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Papers by Michael Krychman

The Journal of Sexual Medicine, 2017

Material and Methods: We searched the previous articles about BPH surgeries and summarized it tog... more Material and Methods: We searched the previous articles about BPH surgeries and summarized it together according to the history development. Results: The BPH has plagued men since antiquity and the real first description of the prostate gland was by Venetian anatomist Nicolo Massa in the 16th century. The earliest operations performed on prostate were in 1639 when French urologist Joseph Covillard described the transperineal incision to remove the prostate tissue in lithotomy position. These surgeries were deemed to be perilous at that period. Even in the Hippocratic Oath, it was warned that "not use the knife, not even on sufferers from stone." Eugene Fuller in 1895 published an account of six cases of 'suprapubic prostatectomy' and illustrated this new improvement. To reduce the high rate of complications and the operation risk, the Irish urologist, Terence Millin developed an open, retropubic approach reported later in 1945. As early as in 1830, George James Guthrie incised the bladder neck with a concealed knife through the urethra, which was the first urethral prostate surgery. However, with no clear surgical view during the operation, haemorrhage and incontinence happened usually. Only until to 1897, A. Freudenberg modified previous methods by combining them with the cystoscope and the 'blind era' finally came to an end. Edwin Beer, in 1910, made the application of high-frequency electrical current for the surgery. In the following years, ST. M. Davis reported the transurethral resection of the prostate (TURP) in 1931 which stays as the gold standard for quite a long time. Fortunately, in the 1990s, Peter Gilling for the first time raised the concept of transurethral enucleation of prostate (TUEP) using holmium laser. Later, lots of energy platforms were used in the clinic. Numerous papers have reported that TUEP is safer and more efficient than TURP. The time for TUEP may be coming soon. Conclusions: During the long history for surgical treatment of BPH, there may be three landmarks: the appearance of the BPH surgery, the transurethral prostatectomy and TUEP. Anyway, the 'gold standard' belongs only to the past and the present, but not the future. Change is the only thing that stays still. With the development of the technology, the future of the treatment for BPH will be brighter and more glorious. Disclosure: Work supported by industry: no.

The Journal of Sexual Medicine, 2005

Introduction. Persistent sexual arousal syndrome is an uncommon sexual complaint. Patients with t... more Introduction. Persistent sexual arousal syndrome is an uncommon sexual complaint. Patients with this disorder can be distressed by the escalation of tension in the pelvic region and the prevailing necessity to diminish the pressure by self-stimulation. Patients frequently suffer from guilt or shame and often do not seek medical care. There are many potential causes of this disorder; however, a definitive etiology has yet to be elucidated. Case. The patient is a 44-year-old female who presented to her gynecologist for evaluation of dysmenorrhea and menometrorrhagia. During the review of systems, the patient reported 5-6 months of increased pelvic tension, not associated with an increase in desire that required her to self-stimulate to orgasm approximately 15 times daily. Upon further inquiry, the patient disclosed that her dietary regimen included soy intake in excess of 4 pounds per day that began approximately 1 month prior to the onset of symptoms. Results. Treatment consisted of supportive counseling and dietary modification. At the 3-month follow-up visit, the patient's menstrual difficulties and sexual complaints resolved. Conclusions. Although no known cause or cure of persistent sexual arousal syndrome has been identified to date, the success of reducing dietary of phytoestrogens in this patient may provide insight into the etiology of the disorder and suggest potential treatments.

The Journal of Sexual Medicine, 2006

Editorial Comment: The role of progesterone receptors (PR) has traditionally been relegated to th... more Editorial Comment: The role of progesterone receptors (PR) has traditionally been relegated to the field of female reproductive biology. Although previous studies have suggested that progesterone influences the development of the male nervous system as well as sexual and reproductive behavior, little is known about PR with respect to male sexual function. In this study, the investigators measured parameters of sexual behavior in male mice lacking the PR gene. When PR knockout mice were paired with sexually receptive females, initial mounting behavior occurred significantly faster than that of wild-type male mice. However, the number of mounts and intromissions were not significantly different between genotypes. Similar trends were observed when wild-type mice were treated with the PR antagonist RU486 for 12 days. Anxiety-related behaviors were determined to be unrelated to changes in mounting latency. Interestingly, androgen receptor immunoreactivity in the medial preoptic area was significantly greater in PR knockouts than in wild-type mice. PR knockout mice exhibited no change in plasma testosterone and luteinizing hormone levels, but had decreased folliclestimulating hormone along with elevated inhibin. However, no major functional change in the hypothalamic-pituitary-testicular axis was noted in PR knockouts, as testicular weight and morphology were similar between genotypes and sperm production was normal after 9 weeks of age. The postulated inhibitory action of PR on sexual behavior and its influence on androgen receptor expression in a key area of the brain that regulates sexual function provides a novel perspective on the role of progesterone in male sexual function.

The Journal of Sexual Medicine, 2007

Introduction. Sexual dysfunction, including problems with vaginal dryness, dyspareunia, decreased... more Introduction. Sexual dysfunction, including problems with vaginal dryness, dyspareunia, decreased libido, and difficulty with orgasm, is a common complaint among female breast cancer survivors. Despite the prevalence of female sexual dysfunction, there is a lack of Food and Drug Administration (FDA)-approved treatment options for hypoactive sexual desire disorder (HSDD) in women. Testosterone therapy may be one option. Aim. This is a case series describing the experience of breast cancer patients who used testosterone to treat sexual dysfunction. Methods. We report on three patients with a history of breast cancer who chose to continue testosterone therapy for improved sexual function despite conflicting reports of efficacy and lack of safety data on testosterone use in breast cancer patients. The patients described here expressed understanding of the risks and adamantly wished to continue testosterone therapy. Main Outcome Measures. All patients received a comprehensive sexual medicine evaluation including complete gynecological and psychosexual evaluations. Results. The improved sexual functioning is a quality-of-life parameter for these patients, and the unknown testosterone safety profile is an individually accepted level of risk. As studies emerge reporting beneficial effects of testosterone on libido and sexual function, the use of testosterone-containing therapies can be expected to increase among postmenopausal women. Conclusions. Further studies are needed to investigate the long-term effects of testosterone use in patients with breast cancer or at increased risk for developing breast cancer to definitively address the safety issues. Krychman ML, Stelling CJ, Carter J, and Hudis CA. A case series of androgen use in breast cancer survivors with sexual dysfunction.

The Journal of Sexual Medicine, 2007

The Journal of Sexual Medicine, 2012

Sexual health is the result of a complex interplay between social, relational, intrapsychic, and ... more Sexual health is the result of a complex interplay between social, relational, intrapsychic, and medical aspects. Sexual health care professionals (SHCP) may face several ethical issues. Some SHCP prescribe Internet pornography for both diagnosis and therapy and some others directly sell vibrators and sex aids in their offices. Five scientists, with different perspectives, debate the ethical aspects in the clinical practice of the SHCP. To give to the Journal of Sexual Medicine's reader enough data to form her/his own opinion on an important ethical topic. Expert #1, who is Controversy's Section Editor, together with two coworkers, expert psycho-sexologists, reviews data from literature regarding the use of the Internet in the SHCP. Expert #2 argues that licensed professionals, who treat sexual problems, should not sell sexual aids such as vibrators, lubricants, erotica, and instructional DVDs to their clients. On the other hand, Expert #3 is in favor of the possibility, for the patient, to directly purchase sexual aids from the SHCP in order to avoid embarrassment, confusion, and non-adherence to treatment. Evidence and intelligence would suggest that both the Internet (in selected subjects) and the vibrators (in the correct clinical setting), with the due efforts in counseling the patients and tailoring their therapy, are not-harmful, excellent tools in promoting sexual health.

The Journal of Sexual Medicine, 2011

Introduction. Little is known regarding the impact of a sexual health program on the sexual funct... more Introduction. Little is known regarding the impact of a sexual health program on the sexual functioning of patients with a history of a gynecologic malignancy. Aim. To evaluate as a pilot study the prevalence of common sexual health symptoms and evaluate the effects and compliance with clinical recommendations in gynecologic oncology patients. Methods. A retrospective cohort study of 259 female cancer patients who attended a survivorship program at an academic medical center from March 1, 2003 through December 31, 2004. Patients received symptomatic treatment recommendations including hormone therapy alternatives, psychosexual counseling, minimally absorbed vaginal estrogen suppositories, and vaginal dilators. Main Outcome Measures. Patient self-report of the severity of sexual symptomology at follow-up visit. Results. Ninety-six patients (37%) had gynecologic neoplasms and the most common gynecologic malignancy seen was ovarian (27%). Median age at initial visit was 51 years (range 25-76) and 88 patients (92%) were postmenopausal. The most frequent presenting complaint encountered was dyspareunia (72%), atrophic vaginitis (65%), hypoactive desire (43%), and orgasmic dysfunction (17%). At a median of 6 months (range 0-20), 60 patients (63%) received follow-up, and of them 42 (70%) self-reported improvement in their symptoms. Conclusions. The establishment of a well-structured sexual health program in a cancer setting can result in a 63% compliance rate with a 70% subjective improvement in sexual health complaints. Further research with objective measures of sexual dysfunction is needed to better evaluate patients' progress in this setting. Amsterdam A, and Krychman ML. Sexual dysfunction in patients with gynecologic neoplasms: a retrospective pilot study. J Sex Med 2006;3:646-649.

The Journal of Sexual Medicine, 2010

Introduction. There are many data on sexual problems subsequent to cancer and its treatment, alth... more Introduction. There are many data on sexual problems subsequent to cancer and its treatment, although the likelihood of problems in specific individuals depends on multiple variables. Aims. To gain knowledge about the risks of sexual problems among persons with cancer and to provide recommendations concerning their prevention and optimal treatment. Methods. A committee of multidisciplinary specialists was formed as part of a larger International Consultation working with urologic and sexual medicine societies over a 2-year period to review the result of chronic illness management on sexual function and satisfaction. The aims, goals, data collection techniques, and report format were defined by a central committee. Main Outcomes Measures. Expert consensus was based on evidence-based medical and psychosocial literature review, extensive group discussion, and an open presentation with a substantial discussion period. Results. Cancer and cancer treatments have both direct and indirect effects on physiologic, psychological, and interpersonal factors that can all impact negatively on sexual function and satisfaction. Data on the likelihood of specific sexual problems occurring with cancer and its management vary depending on prediagnosis function, patient response, support from the treatment team, specific treatments used, proactive counseling, and efforts to mitigate potential problems. This summary details available literature concerning the pathophysiologic and psychological impacts of cancer diagnosis and treatment on sexual function, plus recommendations for their prevention and management. Conclusions. Cancer and its management have a significant negative impact on sexual function and satisfaction. These negative effects can be somewhat mitigated by understanding prediagnosis sexual functioning level, counseling, careful treatment choices, and, when indicated, therapy post-treatment using educational, psychological, pharmacologic, and mechanical modalities.

Journal of Sexual Medicine, 2009

Introduction. Clitoral atrophy is often a neglected cause of female arousal complaints and warran... more Introduction. Clitoral atrophy is often a neglected cause of female arousal complaints and warrants treatment with localized treatments. Aim. This is a case series of patients with clitoral atrophy in which localized estrogens were used to treat separate, distinct sexual complaints. Methods. We report on three patients who were treated with localized estrogen tablets and cream for symptomatic clitoral atrophy despite a lack of data for use of these agents for the treatment of this diagnosis. The patients described here expressed understanding of the risks of vaginal hormonal therapy prior to treatment and at follow-up visits while on therapy. Main Outcome Measures. Patient reports, physical examination, and vaginal pH. Results. All patients reported improvement or resolution of symptoms after the treatment with localized estrogen tablets and/or cream. Conclusions. Low-dose minimally absorbed local estrogen products can be used in combination with excellent tolerance and low side-effect profile to treat female sexual complaints. Amsterdam A, and Krychman M. Clitoral atrophy: A case series.

The Journal of Sexual Medicine, 2012

The sexual consequences of breast cancer and its treatments are well known and previously reviewe... more The sexual consequences of breast cancer and its treatments are well known and previously reviewed. Alterations in body image, with or without breast reconstruction, changes in sexual self-esteem and self-efficacy, vulvovaginal atrophy as a result of chemotherapy and/or adjuvant hormone therapy, and loss of libido secondary to dyspareunia and body image issues are common in survivors of breast cancer. Medications that are prescribed for long-term use including those in the class of aromatase inhibitors can have far-reaching implications on quality of life by contributing to vulvar and vaginal atrophic changes. While this is an important issue, there are few widely accepted treatments that have been evaluated for efficacy and safety for these sexual challenges in the breast cancer population. However, progress is being made in finding new and innovative solutions for many of the sexual problems faced by breast cancer survivors and their partners. Many institutions are now compelled to address survivorship concerns and addressing sexuality and intimacy are paramount issues in survivorship care. In this article, we present the evidence for the multimodal approach to the management of sexuality concerns in the breast cancer survivor. Pharmacologic, nonpharmacologic, and psychosocial interventions will be reviewed. Krychman ML and Katz A. Breast cancer and sexuality: Multi-modal treatment options.

The Journal of Sexual Medicine, 2013

Vulvar and vaginal atrophy (VVA) is a chronic medical condition experienced by many postmenopausa... more Vulvar and vaginal atrophy (VVA) is a chronic medical condition experienced by many postmenopausal women. Symptoms include dyspareunia (pain with intercourse), vaginal dryness, and irritation and may affect sexual activities, relationships, and activities of daily life. The aim of this study is to characterize postmenopausal women's experience with and perception of VVA symptoms, interactions with healthcare professionals (HCPs), and available treatment options. An online survey was conducted in the United States in women from KnowledgePanel(®) , a 56,000-member probability-selected Internet panel projectable to the overall US population. Altogether, 3,046 postmenopausal women with VVA symptoms (the largest US cohort of recent surveys) responded to questions about their knowledge of VVA, impact of symptoms on their activities, communication with HCPs, and use of available treatments. Percent is calculated as the ratio of response over total responding for each question for all and stratified participants. The most common VVA symptoms were dryness (55% of participants), dyspareunia (44%), and irritation (37%). VVA symptoms affected enjoyment of sex in 59% of participants. Additionally, interference with sleep, general enjoyment of life, and temperament were reported by 24%, 23%, and 23% of participants, respectively. Few women attributed symptoms to menopause (24%) or hormonal changes (12%). Of all participants, 56% had ever discussed VVA symptoms with an HCP and 40% currently used VVA-specific topical treatments (vaginal over-the-counter [OTC] products [29%] and vaginal prescription therapies [11%]). Of those who had discussed symptoms with an HCP, 62% used OTC products. Insufficient symptom relief and inconvenience were cited as major limitations of OTC products and concerns about side effects and cancer risk limited use of topical vaginal prescription therapies. VVA symptoms are common in postmenopausal women. Significant barriers to treatment include lack of knowledge about VVA, reluctance to discuss symptoms with HCPs, safety concerns, inconvenience, and inadequate symptom relief from available treatments.

The Journal of Sexual Medicine, 2013

The Journal of Sexual Medicine, 2011

Introduction. Vaginal atrophy, which is associated with vaginal itching, burning, dryness, irrita... more Introduction. Vaginal atrophy, which is associated with vaginal itching, burning, dryness, irritation, and pain, is estimated to affect up to 40% of postmenopausal women. Estrogens play a key role in maintaining vaginal health; women with low serum estradiol are more likely to experience vaginal dryness, dyspareunia, and reduced sexual activity compared with women who have higher estradiol levels. Aims. The purpose of this review is to assess the prevalence and impact of dyspareunia, a symptom of vaginal atrophy, on the health of postmenopausal women and to evaluate treatment options using vaginal estrogens (U.S. Food and Drug Administration [FDA] approved). Methods. Relevant published literature was identified by searching Index Medicus using the PubMed online database. The search terms dyspareunia, vaginal estrogen, vaginal hormone therapy, vaginal atrophy, and atrophic vaginitis were the focus of the literature review. Results. Current treatment guidelines for vaginal atrophy recommend the use of minimally absorbed local vaginal estrogens, along with non-hormonal lubricants or moisturizers, coupled with maintenance of sexual activity. Vaginal estrogen therapy has been shown to provide improvement in the signs and symptoms of vaginal or vulvar atrophy. Vaginal tablets, rings, and creams are indicated for the treatment of vaginal atrophy, and the FDA has recently approved a low-dose regimen of conjugated estrogens cream to treat moderate-to-severe postmenopausal dyspareunia. The use of low-dose vaginal estrogens has been shown to be effective in treating symptoms of vaginal atrophy without causing significant proliferation of the endometrial lining, and no significant differences have been seen among vaginal preparations in terms of endometrial safety. Conclusion. Women should be informed of the potential benefits and risks of the treatment options available, and with the help of their healthcare provider, choose an intervention that is most suitable to their individual needs and circumstances. Krychman ML. Vaginal estrogens for the treatment of dyspareunia.

The Journal of Sexual Medicine, 2011

These are "interesting times" in the fi eld of female sexual function and dysfunction. We are sti... more These are "interesting times" in the fi eld of female sexual function and dysfunction. We are still working without any FDA-approved phamacotherapy for our patient population, so we rely on off-label medication in addition to our behavioral and relationship therapy. In spite of this, we continue to move forward. Unfortunately, we are now faced with those in the fi eld who espouse that FSD is just another "made-up-by-pharmadisease" to sell drugs and make money for their stockholders. ISSWSH has responded with a position statement that will be circulated among all the societies dedicated to both male and female sexual function. This will be an important effort for our patients, whose voices are not being heard.

The Journal of Sexual Medicine, 2013

Introduction. Sexual health issues for women who have cancer are an important and under-diagnosed... more Introduction. Sexual health issues for women who have cancer are an important and under-diagnosed and undertreated survivorship issue. Survivorship begins at the time a cancer is detected and addresses health-care issues beyond diagnosis and acute treatment. This includes improving access to care and quality-of-life considerations, as well as dealing with the late effects of treatment. Difficulties with sexual function are one of the more common late effects in women. Aim. This article attempted to characterize the etiology, prevalence, and treatment for sexual health concerns for women with gynecological cancer. Methods. A systematic survey of currently available relevant literature published in English was conducted. Results. The issue of sexual health for women with cancer is a prevalent medical concern that is rarely addressed in clinical practice. The development of sexual morbidity in the female cancer survivor is a multifactorial problem incorporating psychological, physiologic, and sociological elements. Treatments such as chemotherapy, radiation therapy, surgery, and hormonal manipulation appear to have the greatest influence on the development of sexual consequences. Sexual complaints include but are not limited to changes in sexual desire, arousal, and orgasmic intensity and latency. Many women suffer from debilitating vaginal dryness and painful intercourse. Conclusions. Many of the sexual health issues experienced by cancer survivors can be addressed in clinical practice. A multimodal treatment paradigm is necessary to effectively treat these sexual complaints in this special patient population. Krychman M and Millheiser LS. Sexual health issues in women with cancer.

The Journal of Sexual Medicine, 2006

Penile erection requires association of soluble guanylyl cyclase with endothelial caveolin-1 in r... more Penile erection requires association of soluble guanylyl cyclase with endothelial caveolin-1 in rat corpus cavernosum.

The Journal of Sexual Medicine, 2006

Oncology patients often present to healthcare providers with a history of pre-existing psychiatri... more Oncology patients often present to healthcare providers with a history of pre-existing psychiatric conditions. Associated treatments are well known to impact sexual functioning. The identification of these confounding conditions and medications is an integral part of the comprehensive management of sexual dysfunction in oncology patients. To report the prevalence of psychiatric diagnoses and agents in an oncology sexual health clinic. A retrospective review was performed using 204 sequential charts of patients who attended the Sexual Health Program at Memorial Sloan-Kettering Cancer Center from March 2003 through August 2004. All patients were evaluated by a sexual medicine gynecologist and received an extensive medical history, psychosexual assessment, and a focused gynecologic examination. Fourteen patients (7%) did not have cancer and were excluded from further analysis. Of the remaining 190 patients, the median age at initial visit was 48 years (range 22-76) and the majority of patients were menopausal (87%). The most common diagnosis was breast cancer (44%). One hundred twenty-eight patients (67%) had prior pelvic surgery and 43 (23%) had prior pelvic radiation. The most frequently encountered sexual complaints were dyspareunia (65%), vaginal dryness (63%), hypoactive desire disorder (46%), and orgasmic dysfunction (7%). At initial presentation, 52 patients (27%) reported having a prior or concurrent psychiatric diagnosis and 72 (38%) were taking an anti-depressant and/or an anxiolytic. Treatment recommendations for sexual dysfunction consisted of psychosexual counseling, psychiatric referral, vaginal moisturizers and lubricants, hormonal therapy with minimally absorbed vaginal estrogen suppositories, vaginal dilators, and/or skilled exercise. Psychiatric conditions are commonly encountered in the oncology population as are the medications to treat them. Because it is well established that these medications are often implicated in sexual dysfunction, further research is needed to determine the mechanism of action within the desire pathway of the cancer patient and treatment of such disorders.

The Journal of Sexual Medicine, 2013

Introduction. Vaginal atrophy results from a decrease in circulating estrogen and is experienced ... more Introduction. Vaginal atrophy results from a decrease in circulating estrogen and is experienced by approximately 50% of postmenopausal women. Its symptoms affect multiple dimensions of genitopelvic health, sexuality, and overall quality of life. Nonhormonal over-the-counter treatments may provide temporary symptom relief, but the condition is progressive, and hormonal treatment may be warranted. Aim. The study aims to review the literature and discuss the impact of atrophic vaginitis and various treatment options, including the resistance and barriers to the use of local estrogen therapy for atrophic vaginitis. This article also aims to provide a greater awareness of the condition and the difficulties in communicating effectively with patients, and to provide strategies to help healthcare professionals acquire effective communication skills to initiate a candid dialogue with patients who may be suffering in silence and may benefit from therapy. Methods. This review was based on peer-reviewed publications on the topic of atrophic vaginitis and local estrogen therapy identified from key word searches of PubMed, in addition to landmark studies/surveys and treatment guidelines/recommendations on menopause available in the literature and on the Internet. Main Outcome Measures. The main outcomes are the impact of atrophic vaginitis and the various treatment options, including the resistance and barriers to the use of local estrogen therapy. Results. Minimally absorbed local vaginal estrogen therapy enables administration of estrogen doses much lower than systemic doses used for vasomotor symptoms. Local therapy is also the first-line pharmacologic treatment recommended by the North American Menopause and International Menopause Societies. Despite treatment options, the sensitive nature of the condition and embarrassment may prohibit or limit many women from openly discussing symptoms with healthcare professionals. Many are hesitant to initiate hormonal treatment because of safety concerns. Conclusions. Healthcare professionals should initiate and encourage frank and candid conversation about vaginal atrophy at annual visits and provide follow-up and treatment as needed. Kingsberg SA and Krychman ML. Resistance and barriers to local estrogen therapy in women with atrophic vaginitis.

International Journal of Women's Health, 2013

Several recent, large-scale studies have provided valuable insights into patient perspectives on ... more Several recent, large-scale studies have provided valuable insights into patient perspectives on postmenopausal vulvovaginal health. Symptoms of vulvovaginal atrophy, which include dryness, irritation, itching, dysuria, and dyspareunia, can adversely affect interpersonal relationships, quality of life, and sexual function. While approximately half of postmenopausal women report these symptoms, far fewer seek treatment, often because they are uninformed about hypoestrogenic postmenopausal vulvovaginal changes and the availability of safe, effective, and well-tolerated treatments, particularly local vaginal estrogen therapy. Because women hesitate to seek help for symptoms, a proactive approach to conversations about vulvovaginal discomfort would improve diagnosis and treatment.

Gynecologic Oncology, 2004

Chemotherapy can cause vaginal irritation and mucositis, although rarely reported. A 62-year-old ... more Chemotherapy can cause vaginal irritation and mucositis, although rarely reported. A 62-year-old patient with ovarian cancer reported vaginal burning associated with dyspareunia, which emerged 3-5 days after her initial chemotherapy and persisted throughout her treatment. Her discomfort persisted until she was evaluated by our sexual health service and interventions were implemented. On examination, her vaginal vault was erythematous, with mild signs of vaginal atrophy. Her management schema consisted of the following: avoidance of intercourse 3-5 days after chemotherapy, intravaginal vitamin E suppositories three times per week, intravaginal estrogen tablets (initial course of 14 days followed by twice weekly usage), use of lubricants (Astroglide) during coitus, and counseling. Once interventions were introduced, she subsequently resumed sexual intercourse during the remainder of her chemotherapy treatments. Patients with sexual complaints during or following cancer treatment can be treated by their community gynecologists or gynecology oncologists or can be treated through a comprehensive sexual health program with restoration of sexual function.

The Journal of Sexual Medicine, 2017

Material and Methods: We searched the previous articles about BPH surgeries and summarized it tog... more Material and Methods: We searched the previous articles about BPH surgeries and summarized it together according to the history development. Results: The BPH has plagued men since antiquity and the real first description of the prostate gland was by Venetian anatomist Nicolo Massa in the 16th century. The earliest operations performed on prostate were in 1639 when French urologist Joseph Covillard described the transperineal incision to remove the prostate tissue in lithotomy position. These surgeries were deemed to be perilous at that period. Even in the Hippocratic Oath, it was warned that "not use the knife, not even on sufferers from stone." Eugene Fuller in 1895 published an account of six cases of 'suprapubic prostatectomy' and illustrated this new improvement. To reduce the high rate of complications and the operation risk, the Irish urologist, Terence Millin developed an open, retropubic approach reported later in 1945. As early as in 1830, George James Guthrie incised the bladder neck with a concealed knife through the urethra, which was the first urethral prostate surgery. However, with no clear surgical view during the operation, haemorrhage and incontinence happened usually. Only until to 1897, A. Freudenberg modified previous methods by combining them with the cystoscope and the 'blind era' finally came to an end. Edwin Beer, in 1910, made the application of high-frequency electrical current for the surgery. In the following years, ST. M. Davis reported the transurethral resection of the prostate (TURP) in 1931 which stays as the gold standard for quite a long time. Fortunately, in the 1990s, Peter Gilling for the first time raised the concept of transurethral enucleation of prostate (TUEP) using holmium laser. Later, lots of energy platforms were used in the clinic. Numerous papers have reported that TUEP is safer and more efficient than TURP. The time for TUEP may be coming soon. Conclusions: During the long history for surgical treatment of BPH, there may be three landmarks: the appearance of the BPH surgery, the transurethral prostatectomy and TUEP. Anyway, the 'gold standard' belongs only to the past and the present, but not the future. Change is the only thing that stays still. With the development of the technology, the future of the treatment for BPH will be brighter and more glorious. Disclosure: Work supported by industry: no.

The Journal of Sexual Medicine, 2005

Introduction. Persistent sexual arousal syndrome is an uncommon sexual complaint. Patients with t... more Introduction. Persistent sexual arousal syndrome is an uncommon sexual complaint. Patients with this disorder can be distressed by the escalation of tension in the pelvic region and the prevailing necessity to diminish the pressure by self-stimulation. Patients frequently suffer from guilt or shame and often do not seek medical care. There are many potential causes of this disorder; however, a definitive etiology has yet to be elucidated. Case. The patient is a 44-year-old female who presented to her gynecologist for evaluation of dysmenorrhea and menometrorrhagia. During the review of systems, the patient reported 5-6 months of increased pelvic tension, not associated with an increase in desire that required her to self-stimulate to orgasm approximately 15 times daily. Upon further inquiry, the patient disclosed that her dietary regimen included soy intake in excess of 4 pounds per day that began approximately 1 month prior to the onset of symptoms. Results. Treatment consisted of supportive counseling and dietary modification. At the 3-month follow-up visit, the patient's menstrual difficulties and sexual complaints resolved. Conclusions. Although no known cause or cure of persistent sexual arousal syndrome has been identified to date, the success of reducing dietary of phytoestrogens in this patient may provide insight into the etiology of the disorder and suggest potential treatments.

The Journal of Sexual Medicine, 2006

Editorial Comment: The role of progesterone receptors (PR) has traditionally been relegated to th... more Editorial Comment: The role of progesterone receptors (PR) has traditionally been relegated to the field of female reproductive biology. Although previous studies have suggested that progesterone influences the development of the male nervous system as well as sexual and reproductive behavior, little is known about PR with respect to male sexual function. In this study, the investigators measured parameters of sexual behavior in male mice lacking the PR gene. When PR knockout mice were paired with sexually receptive females, initial mounting behavior occurred significantly faster than that of wild-type male mice. However, the number of mounts and intromissions were not significantly different between genotypes. Similar trends were observed when wild-type mice were treated with the PR antagonist RU486 for 12 days. Anxiety-related behaviors were determined to be unrelated to changes in mounting latency. Interestingly, androgen receptor immunoreactivity in the medial preoptic area was significantly greater in PR knockouts than in wild-type mice. PR knockout mice exhibited no change in plasma testosterone and luteinizing hormone levels, but had decreased folliclestimulating hormone along with elevated inhibin. However, no major functional change in the hypothalamic-pituitary-testicular axis was noted in PR knockouts, as testicular weight and morphology were similar between genotypes and sperm production was normal after 9 weeks of age. The postulated inhibitory action of PR on sexual behavior and its influence on androgen receptor expression in a key area of the brain that regulates sexual function provides a novel perspective on the role of progesterone in male sexual function.

The Journal of Sexual Medicine, 2007

Introduction. Sexual dysfunction, including problems with vaginal dryness, dyspareunia, decreased... more Introduction. Sexual dysfunction, including problems with vaginal dryness, dyspareunia, decreased libido, and difficulty with orgasm, is a common complaint among female breast cancer survivors. Despite the prevalence of female sexual dysfunction, there is a lack of Food and Drug Administration (FDA)-approved treatment options for hypoactive sexual desire disorder (HSDD) in women. Testosterone therapy may be one option. Aim. This is a case series describing the experience of breast cancer patients who used testosterone to treat sexual dysfunction. Methods. We report on three patients with a history of breast cancer who chose to continue testosterone therapy for improved sexual function despite conflicting reports of efficacy and lack of safety data on testosterone use in breast cancer patients. The patients described here expressed understanding of the risks and adamantly wished to continue testosterone therapy. Main Outcome Measures. All patients received a comprehensive sexual medicine evaluation including complete gynecological and psychosexual evaluations. Results. The improved sexual functioning is a quality-of-life parameter for these patients, and the unknown testosterone safety profile is an individually accepted level of risk. As studies emerge reporting beneficial effects of testosterone on libido and sexual function, the use of testosterone-containing therapies can be expected to increase among postmenopausal women. Conclusions. Further studies are needed to investigate the long-term effects of testosterone use in patients with breast cancer or at increased risk for developing breast cancer to definitively address the safety issues. Krychman ML, Stelling CJ, Carter J, and Hudis CA. A case series of androgen use in breast cancer survivors with sexual dysfunction.

The Journal of Sexual Medicine, 2007

The Journal of Sexual Medicine, 2012

Sexual health is the result of a complex interplay between social, relational, intrapsychic, and ... more Sexual health is the result of a complex interplay between social, relational, intrapsychic, and medical aspects. Sexual health care professionals (SHCP) may face several ethical issues. Some SHCP prescribe Internet pornography for both diagnosis and therapy and some others directly sell vibrators and sex aids in their offices. Five scientists, with different perspectives, debate the ethical aspects in the clinical practice of the SHCP. To give to the Journal of Sexual Medicine's reader enough data to form her/his own opinion on an important ethical topic. Expert #1, who is Controversy's Section Editor, together with two coworkers, expert psycho-sexologists, reviews data from literature regarding the use of the Internet in the SHCP. Expert #2 argues that licensed professionals, who treat sexual problems, should not sell sexual aids such as vibrators, lubricants, erotica, and instructional DVDs to their clients. On the other hand, Expert #3 is in favor of the possibility, for the patient, to directly purchase sexual aids from the SHCP in order to avoid embarrassment, confusion, and non-adherence to treatment. Evidence and intelligence would suggest that both the Internet (in selected subjects) and the vibrators (in the correct clinical setting), with the due efforts in counseling the patients and tailoring their therapy, are not-harmful, excellent tools in promoting sexual health.

The Journal of Sexual Medicine, 2011

Introduction. Little is known regarding the impact of a sexual health program on the sexual funct... more Introduction. Little is known regarding the impact of a sexual health program on the sexual functioning of patients with a history of a gynecologic malignancy. Aim. To evaluate as a pilot study the prevalence of common sexual health symptoms and evaluate the effects and compliance with clinical recommendations in gynecologic oncology patients. Methods. A retrospective cohort study of 259 female cancer patients who attended a survivorship program at an academic medical center from March 1, 2003 through December 31, 2004. Patients received symptomatic treatment recommendations including hormone therapy alternatives, psychosexual counseling, minimally absorbed vaginal estrogen suppositories, and vaginal dilators. Main Outcome Measures. Patient self-report of the severity of sexual symptomology at follow-up visit. Results. Ninety-six patients (37%) had gynecologic neoplasms and the most common gynecologic malignancy seen was ovarian (27%). Median age at initial visit was 51 years (range 25-76) and 88 patients (92%) were postmenopausal. The most frequent presenting complaint encountered was dyspareunia (72%), atrophic vaginitis (65%), hypoactive desire (43%), and orgasmic dysfunction (17%). At a median of 6 months (range 0-20), 60 patients (63%) received follow-up, and of them 42 (70%) self-reported improvement in their symptoms. Conclusions. The establishment of a well-structured sexual health program in a cancer setting can result in a 63% compliance rate with a 70% subjective improvement in sexual health complaints. Further research with objective measures of sexual dysfunction is needed to better evaluate patients' progress in this setting. Amsterdam A, and Krychman ML. Sexual dysfunction in patients with gynecologic neoplasms: a retrospective pilot study. J Sex Med 2006;3:646-649.

The Journal of Sexual Medicine, 2010

Introduction. There are many data on sexual problems subsequent to cancer and its treatment, alth... more Introduction. There are many data on sexual problems subsequent to cancer and its treatment, although the likelihood of problems in specific individuals depends on multiple variables. Aims. To gain knowledge about the risks of sexual problems among persons with cancer and to provide recommendations concerning their prevention and optimal treatment. Methods. A committee of multidisciplinary specialists was formed as part of a larger International Consultation working with urologic and sexual medicine societies over a 2-year period to review the result of chronic illness management on sexual function and satisfaction. The aims, goals, data collection techniques, and report format were defined by a central committee. Main Outcomes Measures. Expert consensus was based on evidence-based medical and psychosocial literature review, extensive group discussion, and an open presentation with a substantial discussion period. Results. Cancer and cancer treatments have both direct and indirect effects on physiologic, psychological, and interpersonal factors that can all impact negatively on sexual function and satisfaction. Data on the likelihood of specific sexual problems occurring with cancer and its management vary depending on prediagnosis function, patient response, support from the treatment team, specific treatments used, proactive counseling, and efforts to mitigate potential problems. This summary details available literature concerning the pathophysiologic and psychological impacts of cancer diagnosis and treatment on sexual function, plus recommendations for their prevention and management. Conclusions. Cancer and its management have a significant negative impact on sexual function and satisfaction. These negative effects can be somewhat mitigated by understanding prediagnosis sexual functioning level, counseling, careful treatment choices, and, when indicated, therapy post-treatment using educational, psychological, pharmacologic, and mechanical modalities.

Journal of Sexual Medicine, 2009

Introduction. Clitoral atrophy is often a neglected cause of female arousal complaints and warran... more Introduction. Clitoral atrophy is often a neglected cause of female arousal complaints and warrants treatment with localized treatments. Aim. This is a case series of patients with clitoral atrophy in which localized estrogens were used to treat separate, distinct sexual complaints. Methods. We report on three patients who were treated with localized estrogen tablets and cream for symptomatic clitoral atrophy despite a lack of data for use of these agents for the treatment of this diagnosis. The patients described here expressed understanding of the risks of vaginal hormonal therapy prior to treatment and at follow-up visits while on therapy. Main Outcome Measures. Patient reports, physical examination, and vaginal pH. Results. All patients reported improvement or resolution of symptoms after the treatment with localized estrogen tablets and/or cream. Conclusions. Low-dose minimally absorbed local estrogen products can be used in combination with excellent tolerance and low side-effect profile to treat female sexual complaints. Amsterdam A, and Krychman M. Clitoral atrophy: A case series.

The Journal of Sexual Medicine, 2012

The sexual consequences of breast cancer and its treatments are well known and previously reviewe... more The sexual consequences of breast cancer and its treatments are well known and previously reviewed. Alterations in body image, with or without breast reconstruction, changes in sexual self-esteem and self-efficacy, vulvovaginal atrophy as a result of chemotherapy and/or adjuvant hormone therapy, and loss of libido secondary to dyspareunia and body image issues are common in survivors of breast cancer. Medications that are prescribed for long-term use including those in the class of aromatase inhibitors can have far-reaching implications on quality of life by contributing to vulvar and vaginal atrophic changes. While this is an important issue, there are few widely accepted treatments that have been evaluated for efficacy and safety for these sexual challenges in the breast cancer population. However, progress is being made in finding new and innovative solutions for many of the sexual problems faced by breast cancer survivors and their partners. Many institutions are now compelled to address survivorship concerns and addressing sexuality and intimacy are paramount issues in survivorship care. In this article, we present the evidence for the multimodal approach to the management of sexuality concerns in the breast cancer survivor. Pharmacologic, nonpharmacologic, and psychosocial interventions will be reviewed. Krychman ML and Katz A. Breast cancer and sexuality: Multi-modal treatment options.

The Journal of Sexual Medicine, 2013

Vulvar and vaginal atrophy (VVA) is a chronic medical condition experienced by many postmenopausa... more Vulvar and vaginal atrophy (VVA) is a chronic medical condition experienced by many postmenopausal women. Symptoms include dyspareunia (pain with intercourse), vaginal dryness, and irritation and may affect sexual activities, relationships, and activities of daily life. The aim of this study is to characterize postmenopausal women's experience with and perception of VVA symptoms, interactions with healthcare professionals (HCPs), and available treatment options. An online survey was conducted in the United States in women from KnowledgePanel(®) , a 56,000-member probability-selected Internet panel projectable to the overall US population. Altogether, 3,046 postmenopausal women with VVA symptoms (the largest US cohort of recent surveys) responded to questions about their knowledge of VVA, impact of symptoms on their activities, communication with HCPs, and use of available treatments. Percent is calculated as the ratio of response over total responding for each question for all and stratified participants. The most common VVA symptoms were dryness (55% of participants), dyspareunia (44%), and irritation (37%). VVA symptoms affected enjoyment of sex in 59% of participants. Additionally, interference with sleep, general enjoyment of life, and temperament were reported by 24%, 23%, and 23% of participants, respectively. Few women attributed symptoms to menopause (24%) or hormonal changes (12%). Of all participants, 56% had ever discussed VVA symptoms with an HCP and 40% currently used VVA-specific topical treatments (vaginal over-the-counter [OTC] products [29%] and vaginal prescription therapies [11%]). Of those who had discussed symptoms with an HCP, 62% used OTC products. Insufficient symptom relief and inconvenience were cited as major limitations of OTC products and concerns about side effects and cancer risk limited use of topical vaginal prescription therapies. VVA symptoms are common in postmenopausal women. Significant barriers to treatment include lack of knowledge about VVA, reluctance to discuss symptoms with HCPs, safety concerns, inconvenience, and inadequate symptom relief from available treatments.

The Journal of Sexual Medicine, 2013

The Journal of Sexual Medicine, 2011

Introduction. Vaginal atrophy, which is associated with vaginal itching, burning, dryness, irrita... more Introduction. Vaginal atrophy, which is associated with vaginal itching, burning, dryness, irritation, and pain, is estimated to affect up to 40% of postmenopausal women. Estrogens play a key role in maintaining vaginal health; women with low serum estradiol are more likely to experience vaginal dryness, dyspareunia, and reduced sexual activity compared with women who have higher estradiol levels. Aims. The purpose of this review is to assess the prevalence and impact of dyspareunia, a symptom of vaginal atrophy, on the health of postmenopausal women and to evaluate treatment options using vaginal estrogens (U.S. Food and Drug Administration [FDA] approved). Methods. Relevant published literature was identified by searching Index Medicus using the PubMed online database. The search terms dyspareunia, vaginal estrogen, vaginal hormone therapy, vaginal atrophy, and atrophic vaginitis were the focus of the literature review. Results. Current treatment guidelines for vaginal atrophy recommend the use of minimally absorbed local vaginal estrogens, along with non-hormonal lubricants or moisturizers, coupled with maintenance of sexual activity. Vaginal estrogen therapy has been shown to provide improvement in the signs and symptoms of vaginal or vulvar atrophy. Vaginal tablets, rings, and creams are indicated for the treatment of vaginal atrophy, and the FDA has recently approved a low-dose regimen of conjugated estrogens cream to treat moderate-to-severe postmenopausal dyspareunia. The use of low-dose vaginal estrogens has been shown to be effective in treating symptoms of vaginal atrophy without causing significant proliferation of the endometrial lining, and no significant differences have been seen among vaginal preparations in terms of endometrial safety. Conclusion. Women should be informed of the potential benefits and risks of the treatment options available, and with the help of their healthcare provider, choose an intervention that is most suitable to their individual needs and circumstances. Krychman ML. Vaginal estrogens for the treatment of dyspareunia.

The Journal of Sexual Medicine, 2011

These are "interesting times" in the fi eld of female sexual function and dysfunction. We are sti... more These are "interesting times" in the fi eld of female sexual function and dysfunction. We are still working without any FDA-approved phamacotherapy for our patient population, so we rely on off-label medication in addition to our behavioral and relationship therapy. In spite of this, we continue to move forward. Unfortunately, we are now faced with those in the fi eld who espouse that FSD is just another "made-up-by-pharmadisease" to sell drugs and make money for their stockholders. ISSWSH has responded with a position statement that will be circulated among all the societies dedicated to both male and female sexual function. This will be an important effort for our patients, whose voices are not being heard.

The Journal of Sexual Medicine, 2013

Introduction. Sexual health issues for women who have cancer are an important and under-diagnosed... more Introduction. Sexual health issues for women who have cancer are an important and under-diagnosed and undertreated survivorship issue. Survivorship begins at the time a cancer is detected and addresses health-care issues beyond diagnosis and acute treatment. This includes improving access to care and quality-of-life considerations, as well as dealing with the late effects of treatment. Difficulties with sexual function are one of the more common late effects in women. Aim. This article attempted to characterize the etiology, prevalence, and treatment for sexual health concerns for women with gynecological cancer. Methods. A systematic survey of currently available relevant literature published in English was conducted. Results. The issue of sexual health for women with cancer is a prevalent medical concern that is rarely addressed in clinical practice. The development of sexual morbidity in the female cancer survivor is a multifactorial problem incorporating psychological, physiologic, and sociological elements. Treatments such as chemotherapy, radiation therapy, surgery, and hormonal manipulation appear to have the greatest influence on the development of sexual consequences. Sexual complaints include but are not limited to changes in sexual desire, arousal, and orgasmic intensity and latency. Many women suffer from debilitating vaginal dryness and painful intercourse. Conclusions. Many of the sexual health issues experienced by cancer survivors can be addressed in clinical practice. A multimodal treatment paradigm is necessary to effectively treat these sexual complaints in this special patient population. Krychman M and Millheiser LS. Sexual health issues in women with cancer.

The Journal of Sexual Medicine, 2006

Penile erection requires association of soluble guanylyl cyclase with endothelial caveolin-1 in r... more Penile erection requires association of soluble guanylyl cyclase with endothelial caveolin-1 in rat corpus cavernosum.

The Journal of Sexual Medicine, 2006

Oncology patients often present to healthcare providers with a history of pre-existing psychiatri... more Oncology patients often present to healthcare providers with a history of pre-existing psychiatric conditions. Associated treatments are well known to impact sexual functioning. The identification of these confounding conditions and medications is an integral part of the comprehensive management of sexual dysfunction in oncology patients. To report the prevalence of psychiatric diagnoses and agents in an oncology sexual health clinic. A retrospective review was performed using 204 sequential charts of patients who attended the Sexual Health Program at Memorial Sloan-Kettering Cancer Center from March 2003 through August 2004. All patients were evaluated by a sexual medicine gynecologist and received an extensive medical history, psychosexual assessment, and a focused gynecologic examination. Fourteen patients (7%) did not have cancer and were excluded from further analysis. Of the remaining 190 patients, the median age at initial visit was 48 years (range 22-76) and the majority of patients were menopausal (87%). The most common diagnosis was breast cancer (44%). One hundred twenty-eight patients (67%) had prior pelvic surgery and 43 (23%) had prior pelvic radiation. The most frequently encountered sexual complaints were dyspareunia (65%), vaginal dryness (63%), hypoactive desire disorder (46%), and orgasmic dysfunction (7%). At initial presentation, 52 patients (27%) reported having a prior or concurrent psychiatric diagnosis and 72 (38%) were taking an anti-depressant and/or an anxiolytic. Treatment recommendations for sexual dysfunction consisted of psychosexual counseling, psychiatric referral, vaginal moisturizers and lubricants, hormonal therapy with minimally absorbed vaginal estrogen suppositories, vaginal dilators, and/or skilled exercise. Psychiatric conditions are commonly encountered in the oncology population as are the medications to treat them. Because it is well established that these medications are often implicated in sexual dysfunction, further research is needed to determine the mechanism of action within the desire pathway of the cancer patient and treatment of such disorders.

The Journal of Sexual Medicine, 2013

Introduction. Vaginal atrophy results from a decrease in circulating estrogen and is experienced ... more Introduction. Vaginal atrophy results from a decrease in circulating estrogen and is experienced by approximately 50% of postmenopausal women. Its symptoms affect multiple dimensions of genitopelvic health, sexuality, and overall quality of life. Nonhormonal over-the-counter treatments may provide temporary symptom relief, but the condition is progressive, and hormonal treatment may be warranted. Aim. The study aims to review the literature and discuss the impact of atrophic vaginitis and various treatment options, including the resistance and barriers to the use of local estrogen therapy for atrophic vaginitis. This article also aims to provide a greater awareness of the condition and the difficulties in communicating effectively with patients, and to provide strategies to help healthcare professionals acquire effective communication skills to initiate a candid dialogue with patients who may be suffering in silence and may benefit from therapy. Methods. This review was based on peer-reviewed publications on the topic of atrophic vaginitis and local estrogen therapy identified from key word searches of PubMed, in addition to landmark studies/surveys and treatment guidelines/recommendations on menopause available in the literature and on the Internet. Main Outcome Measures. The main outcomes are the impact of atrophic vaginitis and the various treatment options, including the resistance and barriers to the use of local estrogen therapy. Results. Minimally absorbed local vaginal estrogen therapy enables administration of estrogen doses much lower than systemic doses used for vasomotor symptoms. Local therapy is also the first-line pharmacologic treatment recommended by the North American Menopause and International Menopause Societies. Despite treatment options, the sensitive nature of the condition and embarrassment may prohibit or limit many women from openly discussing symptoms with healthcare professionals. Many are hesitant to initiate hormonal treatment because of safety concerns. Conclusions. Healthcare professionals should initiate and encourage frank and candid conversation about vaginal atrophy at annual visits and provide follow-up and treatment as needed. Kingsberg SA and Krychman ML. Resistance and barriers to local estrogen therapy in women with atrophic vaginitis.

International Journal of Women's Health, 2013

Several recent, large-scale studies have provided valuable insights into patient perspectives on ... more Several recent, large-scale studies have provided valuable insights into patient perspectives on postmenopausal vulvovaginal health. Symptoms of vulvovaginal atrophy, which include dryness, irritation, itching, dysuria, and dyspareunia, can adversely affect interpersonal relationships, quality of life, and sexual function. While approximately half of postmenopausal women report these symptoms, far fewer seek treatment, often because they are uninformed about hypoestrogenic postmenopausal vulvovaginal changes and the availability of safe, effective, and well-tolerated treatments, particularly local vaginal estrogen therapy. Because women hesitate to seek help for symptoms, a proactive approach to conversations about vulvovaginal discomfort would improve diagnosis and treatment.

Gynecologic Oncology, 2004

Chemotherapy can cause vaginal irritation and mucositis, although rarely reported. A 62-year-old ... more Chemotherapy can cause vaginal irritation and mucositis, although rarely reported. A 62-year-old patient with ovarian cancer reported vaginal burning associated with dyspareunia, which emerged 3-5 days after her initial chemotherapy and persisted throughout her treatment. Her discomfort persisted until she was evaluated by our sexual health service and interventions were implemented. On examination, her vaginal vault was erythematous, with mild signs of vaginal atrophy. Her management schema consisted of the following: avoidance of intercourse 3-5 days after chemotherapy, intravaginal vitamin E suppositories three times per week, intravaginal estrogen tablets (initial course of 14 days followed by twice weekly usage), use of lubricants (Astroglide) during coitus, and counseling. Once interventions were introduced, she subsequently resumed sexual intercourse during the remainder of her chemotherapy treatments. Patients with sexual complaints during or following cancer treatment can be treated by their community gynecologists or gynecology oncologists or can be treated through a comprehensive sexual health program with restoration of sexual function.