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Coital Incontinence: The Tip of the Iceberg?
2287
Letters to the Editor References 1 Kohn LT, Corrigan J, Donaldson MS. To err is human: Building a safer health system. Washington, DC: National Academy Press; 2000. 2 Sathesh-Kumar T, Hanna-Jumma S, De’zoysa N, Saleemi A. Genitalia strangulation—Fireman to the rescue! Ann R Coll Surg Engl 2009;91:W15–6. 3 Silberstein J, Grabowski J, Lakin C, Goldstein I. Penile constriction devices: Case report, review of the literature, and recommendations for extrication. J Sex Med 2008;5:1747–57. 4 Yacobi Y, Tsivian A, Sidi AA. Emergent and surgical interventions for injuries associated with eroticism: A review. J Trauma 2007;62:1522–30. 5 Koornstra JJ, Weersma RK. Management of rectal foreign bodies: Description of a new technique and clinical practice guidelines. World J Gastroenterol 2008;14:4403–6.
6 Griffin R, McGwin G, Jr. Sexual stimulation device-related injuries. J Sex Marital Ther 2009;35:253–61. 7 Overview of the Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP)website. 2006. Available at: http://www.hcup-us.ahrq.gov/nisoverview.jsp. (accessed April 24, 2009). 8 Herbenick D, Reece M, Sanders S, Dodge B, Ghassemi A, Fortenberry JD. Prevalence and characteristics of vibrator use by women in the United States: Results from a nationally representative study. J Sex Med 2009;6:1857–66. 9 Reece M, Herbenick D, Sanders SA, Dodge B, Ghassemi A, Fortenberry JD. Prevalence and characteristics of vibrator use by men in the United States. J Sex Med 2009;6:1867–74. 10 Ferenidou F, Kapoteli V, Moisidis K, Koutsogiannis I, Giakoumelos A, Hatzichristou D. Presence of a sexual problem may not affect women’s satisfaction from their sexual function. J Sex Med 2008;5:631–9.
Coital Incontinence: The Tip of the Iceberg?
jsm_1803
2287..2297
DOI: 10.1111/j.1743-6109.2010.01803.x
In November 2009, the International Urogynecological Association and the International Continence Society published a new joint report on the terminology for female pelvic floor dysfunction [1]. For the first time, coital incontinence (CI) was included in the Symptoms section and defined as the “complaint of involuntary loss of urine with coitus.” Its classification is based also on the timing of occurrence: “This symptom might be further divided into that occurring with penetration and that occurring at orgasm.” This is a relevant step for a better understanding and managing of this dramatic and, until now understudied, urinary and sexual disorder. The overall prevalence of urinary incontinence in a female general population varies between 25% and 45% [2] and a recent study reported that about 25% of sexually active incontinent women also complain of urinary incontinence during intercourse [3]. This symptom can cause very relevant consequences on sexual function of this female population. In fact, a recently published paper demonstrated that among sexually active women with urinary symptoms, patients with coital urinary incontinence had a higher impact on their quality of life (QoL) than those without CI. In this study, CI was the only variable independently related to a King’s Health Questionnaire high score, suggesting worse QoL [4]. Despite this,
only recently, researchers have focused their attention on this topic. Some papers in fact demonstrated two different pathophysiological mechanisms for CI: urodynamic stress incontinence (USI) in case of CI at penetration and detrusor overactivity in case of CI during orgasm [5,6]. This classification seems to be important also in the therapy choice, which reaches a better efficacy if antimuscarinics are prescribed in case of CI occurring at orgasm [6] or if a mid-urethral sling is performed when it occurs at penetration [5,7]. In November 2009, The Journal of Sexual Medicine published an interesting and intriguing paper, specifically designed to investigate the relevance of CI in the sexual function improvement following slings for USI [3]. Although this study had some biases, such as the retrospective design, the use of nonvalidated questionnaire, and the lack of distinction between incontinence during orgasm or at penetration, it is very important and original demonstrating for the first time that the most significant prognostic factor in the improvement of sexual function of these patients was the cure of CI. What was described about CI can be just the tip of the iceberg: further larger prospective studies on this issue will be hopefully to understand the real prevalence, the impact on QoL, the J Sex Med 2010;7:2284–2294
2288 pathophysiology, and the cure rate of this urinary and sexual symptom. Maurizio Serati, MD Elena Cattoni, MD, and Stefano Salvatore, MD University of Insubria, Del Ponte Hospital— Department of Obstetrics and Gynecology, Varese, Italy Conflict of Interest: None. Statement of Authorship
Category 1 (a) Conception and Design Maurizio Serati; Elena Cattoni; Stefano Salvatore
Category 2 (a) Drafting the Article Maurizio Serati; Elena Cattoni (b) Revising It for Intellectual Content Stefano Salvatore
Letters to the Editor References 1 Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, Monga A, Petri E, Rizk DE, Sand PK, Schaer GN. An International Urogynecological Association (IUGA)/ International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2010;21:5–26. 2 Milsom I. Lower urinary tract symptoms in women. Curr Opin Urol 2009;19:337–41. 3 Bekker M, Beck J, Putter H, Venema P, A Nijeholt AL, Pelger R, Elzevier H. Sexual function improvement following surgery for stress incontinence: The relevance of coital incontinence. J Sex Med 2009;6:3208–13. 4 Espuña Pons M, Puig Clota M. Coital urinary incontinence: Impact on quality of life as measured by the King’s Health Questionnaire. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:621–5. 5 Serati M, Salvatore S, Uccella S, Nappi RE, Bolis P. Female urinary incontinence during intercourse: A review on an understudied problem for women’s sexuality. J Sex Med 2009;6:40– 8. 6 Serati M, Salvatore S, Uccella S, Cromi A, Khullar V, Cardozo L, Bolis P. Urinary incontinence at orgasm: Relation to detrusor overactivity and treatment efficacy. Eur Urol 2008;54:911–5. 7 Serati M, Salvatore S, Uccella S, Zanirato M, Cattoni E, Nappi RE, Bolis P. The impact of the mid-urethral slings for the treatment of stress urinary incontinence on female sexuality. J Sex Med 2009;6:1534–42.
Category 3 (a) Final Approval of the Completed Article Maurizio Serati; Elena Cattoni; Stefano Salvatore
Fractured Penis: Diagnosis and Management—A Comment
jsm_1813
2288..2298
DOI: 10.1111/j.1743-6109.2010.01813.x
Regarding “Fractured Penis: Diagnosis and Management”
I commend Dr. Al-Shaili and his co authors on their excellent review article, and wish to comment on one small issue in the etiology section [1]. Stating that penile fractures occur when short-term intracavernous pressure exceeds tunica tensile strength during acute loading implies that these injuries are “blow outs.” While I agree that intracavernous pressures can be very high during sex and that the erect penis is prone to injury, I think penile fractures are not high pressure effects but rather tears in the tunica brought on by bending [2]. I believe two bits of evidence support this view. The first is empirical, cited by the authors as the tendency for fractures to be transverse in orientation. Sudden angulation creates longitudinal tensile stress along the convexity, which would tend to make the tunica fail transversely. The second consideration is more theoretical. Calculation shows J Sex Med 2010;7:2284–2294
that transverse or hoop-oriented wall stress in a cylindrical pressure vessel is exactly twice the value of longitudinal stress [2], making “blow outs” or pressure failures of a cylindrical vessel manifest as longitudinal splits. The authors commented on the rarity of longitudinal tears in penile fractures. The forgoing has little clinical significance, and in no way detracts from a very informative and well-written article. Martin K. Gelbard, MD UCLA School of Medicine Conflict of Interest: None. References 1 Al-Shaiji TF, Amann J, Brock GB. Fractured penis: Diagnosis and management. J Sex Med 2009;6:3231–40. 2 Gelbard M. The disposition and function of elastic and collagenous fibers in the tunic of the corpus cavernosum. J Urol 1982;128:850–1.
Letters to the Editor References 1 Kohn LT, Corrigan J, Donaldson MS. To err is human: Building a safer health system. Washington, DC: National Academy Press; 2000. 2 Sathesh-Kumar T, Hanna-Jumma S, De’zoysa N, Saleemi A. Genitalia strangulation—Fireman to the rescue! Ann R Coll Surg Engl 2009;91:W15–6. 3 Silberstein J, Grabowski J, Lakin C, Goldstein I. Penile constriction devices: Case report, review of the literature, and recommendations for extrication. J Sex Med 2008;5:1747–57. 4 Yacobi Y, Tsivian A, Sidi AA. Emergent and surgical interventions for injuries associated with eroticism: A review. J Trauma 2007;62:1522–30. 5 Koornstra JJ, Weersma RK. Management of rectal foreign bodies: Description of a new technique and clinical practice guidelines. World J Gastroenterol 2008;14:4403–6.
6 Griffin R, McGwin G, Jr. Sexual stimulation device-related injuries. J Sex Marital Ther 2009;35:253–61. 7 Overview of the Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP)website. 2006. Available at: http://www.hcup-us.ahrq.gov/nisoverview.jsp. (accessed April 24, 2009). 8 Herbenick D, Reece M, Sanders S, Dodge B, Ghassemi A, Fortenberry JD. Prevalence and characteristics of vibrator use by women in the United States: Results from a nationally representative study. J Sex Med 2009;6:1857–66. 9 Reece M, Herbenick D, Sanders SA, Dodge B, Ghassemi A, Fortenberry JD. Prevalence and characteristics of vibrator use by men in the United States. J Sex Med 2009;6:1867–74. 10 Ferenidou F, Kapoteli V, Moisidis K, Koutsogiannis I, Giakoumelos A, Hatzichristou D. Presence of a sexual problem may not affect women’s satisfaction from their sexual function. J Sex Med 2008;5:631–9.
Coital Incontinence: The Tip of the Iceberg?
jsm_1803
2287..2297
DOI: 10.1111/j.1743-6109.2010.01803.x
In November 2009, the International Urogynecological Association and the International Continence Society published a new joint report on the terminology for female pelvic floor dysfunction [1]. For the first time, coital incontinence (CI) was included in the Symptoms section and defined as the “complaint of involuntary loss of urine with coitus.” Its classification is based also on the timing of occurrence: “This symptom might be further divided into that occurring with penetration and that occurring at orgasm.” This is a relevant step for a better understanding and managing of this dramatic and, until now understudied, urinary and sexual disorder. The overall prevalence of urinary incontinence in a female general population varies between 25% and 45% [2] and a recent study reported that about 25% of sexually active incontinent women also complain of urinary incontinence during intercourse [3]. This symptom can cause very relevant consequences on sexual function of this female population. In fact, a recently published paper demonstrated that among sexually active women with urinary symptoms, patients with coital urinary incontinence had a higher impact on their quality of life (QoL) than those without CI. In this study, CI was the only variable independently related to a King’s Health Questionnaire high score, suggesting worse QoL [4]. Despite this,
only recently, researchers have focused their attention on this topic. Some papers in fact demonstrated two different pathophysiological mechanisms for CI: urodynamic stress incontinence (USI) in case of CI at penetration and detrusor overactivity in case of CI during orgasm [5,6]. This classification seems to be important also in the therapy choice, which reaches a better efficacy if antimuscarinics are prescribed in case of CI occurring at orgasm [6] or if a mid-urethral sling is performed when it occurs at penetration [5,7]. In November 2009, The Journal of Sexual Medicine published an interesting and intriguing paper, specifically designed to investigate the relevance of CI in the sexual function improvement following slings for USI [3]. Although this study had some biases, such as the retrospective design, the use of nonvalidated questionnaire, and the lack of distinction between incontinence during orgasm or at penetration, it is very important and original demonstrating for the first time that the most significant prognostic factor in the improvement of sexual function of these patients was the cure of CI. What was described about CI can be just the tip of the iceberg: further larger prospective studies on this issue will be hopefully to understand the real prevalence, the impact on QoL, the J Sex Med 2010;7:2284–2294
2288 pathophysiology, and the cure rate of this urinary and sexual symptom. Maurizio Serati, MD Elena Cattoni, MD, and Stefano Salvatore, MD University of Insubria, Del Ponte Hospital— Department of Obstetrics and Gynecology, Varese, Italy Conflict of Interest: None. Statement of Authorship
Category 1 (a) Conception and Design Maurizio Serati; Elena Cattoni; Stefano Salvatore
Category 2 (a) Drafting the Article Maurizio Serati; Elena Cattoni (b) Revising It for Intellectual Content Stefano Salvatore
Letters to the Editor References 1 Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, Monga A, Petri E, Rizk DE, Sand PK, Schaer GN. An International Urogynecological Association (IUGA)/ International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2010;21:5–26. 2 Milsom I. Lower urinary tract symptoms in women. Curr Opin Urol 2009;19:337–41. 3 Bekker M, Beck J, Putter H, Venema P, A Nijeholt AL, Pelger R, Elzevier H. Sexual function improvement following surgery for stress incontinence: The relevance of coital incontinence. J Sex Med 2009;6:3208–13. 4 Espuña Pons M, Puig Clota M. Coital urinary incontinence: Impact on quality of life as measured by the King’s Health Questionnaire. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:621–5. 5 Serati M, Salvatore S, Uccella S, Nappi RE, Bolis P. Female urinary incontinence during intercourse: A review on an understudied problem for women’s sexuality. J Sex Med 2009;6:40– 8. 6 Serati M, Salvatore S, Uccella S, Cromi A, Khullar V, Cardozo L, Bolis P. Urinary incontinence at orgasm: Relation to detrusor overactivity and treatment efficacy. Eur Urol 2008;54:911–5. 7 Serati M, Salvatore S, Uccella S, Zanirato M, Cattoni E, Nappi RE, Bolis P. The impact of the mid-urethral slings for the treatment of stress urinary incontinence on female sexuality. J Sex Med 2009;6:1534–42.
Category 3 (a) Final Approval of the Completed Article Maurizio Serati; Elena Cattoni; Stefano Salvatore
Fractured Penis: Diagnosis and Management—A Comment
jsm_1813
2288..2298
DOI: 10.1111/j.1743-6109.2010.01813.x
Regarding “Fractured Penis: Diagnosis and Management”
I commend Dr. Al-Shaili and his co authors on their excellent review article, and wish to comment on one small issue in the etiology section [1]. Stating that penile fractures occur when short-term intracavernous pressure exceeds tunica tensile strength during acute loading implies that these injuries are “blow outs.” While I agree that intracavernous pressures can be very high during sex and that the erect penis is prone to injury, I think penile fractures are not high pressure effects but rather tears in the tunica brought on by bending [2]. I believe two bits of evidence support this view. The first is empirical, cited by the authors as the tendency for fractures to be transverse in orientation. Sudden angulation creates longitudinal tensile stress along the convexity, which would tend to make the tunica fail transversely. The second consideration is more theoretical. Calculation shows J Sex Med 2010;7:2284–2294
that transverse or hoop-oriented wall stress in a cylindrical pressure vessel is exactly twice the value of longitudinal stress [2], making “blow outs” or pressure failures of a cylindrical vessel manifest as longitudinal splits. The authors commented on the rarity of longitudinal tears in penile fractures. The forgoing has little clinical significance, and in no way detracts from a very informative and well-written article. Martin K. Gelbard, MD UCLA School of Medicine Conflict of Interest: None. References 1 Al-Shaiji TF, Amann J, Brock GB. Fractured penis: Diagnosis and management. J Sex Med 2009;6:3231–40. 2 Gelbard M. The disposition and function of elastic and collagenous fibers in the tunic of the corpus cavernosum. J Urol 1982;128:850–1.