Choking the chicken has risks.

Masturbation

When it comes to sexual pleasure, masturbation can both help and hurt your sexual satisfaction. For those of you uncertain exactly what masturbation entails,  masturbation is the term for genital self-stimulation.

The downside of masturbation? Reaching orgasm through masturbation can make orgasm difficult to achieve with a partner.

Men can develop what is called “delayed ejaculation”, where it’s difficult — or even impossible — to orgasm during partner sex because he’s man-handled himself to the point where orgasm occurs only through the EXACT pressure, friction and rhythm from his own hand, something a partner’s hand, mouth, vagina or anus simply cannot replicate. Further, the instant gratification from masturbating can be so appealing that one loses interest in sex with a partner.

Sex Addiction & Pornography

Internet-fueled pornography addiction lends a modern day wrinkle to the ramifications of masturbation, where men (usually) become so acclimated to the variety and instant, rapid fire gratification potential of online pornography that they become sexual anorexics when it comes to real-time sex with a real live woman. How sad! There’s even a website devoted to this social blight: Partners of Sex Addicts Resource Center that offers help for porn-addiction and related issues. Porn masturbation sex addiction is ruining relationships with such voraciousness that the courts are clogged with the detritus of porn-rocked marriages suffering from cybersex addicted spouses.

Women run the risk of developing their own version of “delayed ejaculation” finding themselves in a similar predicament where orgasm is possible only through genital self-stimulation, without which anorgasmia takes over, making partner-sex, well, “anti-climatic”….

Onanism

Traditionally reviled in Judeo-Christian societies, ejaculating outside of the reproductive parts of a woman was a mortal sin for which Onan, second son of Judah, was struck dead prematurely by Yahweh Himself for “spilling his seed upon the ground”. References to the evil and inevitable effects of “Onanism” in Victorian-era health manuals included cerebral palsy (they had a different name for it back then), mental retardation and birth defects of all varieties, not to mention insanity and infertility in the afflicted self-abusers. Oye!

The upside of masturbation (beyond male hydraulics)? Contemporary sex science shows that masturbation can help men control orgasm and avoid premature ejaculation, –and can help both men and women feel more confident about sexuality by allowing you to discover the variety of maneuvers your partner finds advantageous.

The moral (don’t act like you didn’t see this coming) of the masturbation story? Use it, don’t abuse it.

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Vaginal prolapse surgery with synthetic and non-synthetic graft material -

Concerns about the use of graft material, particularly Prolene mesh, continue to mount after the most recent FDA warning on mesh in vaginal surgery.  These diligent authors from Michigan, Texas, Massachussetts, Washington State, New Mexico and Israel combed the international medical literature in all languages from 1950 to present, looking for data on adverse events when graft material is used at the time of vaginal prolapse repair. Three common problems, erosion (graft eroding through the vaginal skin so that it is palpable to touch and/or visible to the examining eye), granulation tissue (“proud flesh” commonly found in wounds as they heal inside and outside of the body), and dyspareunia (painful sex) were the key factors under review.

Granulation, Erosion, Dyspareunia and Prolapse Organ Prolapse Surgery with Graft Materials

What they found is that rates of each of the three complications did not differ between synthetic (such as non-absorbable Prolene or absorbable  Vicryl mesh) vs non-synthetic (such as porcine [Surgisis] or bovine [Xenform] or human cadaver-based) graft material, and that reportage with regard to sexual problems was so spotty and incomplete that it was difficult to figure out if women with sexual pain after surgery had sexual pain before surgery with the problem persisting after reconstruction, or whether it was clear that the surgery definitely caused the dyspareunia (sexual pain).

Of the more than 2000 mauscripts considered, less than 200 were included and most did not report on all three of these possible complications. In more recent years, the reportage tended to be consistent with our modern-day concerns, as one might expect the case to be.

Bottom line: there are no guarantees. Grafts reduce prolapse recurrence rates, but come with their own set of headaches.

To mesh or not to mesh?

Synopsis for the Journal of Sexual Medicine from original manscript published in the July 2011 issue of the International Urogynecology Journal:

Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Roberts RG

Incidence and management of graft eriosion, wound granulation and dyspareunia following vagianl prolapse repair with graft maeriasl: a stematic review.

Int Urogynecol J (2011) 22:789-98.

This metanalysis reviewed global data published from 1950-2010 from papers  reporting adverse events after vaginal prolapse repairs using graft materials. 2260 citations were identified using Medline search terms including vaginal or uterine prolapse, rectocele, surgical mesh, cystocele, and similar pelvic  floor terms. After review of each, data from 196 manuscripts was included in this analysis. Graft erosion was reported in 110 studies (10.3%) with similar rates for synthetic and biologic grafts.  Diagnosis of erosion occurred between 6 weeks and 12 months. The most common risk factor for erosion was concomitant hysterectomy, as well as patient age, smoking and diabetes, surgeon experience, and use of T incision of vaginal skin during dissection. Granulation tissue as reported in 7.8% of the 16 papers reporting on this outcome in series using a single type of graft material. While not statistically significant, the reported rate of granulation was higher with biologic graft material than with synthetic/permanent graft material (9.1% and 6.8%, respectively). Spontaneous resolution of granulation tissue and resolution with suture removal and silver nitrate treatment were reported treatment options.

Dyspareunia was reported in 71 papers with overall incidence of 9.1%, rates similar between synthetic and biologic grafts, with risk factors including posterior repair and mesh erosion. Listed treatments included vaginal estrogen cream and excision of eroded mesh. The authors point out that many of these studies did not limit reportage to sexually active women, nor make clear whether the painful sex was persistent or de novo. They also remind the readers that dyspareunia is known to occur with native tissue repairs also, operations where no graft material of any sort is used. The authors go on to report that most of the studies did not including what proportion of women sere sexually active, how may had pre-existing sexual dysfunction and how many benefited from improved sexual function. They state that as more studies use the validated quality of life Pelvic Organ Prolapse / Urinary Incontinence Sexual Questionnaire, the quality of  data on the impact of pelvic floor surgery on sexual function will improve in accuracy and clinical relevance.

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Vaginal Prolapse Surgery, Vaginal Contour and Female Sexual Function

This is another manuscript I reviewed for the Journal of Sexual Medicine, published by colleagues from The Mayo Clinic in the International Urogynecology Journal July 2011 issue. These authors looked carefully at the possibility of change in vaginal contour resulting from pelvic organ prolapse surgery with regards to female sexual function. They measured vaginal length and width before, immediately after (patient still in the operating room under anesthesia, case finished), and 6 months after surgery. The women completed a validated questionnaire for prolapse, incontinence and sexual function in women called the PISQ-12 before and 6 months after surgery. In summary, vaginas were a bit shorter and a bit narrower after surgery, and sexual function quality of life questionnaire scores did not change, nor did sexual satisfaction or lack thereof correlate to vaginal measurements either before or after surgery.  This helpful study will no doubt be repeated in various fashion as we in the field of urogynecology do our best to adhere to the mandate of “primum non nocere” (first, do no harm).

Once you’ve done this:

Childbirth - good thing they're so cute

You might need this:

Cutting & Sewing - 2 darts and a dash of facing, voila!

To get back to this:

Anatomy in 3-D - the vagina in relation to the rest of you

Journal summary:

Ochhino JA, Trabuco EC, Heisler CA, Klingele CJ, Gebhart JB.

Changes in vaginal anatomy and sexual function after vaginal surgery.

Int Urogynecol J (2011) 22:799-804

The authors enrolled 92 women undergoing vaginal reconstruction prolapse surgery in study including pre- and post-surgery completion of a validated sexual function questionnaire (PISQ-12) and in measurement of vaginal contour before, immediately after, and 6 months after surgery in order to determine whether changes in vaginal length and caliber correlate to changes in sexual function. All but one of the women was white. 72.8% were menopausal and 16.3% had undergone one prior prolapse operation. 47.8% were sexually active before surgery with a preoperation PISQ-12 score of 33.5. Pre-operation vaginal length was 10.4 cm on average with mean caliber 3.2 cm. Some women had intentional coning (narrowing) of the top of the vagina to correct excessive laxity and some did not – those undergoing coning (N=14) were evaluated separately from those who did not (N=78) for post-op vaginal contour measurements.

Immediately after surgery while still anesthetized, vaginal length of women with no coning was reduced to 7.9 cm with caliber 3.0 cm while coned patients measured 6. 8 cm length with caliber 2.8 cm. At 6 months postop, the no-cone women measured 8.7 cm length with 2.8 cm caliber while coned women continued to measure 6.8 cm length with .2 cm caliber.

74 women completed the PISQ-12 prolapse-incontinence-sexual function questionnaire at 6 months post-surgery, with 52.6% sexually active. Only 34 sexually active women completed the questionnaire before and after surgery, and in this group no change in score was demonstrated (33.4 vs 34.7). Further, no correlation was found between pre0operation score and vaginal length or caliber or between post operation score and vaginal length or caliber. The authors did not comment on the drop-out rate for questionnaire completion. They point out that, according to this data in this first study to look at changes in vaginal contour as correlates to sexual function, changes in vaginal dimensions does not seem to affect sexual function in women who were sexually active before and after the pelvic organ prolapse operation.

Level of evidence: III Count: 325 words

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Painful sex after menopause

Hello Dr. R,

I am a 51 year old that has pain upon entry, visited my doctor and he is suggesting a perineoplasty, is that the same procedure as a Fenton’s?  Is there anything else that wouldn’t be as invasive? I do not want to take hormones and I am not ready for my sexual life to be over.  Once the opening is loosened up a bit it doesn’t hurt as long as I use a lubricant. Would this be a senario for a perineoplasty?  Thank you so much!

Painful sex (dyspareunia) after menopause is best treated with a dose of creativity - rush not to the knife!

Dyspareunia: perspective from a urogynecologist

Hello L,

Without examining you, it is impossible to know if a perineoplasty is your only treatment option for painful sex (dyspareunia). I strongly suggest you seek second opinions from urogynecology specialists in your area, which you may locate through American Urogynecologic Society. Therapies may include vaginal estrogen, dilators, pelvic floor physical therapy, pelvic floor electrical stimulation, valium vaginal suppositories, or some combination there-of.  You may consider perineoplasty and Fenton’s to be synonymous for this indication. Keep us posted…

Dr R

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Labiaplasty, cosmetic gynecologic surgery, female sexual function and anatomy of the female vulva

Vulvar anatomy circa 1798. Some things never change. Thank goodness...

Every two months I report for on scientific manuscripts in the recent medical literature for the Journal of Sexual Medicine that pertain to female sexual function. In an anatomic study of vulvar anatomy published in the journal of the American Urogynecologic Society, scientists took a close look at the microscopic goings on of labia minora. The controversy over labiaplasty and other forms of cosmetic gynecologic surgery rages on, with proponents on both sides claiming “fair” and “foul” in equal measure.

The clitoris has erectile function

Unless you believe in the G-Spot orgasm and are of the opinion that there is a difference between “internal/vaginal” and “external/clitoral” orgasms for women, you’re probably in agreement with most physiologists and anatomists that the female orgasm emanates from the clitoris, the organ in the body with the highest density of sensory nerves and an intense erectile response to sexual stimulation. That’s right, ladies. Your clitoris gets a woody every time you have an orgasm, or even get aroused.  The role of labia majora and labia minora in this erectile and orgasmic function is so poorly understood it’s almost criminal. Seriously – do you know how much is understood about male sexual function and role of erectile tissue in a man’s sexual pleasure? They’ve written books about it. An entire pharmaceutical industry is making $$bajillions catering to it. Courses are taught, books are written, Medicare PAYS FOR IT (all of it) right down to the fancy shmancy-est of prosthetic penile implants.

Labia minora: high density of nerve function and blood flow

So this study took a look at the micro-anatomy of labia minora. Few studies have reported any meaningful data on labiaplasty’s (surgical reduction of labia minora) impact on sexual function. There is one study by a renowned cosmetic genital surgeon who reported that out of 166 women undergoing combined labiaplasty and clitoral hood reduction, 38 reported better sexual pleasure and 9 reported a worse, or a negative impact on sexual function, from the procedure. This raises the question that it may be possible for genital cosmetic operations done to improve sexual function may actually have the opposite effect…

Being that the subjects in this particular study were all cadavers, evaluating sexual function was not possible. But the researchers did find a high density of nerve fibers on both the outer and inner surfaces of labia minora in all specimens, in addition to a high density of blood vessels, in excess of that needed to maintain the skin of the labia, indicating a high likelihood that the blood vessels of the labia minora play some role in the sexual response and possibly in the engorgement and erectile function of the clitoris, although these points remain to be proved in studies on live women.

Remember, one study does not an absolute fact make. This area of gynecologic surgery is in evolution, and this anatomy study is one important contribution to that body of literature that will permit, over time, for meaningful conclusions to be made.

Here’s the summary to appear in the Journal of Sexual Medicine sometime this fall:

Ginger VAT, Cold CJ, Yang CC.

Structure and innervation of the labia minora: more than minor skin folds.

2011 Female Pelvic Medicine & Reconstructive Surgery  17:4, 180-3.

Eight fresh cadaveric vulvar specimens were fixed and stained to report the histologic features of the labia minora with regard to female sexual function.

Labia were highly variable in appearance. Labia minora were thin in relation to majora, and in some cases fused. No labia minora contained fatty component, as do the labia majora. After fixation and histologic staining, the inner labum minus were found to be  covered by a basket-weave keratin type dermis.. The substance included numerous vascular structures surrounded by connective collagen and no smooth muscle, thereby making the labia minora vascular tissue non-erectile.  Elastin was abundant, as were neural elements with no difference in distribution of neural elements between the lateral and medial sides of the labia minora. There was a central core of neural elements long the length of the labia, traveling alongside vascular structures to form the neuro-anatomic substrate where sexual arousal results in labial engorgement. Neural elements were sparse with in the labia majora.  Histologic images are included to illustrate these findings. The authors go on to comment on genital labioplasty done for aesthetic or functional reasons, reiterating that reports of diminished sexual responsiveness are documented in at least one series of 166 women undergoing labiaplasty and clitoral hood reduction, where 9 reported negative effect on sexual sensation in contrast to 38 reporting improved sexual sensations.  They note that among reports on labia minora structure, very little mention is made of possible function. They comment that the specimens obtained for hits study were likely, but not know for certain, to be from menopausal women in which degenerative changes would have been present and that despite this, a high density of neural and vascular elements were found in the labia minora of the specimens evaluated.  They finish by stating that “Biochemical and molecular studies may further elucidate (the labia minora’s) role in the female sexual response,… which are specialized vascular structures with densely distributed neural elements providing anatomic substrate for changes observed during sexual arousal”.

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

FEMALE SEXUAL DYSFUNCTION & ANDROGEN DEFICIENCY

Just because you’ve gone through menopause doesn’t mean sex—and the DESIRE for sex—should stop.

Ten years ago, a sex study published in Journal of the American Medical Association found that 43% of women suffer from sexual dysfunction at some point…compared to just 31% of men.

To be fair, and clear, the conclusions drawn from this study continue to be hotly debated since publication, as many in the healthcare profession raised concerns about the medicalization of women’s sexuality and the integrity of this study’s conclusions, which many specialists consider exaggerated.

That said, many women find the age related decrease in sexual urges disturbing and distressing.

Traditionally, a woman reporting problems with libido finds herself thwarted in her efforts to restore prior sexual appetites, as the medical profession is notorious for telling women they have to “live with it”.

Testosterone is good for girls AND boys

Despite this, the only FDA-approved treatments for problems between the sheets—Viagra, Cialis, and Levitra—target men.

This is why Procter and Gamble introduced Intrinsa, a testosterone patch medication designed to treat female sexual dysfunction, or FSD, caused by natural reductions in testosterone as women approach age 50. Low testosterone can affect libido and sexual arousal.

FSD involves any condition involving the inability to become or remain aroused during sex, the inability to achieve an orgasm,  and/or the presence of pain during intercourse. Not all of these symptoms are due to testosterone deficiency. The symptoms of FSD are often more prominent during hormonally vulnerable periods, like menopause or during lactation and breast feeding. Menopause can occur naturally with age, or abruptly when a woman’s ovaries are removed surgically.

Intrinsa is targeted at women who have undergone the menopausal transition and who are suffering sexually as a result of the age-related, inevitable drop in testosterone levels. Intrinsa  is a clear, egg-shaped patch which adheres to the skin on a woman’s belly that works by releasing small, controlled amounts of testosterone into a woman’s bloodstream.

Testosterone is a “masculine” sex hormone which is produced by a woman’s ovaries and adrenal gland. A woman’s testosterone level drops with most with birth control pills, and always with natural or surgical menopause. By age 45 or so, most women’s testosterone levels have decreased  by 50% from peak levels in the mid-20′s!

The theoretical clinical benefit to increasing serum levels of testosterone in the blood is to  reduce libido and arousal symptoms of FSD. Being a patch, Intrinsa CAN cause side effects, such as rash, redness, itching, and irritation at the patch site.

More importantly, testosterone is a powerful hormone, to be used with the greatest of caution and fastidious monitoring. More is NOT better! Because testosterone is a male sex hormone, overdosing may cause extremely troubling and potentially irreversible side effects such as: deepening of the voice, an increase in facial hair, enlargement of the clitoris, weight gain, cardiovascular conditions and hair loss.

Despite Intrinsa’s promise to effectively treat sexual dysfunction, however, the US FDA rejected the medication in 2004, citing a need for more studies. As a result, Proctor and Gamble took Intrinsa to Europe, where it is available by prescription. If you want to try Intrinsa, clear it with your doctor and hop the red-eye. Otherwise, women in the States suffering arousal disorder-type sexual dysfunction can talk to their gynecologist about diagnosing and treating androgen deficiency syndrome…a fancy term for “low testosterone”, that may be treatable with off-label applications of currently available hormone preparations on this side of the pond.

The Center for Disease Control attests that at least 77% of American adults don’t get enough Vitamin D. And while that’s bad news for everyone, it’s often WOMEN who suffer most.

Vitamin D - good for bones, prolapse, incontinence, autism, ...

Vitamin D is involved in regulating up to 2,000 different genes in the human body.

Considering that this amounts to 10% of our makeup, it’s disturbing that so many adults are D deficient.

Recent research shows that women in particular should be concerned about getting adequate levels of vitamin D.

A study at Boston University School of Medicine recently found that pregnant women who are vitamin D deficient are FOUR TIMES more likely to require delivery by cesarean section.

Similarly, the risk for both preeclampsia, which is dangerously high blood pressure, and pre-term labor, is significantly increased when a mom-to-be is lacking the nutrient.

And risks from a mom’s D-deficiency extend to an infant, as well.

Vitamin D is important for the proper development of a fetus’s brain, and it’s a significant factor in preventing respiratory infections and wheezing after birth.

Vitamin D deficiency is also being investigated as a potential culprit in the development of autism!

Low levels of the nutrient can also make it more difficult to conceive a pregnancy in the first place, according to findings reported in the American Journal of Clinical Nutrition.

And even if you’re not trying to conceive, researchers at Creighton University in Omaha found that women who get adequate amounts of vitamin D are up to 60% LESS likely to get breast, skin and lung cancer.

Plus, multiple studies have linked vitamin D deficiency in women to mood disorders such as premenstrual syndrome, seasonal affective disorder, major depressive disorder, and non-specific mood disorder.

Postmenopausal women should be aware that low levels of the nutrient may lead to osteoporosis, or thinning bones.

Women of all ages with vitamin D Deficiency are more likely to suffer urinary incontinence and pelvic organ prolapse.

No matter what your age or stage of life, ensure that you’re getting enough of this VITAL nutrient by asking your doctor to test your blood levels.

Women who are deficient may benefit from a daily supplement or increased sun exposure.

To learn more about essential vitamins and minerals, check out this video on Vitamin D and Womens Health, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.