship of urology to the topic of sexual health and sexual desire. Epidemiology is touched on in places, in an attempt to highlight the high frequency with which sexual health is a component of a urologist’s practice. Recent data suggest that only a small fraction of urology residency programs that are certified by the ACGME program in the United States train residents to specifically query and counsel patients who present to them for often unnoticed sexual dysfunction. Practical ways in which sexual health can be successfully integrated by urology practices in seeing patients who present with sexual complaints related to their specialty are designed to ensure profitable results.

The most important part of evaluation of sexual health is taking a detailed and comprehensive history from the patient. In today’s fast-paced and pressurizing society, being an attentive listener to the patient’s story cannot be overemphasized. Often, the patient has crafted a plausible and likely pat narrative of their complaint. As the urologist, one must have follow-on questions that are pertinent to the patient and well-formulated and relevant to the disease process. One or two open-ended questions designed to further elicitation that zeroes in on the history of the patient’s erectile function are helpful in saying, “In the presence of a partner, how often are you able to acquire and maintain an erection that is adequate for penetration?” The question can be further assessed with questions about the beginning of sexual function in the patient. When were you last able to have successful intercourse with your partner? How has your ability to achieve and maintain an erection been over the past 6 months? The patient’s ability to have sexual intercourse in both sexes in an objective and psychometrically validated way and these are often where the patient’s mindset is. Accurate and detailed assessment of their sexual complaint is crucial to the patient’s physical elimination of life-threatening conditions.

Common Sexual Health Issues in Urology

Sexual health issues are common and have an indirect, no less significant, impact on mental health. In some situations, those specializing in sexual health, often gynecologists or endocrinologists, are not always able to fulfill the clinical demand of both genders, and referral to urologists is more common. Who ‘should’ manage what aspect of male sexual health thus remains poorly defined, although working in multidisciplinary teams and accessing expertise seems the present and the future of these conditions.

Sexual health has changed in its extent and understanding from being primarily focused on sexually transmitted infections and more serious issues surrounding sexual function to considering how this interacts with the physical health of the patient. Sexual health issues are common and have an adverse effect on partner relationships and overall body image. And in tandem, urologists not only have primary involvement in sexual health issues, they also have training and interest in the delicate physiology underlying sexual health. As such, they are often best positioned to manage sexual health issues in males and, increasingly, in females too.

Erectile Dysfunction

Erectile dysfunction (ED) is a significant sign of systemic vascular diseases and is often associated with psychological, neurologic, and endocrine disorders. The multifactorial etiology of ED includes vascular, endothelial, cavernosal, and hormonal factors, as well as changes in PDE5 substrate production. Furthermore, testosterone alone or in association with phosphodiesterase type 5 inhibitors (PDE5i) is a valid first-line therapy, representing treatment success in male hypogonadism with ED. Orchidectomized rats show a significant increase in the expression of endothelial nitric oxide synthase in corpora cavernosa, under PDE5i, with a consequent significant increase in the protein concentration. The study suggests that an alleviation of ED-like symptoms in rats can be induced by Tadalafil in hypogonadal rats, a finding that potentially can be paralleled with results in hypogonadal men with ED. On the other hand, in a randomized, triple-blind, and placebo-controlled trial in hypogonadal men with ED, reported that although the PDE5 inhibitor and T replacement therapy were successful in the short-term treatment of coexisting low libido, T was a better alternative to PDE5 inhibitors when they were looking to improve libido and as a secondary result, satisfaction in men with ED and low testosterone.

Premature Ejaculation

The discovery of these potential mechanisms is an ongoing process. Long considered as a problem predominantly related to psychological factors, two decades ago the involvement of a complex of psychological and biological influences was acknowledged. Today, a range of treatment options are available, including psychological or behavioral treatments, topical anesthetics, phosphodiesterase type 5 inhibitors, selective serotonin reuptake inhibitors (SSRIs), and phosphodiesterase type 5 inhibitors and selective serotonin reuptake inhibitors combinations.

A study by Waldinger et al. presented evidence for lifelong premature ejaculation, which is characterized by very rapid ejaculation from the first sexual experience. Acquired premature ejaculation, by contrast, emerges after many normal ejaculatory experiences. The underlying reason for premature ejaculation remains unclear. Possible factors may be ejaculatory reflex threshold, sexual performance-related anxiety, hyperactive arousability of the ejaculatory system, erectile dysfunction, relationship difficulties, altered neurotransmission, or disturbances in the activities of the brain by the vasa deferentia and the central nervous system.

Premature (early) ejaculation is defined in DSM V as persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. There is no precise time limit that defines premature ejaculation. 1 min of penetrative time is a commonly cited threshold, but some ejaculate before penetration, which can be distressing.

Low Libido

Since then, the definition of low testosterone has become clearer while the discovery of receptor sites in the brain has led to its recognition as a cause of the fatigue associated with the low libido syndrome. More recently, the introduction of selective serotonin reuptake inhibitors (SSRIs) has added another dimension by causing significant sexual side effects. It has resulted in the recognition of another cause of low libido and type syndrome: the negative effect of the SSRIs on libido and the possibility that they may interfere with some of the pathways involved in the synthesis of nitric oxide. The significance of this harmonizes with the increased awareness of the influence of the monoamine energy on sexual function. This subject is important because sexual function is affected in 30% of gynecology patients; SSRI medication is prescribed for 50% of these patients, and sexual side effects occur in negatively 30% of these women.

Low libido, sometimes referred to as hypoactive sexual desire, with particular reference to women, is the most common sexual problem in women. Men are also affected, but details are sketchy. It is standard practice for many more referrals of women for sexual problems to be made to gynecologists than to urologists because the gynecologists have become the focal point for the investigation and management of these problems. Low testosterone is associated with low libido and was recognized by the ancient Greeks in castrated men who suffered from lack of libido, erectile dysfunction, hypoactive sexual desire, and fatigue. The reasons for the existence of this syndrome were only elucidated in the late 19th and early 20th centuries. Testosterone therapy resulted in substantial improvement in the symptoms.

Diagnostic Tools and Techniques in Urology

Sebastian Lechner and others highlighted that talk therapy and narrative diagnostics should remain essential tools to help patients remember the history related to their very personal complaints regarding sexual health. To start with, a positive clinical diagnostic tool is to listen to the patients’ narrative description of their symptoms and verify verbally if these symptoms have a connection with his/her spouse or he or she associates it with previous life-affecting events. Then, follow-up questions should include gender-specific items having universally accepted questionnaires as structured for and commonly used in daily practice, in addition to a directed physical exam and laboratory testing.

To achieve and maintain sexual health, urologists can use diagnostic tools and techniques to identify problems and then restore normal function regarding sexual health. The first step in treating a condition is diagnosing it and exploring the available treatments. Although sexual health presents a challenge to open discussion, it is not a separate entity but an important and complicated urological pathology and potentially a significant stigmatizing condition that needs to be evaluated and treated with due concern. To identify the root cause of sexual health problems, the urological surgeon has a number of methods at their disposal.

Physical Examinations

Once an adolescent has become comfortable with the provider, he or she is more likely to submit to a thorough physical examination. Special attention should be paid to the child or adolescent’s genitalia. The parent should be informed that a genital examination is routine. The physician should describe genital findings in objective, non-assessing language. The penis should be examined for proper development, including checking for hypospadias, the urethral opening. There should not be complete fusion of the labia minora in the postpubescent female. The position and distribution of pubic hair should be checked to gauge maturation. Other tests may be performed, such as evaluating pubic symphysis, Tanner staging, the presence of a hernia, palpating the skin for genital warts, and testing the “milk” line. The degree of patient nudity should be kept to a minimum. Gowns should be available, and the examination should be over as quickly as possible. Because many children and adolescents fear genital or rectal examination, he or she should be prepared for the checkup as simply as possible. The patient and the family should be prepared for what to expect. They should be informed that they can refuse any part of an examination. The reasons for not excluding any exam should be communicated. However, the importance of the primary purpose of examining the genitalia in hiding a biological truth from them is to damage the most important subject of all: trust. The assessment is a contract to protect and to heal. The providers should stress to the patient and to the parents that without trust and good documentation of what takes place during the examination, they cannot protect the child from the sequelae related to unrecognized disease, risk, or injury.

Laboratory Tests

Weiss’ Essentials of Urology provides a detailed listing of the laboratory tests most commonly done in urological practice. Though laboratory results are sometimes confusing, it is still useful to know what is most likely being analyzed. A urine sample, like a serum sample, provides a significant amount of information and should be analyzed effectively because it is a cost-effective way to monitor a variety of conditions. I think that there is very little disagreement that a complete urinalysis that includes visual appearance, specific gravity, pH, glucose, and protein is beneficial, and that the earlier in life that it is addressed, the more likely a urologist or other physician is to identify a condition that needs to be monitored. The number of screenings for microscopic hematuria, especially combined with chemical testing for hemoglobin or a blood test to assess serum creatinine, has increased recently because an increased number of such tumors, many incidentally detected through well-being examinations, have been identified in critical series.

Imaging Studies

However, fluoroscopic and urethrographic methods are not as popular nowadays because we do not frequently perform these studies, even in our practice. The reason is that currently available ultrasound devices enable us to manage our patients with prostate-related problems by providing all necessary imaging information safely, noninvasively, and, most importantly, in real time. The radiation exposure to the doctor performing the study as well as the patient and the possible side effects and allergy to the foreign materials are other issues.

The prostatic urethra can be imaged using fluoroscopic studies or urethrography. Both studies can present ERD and SAX views and are capable of demonstrating the urethra from the bladder neck to the distal bulbar urethra. Slight modifications, such as positioning the patient for normal VCUG or performing the urethrogram after the VCUG, are useful in demonstrating the membranous urethra. The radiologist can understand the voiding pattern of the patient when using singing (or locally injected) toy balloons or other devices in addition to using a catheter.

Treatment Approaches in Urology for Sexual Health Issues

Treatment ranges from general interventions to more specialized and complex options depending on the cause of the issue. General interventions include lifestyle modifications such as looking at and modifying the effect of medications, or aids such as vacuum, ring, or injection for erectile dysfunction in males or pelvic exercises, counseling, or aids in females. Our urologists consult with a multidisciplinary group of urologists, ob/gyn providers, psychologists, physical therapists, and exercise physiologists, sex therapists, and other health care professionals to provide the best level of care deemed appropriate. Comprehensive care that does not defer to sex, gender, or relationship status while clearly articulating the risk and benefits of any intervention, while leaving the ultimate decision to the patient is central to the core values of our urologist community.

Urology treats a range of symptoms related to sexual health, some of which include erectile dysfunction, sexual dysfunction, transgender care, sexually transmitted diseases, and pelvic and sexual pain disorders. When one or more of these symptoms is impeding sexual health, most people generally seek specialized health care focusing on the specific issue. A range of treatment can help these problems, and the impact ranges from significant improvements to full resolution. An important tenet of treatment is to ensure that patients feel comfortable with their consultation.

Medication Therapies

Medication treatments for sexual dysfunction can be divided into two broad categories: oral and local. The use of local medications includes both intraurethral and intracavernosal injections of a vasoactive agent. Penile injections work much the same way as penile pumps. Both treatments deliver healthy, oxygenated blood right into the penis through a tiny needle. “The success rate with erection injections is usually above 70%,” says Dr. Derek Cohen, Associate Professor of Urology at the George Washington University Medical Center in Washington. “As the patient learns to overcome any fear of pain related to the actual injection, the success rate of the treatment goes up.” The use of a vacuum cylinder produces an erection which is then maintained with the help of a constricting band at the base of the penis. Penile implants, both the inflatable and the malleable varieties, are functioning mansends a patient’s concerns about performance and lets him get an erection,” says Dr. Marc C. Gittelman, Director of the Center for Specialized Urology in Aventura, Florida.

Surgical Interventions

Bladder cancer surgery for total cystoprostatectomy or radical cystectomy can result in micturition and erectile dysfunction. Surgical complications can also result in incontinence and bowel dysfunction. Ninety percent of men with stress urinary incontinence after prostate surgery require an intervention, and the most common is placement of an artificial urinary sphincter. Placement of a male sling or other bulking therapy can increase the quality of life after radical prostatectomy. Finally, hydrocele following late urological repair of undescended testes can affect sexual function to a number of degrees, both physiologically and cosmetically.

Many issues in general urology also affect sexual function. In particular, these would include kidney stones, benign and malignant prostate disease, stress urinary incontinence, and overactive bladder. Interstitial cystitis/painful bladder syndrome, pelvic pain, and trauma can decrease sexual function. Sexual function is, of course, profoundly affected by urological surgical interventions for prostate cancer, bladder cancer, and conditions such as hydronephrosis. For men, curative surgery for localized prostate cancer can result in complete erectile dysfunction – this is approximately five times more likely with a radical prostatectomy compared to radiotherapy. Excision of locally extensive prostate cancer can remove the whole organ, including the cavernosal nerves. Radiation changes cause endothelial vascular damage, increasing erectile dysfunction, which is usually delayed in presentation.

Lifestyle Modifications

To improve your sexual health, you might also attempt seeing a couple of sex therapists. Exercises can assist in the strengthening of the pelvic muscle group. Exercises help you in enhancing your control and erection abilities. Regular workouts aid in the avoidance of ED. Popular Kegel exercises aid in the management of urinary continence in people. Partially empty your body until it is complete. Utilize your pelvic muscles to start and quit peeing for a total of 10 seconds during the session. Perform Kegel exercises by tightening and relaxing your pelvic floor muscles for 5 seconds. Using these exercises will improve your sexual health by making your erectile performance better.

If you have a medical condition that can impair your sexual performance, seek therapy. While you are on some type of medicine, you may notice differences in the organ’s size or sexual arousal. Consult your doctor to treat your medical problem and decrease the quantity of prescription medications you take if you experience issues with sexual performance. There is no need for medications, such as synthetic drugs or T harmonizing therapy, to improve your sexual health naturally. Attempt to decrease the number of sips you have had and consider medications that can address your ED. Discontinuing such medications will assist you in regaining an erection promptly.

Sexual health is influenced by nutrition and physical exercise. Maintaining a healthy diet and exercising on a regular basis will help your heart, energy levels, and penile motion. This includes consuming food that is rich in vitamins and minerals. Men should eat blackberries, citrus, tomatoes, nuts, tropical fruits, garlic, and ginger for healthier sexual health. Regular exercise will help you lose weight, sleep better at night, and boost your mood. To assist with ED, you can participate in Kegel exercises.

By modifying one’s lifestyle, it is possible to improve sexual health. Men often neglect themselves and engage in risky behavior. This leads to various health problems, including infertility, sexually transmitted infections and sexually transmitted diseases (STIs and STDs), erectile dysfunction, and less interest in sexual practices. A person’s sexual health may be significantly improved by making some simple adjustments to his lifestyle.

Future Directions and Research in the Field

Thirdly, the field of sexual health research is clearly important for future practice development. Specific studies could include: studies designed to prioritize populations for basic and clinical studies; research aimed at understanding basic sexual biology, sexual development, and reproduction for males with urologic conditions; research to develop and validate practical/functional biomarkers of male fertility/sexual maturity; clinical studies to evaluate the biological and sociocultural effects of early treatment of males with urologic conditions on male reproductive health. Management studies evaluating new treatments for sexual dysfunction; studies aimed at protecting and/or restoring fertility, sexual function, or overall men’s health in males with a pre-existing urological condition; large clinical studies including sex as a biological variable for males with urologic conditions and/or reproductive health endpoints.

Secondly, along with integrating sexual health care within the routine urology clinic, undergraduate and post-graduate education and specialty curriculum development are essential. The development of clinical guidelines for the management of sexual health conditions for all specialties is essential to guide the training needs and future practice of our health care models.

There is much work to be done within the field of urologic sexual health. Firstly, patient care should be centered on an integrated care pathway approach, and both urologists and primary care physicians should be familiar with existing sexual health integrative care clinical pathways and therefore be aware of when to refer. New models of care, such as the advanced practice provider (a registered nurse with advanced education and training; an expert clinician as a nurse practitioner or clinical nurse specialist), appear to be successful, from the literature, for extending our workforce. However, further research is needed to explore and evaluate the role of advanced practice providers and other members of the multidisciplinary team for patients with various sexual dysfunction symptoms within a routine clinical sexual health care setting. The research into preventable lifestyle changes and the impact of pelvic floor muscle exercise on sexual performance and pelvic floor wellness needs to be replicated over time, increasing sample size and also involving larger numbers of men.

Advancements in Technology and Treatment Modalities

These research efforts have increased the capacity for normal, maximal-size erections and a greater understanding of the physiological components of erection and penile size has revealed the lack of the generally accepted definition of ‘normal’ erect phallus. Advances have been made in the use of emerging interventional strategies that aim to improve penile erectile function and increase penile regeneration. The successful organization of clinical and translational studies in the field of sexual medicine is essential in order to develop safe and effective therapies based on the biological functions of a normal penis and to develop and improve future treatments.

The lack of validated animal models and standardized outcome measures in basic research on sexual medicine is a major and continuing problem in this field and affects the translation of basic research findings into practical therapies. In the next few decades, we can expect new treatment modalities in relation to sexual function, and this will be greatly improved by the development of new medical therapies, gene therapy, and stem cell therapies, among other management options. This new area for the development of drug interactions or combination therapies is also worth considering. In conclusion, a multidisciplinary approach and close cooperation between different fields of medicine will greatly benefit our understanding and treatment of any of the clinical manifestations of sexual dysfunction.

Given the growing interest in sexual medicine and male sexual dysfunction, future work may involve the nervous system, peripheral/endothelial function, and the bladder in relation to sexual function. Or one that tries to optimally restore penile function after cancer surgery or radiotherapy. Future therapeutic strategies and the development of therapies or techniques for nerve regeneration or neurogenesis or therapies that protect or promote endothelial and nitrergic function through gene therapy or stem cell therapy are promising.

Emerging Trends in Sexual Health and Urology Research

Almost without exception, sexually distressing symptoms that prompt help-seeking are shared by males and females. Many are (or relate to) genitourinary symptoms, most urologists are, and most urologic output is. However, though perhaps surprisingly, appropriately targeted medical care seems not to be. Since 1957, 12 National Surveys of Sexual Attitudes and Lifestyles (NATSAL) have been conducted in Great Britain. Their findings indicate that a minority (37% of men and 34% of women in the 1999 and 2000 survey) report having at least one sexual problem lasting more than 12 months in the past 12 months.

Formerly, sexual health was measured not just by physical well-being, but also by social health and safety. Evidence about the scale of work on different aspects of sexual health and the impact of different health sectors on sexual health has been compiled. Therefore, it is possible to question the focus of those funding bodies which have failed to fund enough urological research into gender-specific conditions, such as chronic prostatitis, nor those of general interest which focus on same-gender sexual difficulty. Some evidence about this activity is provided by bibliometric studies, which record and analyze the location of articles in the literature about urology (including journals concerned with plastic surgery and children) and sexual health.

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