- Email: [email protected]
P-03-066 Gender dysphoria in adolescence
S204
Methods: He reported erection not sufficient for vaginal penetration in all the sexual attempts. He did not have spontaneous morning erections. He reported normal sexual desire. When he was 4 months old, he developed poliomyelitis and he had flaccid paralysis of the right lower limb. As frequent in poliomyelitis survivors, with ageing he developed fatigue, loss of energy and muscle weakness as well as pain in the paralytic lower limb, conditions consistent with the so-called post-poliomyelitis syndrome. His sexual, physical and psychological symptoms were captured by the International Index on Erectile Function-15 (IIEF-15) and the Aging Male Scale (AMS) questionnaires (Figure 1). Physical exam was normal, except for a borderline body mass index (25 kg/m2) and a slight increase in prostate volume. Penile color Doppler ultrasound, after injection of 10 mcg of prostaglandin E1 (PGE1), showed peak systolic velocity of 34 cm/s and 31.6 cm/s in the right and left arteries, respectively. Total testosterone was 9.1 nmol/L, with sex hormone binding globulin of 40.9 nmol/L (calculated free testosterone 154 pmol/L), LH 1.63 U/L and FSH 10.2 U/L. Results: According to guidelines, low testosterone was confirmed by a second evaluation. All the other hormones and metabolic parameters were normal. PP was diagnosed with hypogonadism and testosterone replacement therapy (TRT) was prescribed. PP started Testosterone gel 2%, 5 applications daily. Follow-up visits were performed every 6 months for the first year and then yearly. Conclusion: He reported a progressive improvement in sexual symptoms, as shown by the IIEF-15 total score and the erectile function subscale (Figure 1, upper panel, blue and red line, respectively) and the AMS sexual subdomain (Figure 1, lower panel, green line). In addition, he reported a great improvement in fatigue, energy and muscle strength, as well as a reduction in right lower limb pain. The improvement in physical symptoms, as assessed by the AMS physical subdomain, is reported in Figure 1 (lower panel, blue line). Psychological symptoms (Figure 2, lower panel, red line) did not change. After 12 months of therapy, a further penile color Doppler ultrasound after PGE1 was performed and an improvement in peak systolic velocity was found (53.6 cm/s and 51 cm/s in the right and left arteries, respectively). Symptoms of late onset hypogonadism are aspecific and often overlap with those of ageing. Low testosterone is frequently found in chronic conditions and it has been reported as a possible late consequence of poliomyelitis. The efficacy of TRT in improving sexual symptoms has been proven by several clinical trials and confirmed by meta-analyses. The efficacy on physical and psychological symptoms is uncertain. This case report shows that TRT, beyond improving sexual symptoms, provided an awesome improvement in physical complaints in a man with post-poliomyelitis syndrome, a condition very bothersome and difficult to treat. Policy of full disclosure: None.
P-03 Cases that Matter Posters
Figure 1. P-03-066 GENDER DYSPHORIA IN ADOLESCENCE Ristori, J.1 1 AOU Careggi, Department of Experimental, Cl, Firenze, Italy Objective: Martin is a 14 years old male born adolescent that came to our clinic with a clear request for a medical treatment for Gender Dysphoria (GD), certain that his intense distress could only be solved by intervening on the body. Before intake, Martin started a rigid diet to stop further body development. Martin lost weight (20 Kg) in a few months reaching a Body Mass Index (BMI) of 17 kg/m2. Methods: After psychological evaluation (clinical psychological interviews and psychometric tests), the GD diagnosis was confirmed. Martin was characterized by early GD onset and by worsening of the distress related to GD with the beginning of puberty. The pubertal body changes going in an unwanted direction underlined his biological and physical male characteristics causing significant distress. Furthermore, puberty was characterized by the onset and/or worsening of symptoms related to depression, low self-esteem, anxiety and suicidal risk as well as negative body image, social withdrawal and early school drop out risk. Those symptoms appeared to be the consequence of the distress related to dealing with GD issues. After intake, Martin underwent also an endocrinological visit at our clinic that revealed a Tanner stage P4 G4 and height of 171 cm. The patient was wearing female underwear and showed intense distress when having to show his genitalia during the medical visit. Results: Considering Martin’s psychological assessment and being elegibility criteria for medical treatment fulfilled, with the pediatric ethical committee permission, Martin was given a gonadotropin-releasing hormone analogue (GnRHa) therapy as a life saving procedure in order to intervene on the suicidal risk and
J Sex Med 2016;13:S172eS212
S205
P-03 Cases that Matter Posters
to improve the severe associated psychopathologies. Also, such medical option, that put a halt to the development of secondary sex characteristics, was aimed to improve psychological wellbeing and favour social adaptation as well as to prevent an early school drop out. Martin started to live in a full time female gender role and choose a female name. Conclusion: From that moment, Martin attended psychological interviews and endocrinological investigations every three months. Results measured at Time 1, 2 and 3 revealed that GnRHa therapy had a positive effect on suicidal risk, mood disorder, anxiety, social adaptation and body image. On the other hand, as expected, GnRHa had no effect on GD. Policy of full disclosure: GnRHa should be available as a medical option for those adolescents with GD that fulfill specific criteria, as indicated by WPATH and Hembree guidelines; specially when severe mood disorders, anxiety disorders, body image disorders or suicidal risk are present. Such option could in fact help adolescents with GD to “buy time” to explore their sexual identity and gender identity, without experiencing the distress of pubertal changes. Therefore, as the effects are reversible, it could be considered as an extended diagnostic phase rather than an actual treatment. Also, in case of persistence of GD and decision for a gender reassignment future invasive surgical treatments could be avoided. This minimizes the harm to the youth, while maximizing the opportunity for a good quality of life. Scientific literature shows that gender dysphoric feelings may have an early onset. While GD in childhood is associated with a variability in outcomes and does not persist into adulthood in more than about 25% of cases, adolescents who were gender dysphoric in childhood and present at gender identity clinics soon after puberty rarely refrain from medical gender reassignment (GR- cross-sex hormones and surgeries). There are many clinics worldwide dedicated GD in children and adolescents. Diagnostic protocols and instruments for adolescents have been developed, and medical interventions, including the halting of puberty, have become available. Various professional organizations and clinics have published treatment guidelines. Although the use of GnRHa to suppress puberty in the clinical management of GD in youth is still is object of various ongoing debates and not always an available medical option. Such limit is not without consequence for GD adolescents’ wellbeing. P-03-067 TREATMENT OF PRIAPISM WITH PDE-5 INHIBITORS Romaniuk, M.1 1 Institute of Urology, Sexopathology and Andrology, Kiev, Ukraine Objective: Patient S., 59 years old, first came to the clinic in 2013 with voiding complains. His diagnosis was BPH stage 2 (PSA ¼ 3,5 ng/ml). TURP was perfomed, but histology showed adenocarcinoma of the prostate (6 Glisson, T2N0M0 2 clinical group, 2 stage). 2014 - extraperitoneal radical prostatectomy. At 12 months after surgery - bulbar urethral stricture (perfomed laser optical urethrotomy, urination normalized). J Sex Med 2016;13:S172eS212
Methods: After radical prostatectomy, the patient had normal erection (best during night sleep), and he made two attempts to sex. During both of them he experienced pain during orgasm (postoperative discomfort in the area of urethrotcystoanastomosis). 1 month after the internal optical urethrotomy - patient noted a strong, prolonged, painful erections during the night, the diagnosis - chronic priapism. But he stopped sexual contacts due to the fear of pain.The patient was interviewed in order to normalize his sex life. Attempts of sex were unsuccessful due to the weak erection during sexual intercourse. Assessement of hormonal profile showed normal parameters: testosterone ¼ 15.3 nmol / L, estradiol ¼ 31.0 pg /ml, prolactin ¼ 6.92 ng / ml, LH ¼ 4,06 mIU / ml, FSH ¼ 11.6 vIU / ml. Doppler penile ultrasound with stimulation (intacavernosal injection of 10 mg of prostaglandin E2) showed: peak systolic velocity after stimulation ¼ 45 cm/sec, end diastolic velocity after stimulation ¼ 12 cm/sec., so we could see the signs of venous insufficiency in the penile blood vessels. Results: Given the actuality of sexual relations in the patient’s family, we prescribed the course of sildenafil citrate 25 mg daily in the morning (the dosage and time of admission were associated with the severity of nocturnal erections) plus for need - 25 mg before sex (preferably in the first half of the day), and sertraline 50 mg per day (at night) for 2 months. During this therapy, the main recommendation was to activate the sexual life, but in case of severe delaying of orgasm - to reduce the dosage of sertraline to 25 mg per day. Conclusion: The control visit was after 1 month. The patient was sexually active, IIEF-5 ¼ 24 points, 3-4 intercourses per week. From the second week of therapy he noted decreasing of strength and intensity of nocturnal erections. Pain during orgasm was not sighnificant. After the end of the treatment course the cancellation of sertraline is planned, and using sildenafil for need, in a suitable dosage. Policy of full disclosure: None. P-03-068 SUCCESSFUL MANAGEMENT OF PGAD AND CLITORODYNIA CAUSED BY A CLOSED COMPARTMENT SYNDROME Aerts, L.1 1 Montréal, Canada Objective: Persistent genital arousal disorder (PGAD) and clitorodynia e a chronic unexplained clitoral pain - are rare conditions that are poorly understood [1,2]. Methods: A 20 years old women presented with persistent genital and urethral awareness since the age of 15. The awareness was similar to arousal, increased by the vibrations in a car and often leaded her to urinate. She rated the bother from the constant awareness to be 10/10. Two years ago, she underwent surgery for endometriosis. She took combined oral contraceptives (COC) for a total of 1.5 years, but recently stopped taking COC as she was not sexually active. TSH and prolactin were normal.
Methods: He reported erection not sufficient for vaginal penetration in all the sexual attempts. He did not have spontaneous morning erections. He reported normal sexual desire. When he was 4 months old, he developed poliomyelitis and he had flaccid paralysis of the right lower limb. As frequent in poliomyelitis survivors, with ageing he developed fatigue, loss of energy and muscle weakness as well as pain in the paralytic lower limb, conditions consistent with the so-called post-poliomyelitis syndrome. His sexual, physical and psychological symptoms were captured by the International Index on Erectile Function-15 (IIEF-15) and the Aging Male Scale (AMS) questionnaires (Figure 1). Physical exam was normal, except for a borderline body mass index (25 kg/m2) and a slight increase in prostate volume. Penile color Doppler ultrasound, after injection of 10 mcg of prostaglandin E1 (PGE1), showed peak systolic velocity of 34 cm/s and 31.6 cm/s in the right and left arteries, respectively. Total testosterone was 9.1 nmol/L, with sex hormone binding globulin of 40.9 nmol/L (calculated free testosterone 154 pmol/L), LH 1.63 U/L and FSH 10.2 U/L. Results: According to guidelines, low testosterone was confirmed by a second evaluation. All the other hormones and metabolic parameters were normal. PP was diagnosed with hypogonadism and testosterone replacement therapy (TRT) was prescribed. PP started Testosterone gel 2%, 5 applications daily. Follow-up visits were performed every 6 months for the first year and then yearly. Conclusion: He reported a progressive improvement in sexual symptoms, as shown by the IIEF-15 total score and the erectile function subscale (Figure 1, upper panel, blue and red line, respectively) and the AMS sexual subdomain (Figure 1, lower panel, green line). In addition, he reported a great improvement in fatigue, energy and muscle strength, as well as a reduction in right lower limb pain. The improvement in physical symptoms, as assessed by the AMS physical subdomain, is reported in Figure 1 (lower panel, blue line). Psychological symptoms (Figure 2, lower panel, red line) did not change. After 12 months of therapy, a further penile color Doppler ultrasound after PGE1 was performed and an improvement in peak systolic velocity was found (53.6 cm/s and 51 cm/s in the right and left arteries, respectively). Symptoms of late onset hypogonadism are aspecific and often overlap with those of ageing. Low testosterone is frequently found in chronic conditions and it has been reported as a possible late consequence of poliomyelitis. The efficacy of TRT in improving sexual symptoms has been proven by several clinical trials and confirmed by meta-analyses. The efficacy on physical and psychological symptoms is uncertain. This case report shows that TRT, beyond improving sexual symptoms, provided an awesome improvement in physical complaints in a man with post-poliomyelitis syndrome, a condition very bothersome and difficult to treat. Policy of full disclosure: None.
P-03 Cases that Matter Posters
Figure 1. P-03-066 GENDER DYSPHORIA IN ADOLESCENCE Ristori, J.1 1 AOU Careggi, Department of Experimental, Cl, Firenze, Italy Objective: Martin is a 14 years old male born adolescent that came to our clinic with a clear request for a medical treatment for Gender Dysphoria (GD), certain that his intense distress could only be solved by intervening on the body. Before intake, Martin started a rigid diet to stop further body development. Martin lost weight (20 Kg) in a few months reaching a Body Mass Index (BMI) of 17 kg/m2. Methods: After psychological evaluation (clinical psychological interviews and psychometric tests), the GD diagnosis was confirmed. Martin was characterized by early GD onset and by worsening of the distress related to GD with the beginning of puberty. The pubertal body changes going in an unwanted direction underlined his biological and physical male characteristics causing significant distress. Furthermore, puberty was characterized by the onset and/or worsening of symptoms related to depression, low self-esteem, anxiety and suicidal risk as well as negative body image, social withdrawal and early school drop out risk. Those symptoms appeared to be the consequence of the distress related to dealing with GD issues. After intake, Martin underwent also an endocrinological visit at our clinic that revealed a Tanner stage P4 G4 and height of 171 cm. The patient was wearing female underwear and showed intense distress when having to show his genitalia during the medical visit. Results: Considering Martin’s psychological assessment and being elegibility criteria for medical treatment fulfilled, with the pediatric ethical committee permission, Martin was given a gonadotropin-releasing hormone analogue (GnRHa) therapy as a life saving procedure in order to intervene on the suicidal risk and
J Sex Med 2016;13:S172eS212
S205
P-03 Cases that Matter Posters
to improve the severe associated psychopathologies. Also, such medical option, that put a halt to the development of secondary sex characteristics, was aimed to improve psychological wellbeing and favour social adaptation as well as to prevent an early school drop out. Martin started to live in a full time female gender role and choose a female name. Conclusion: From that moment, Martin attended psychological interviews and endocrinological investigations every three months. Results measured at Time 1, 2 and 3 revealed that GnRHa therapy had a positive effect on suicidal risk, mood disorder, anxiety, social adaptation and body image. On the other hand, as expected, GnRHa had no effect on GD. Policy of full disclosure: GnRHa should be available as a medical option for those adolescents with GD that fulfill specific criteria, as indicated by WPATH and Hembree guidelines; specially when severe mood disorders, anxiety disorders, body image disorders or suicidal risk are present. Such option could in fact help adolescents with GD to “buy time” to explore their sexual identity and gender identity, without experiencing the distress of pubertal changes. Therefore, as the effects are reversible, it could be considered as an extended diagnostic phase rather than an actual treatment. Also, in case of persistence of GD and decision for a gender reassignment future invasive surgical treatments could be avoided. This minimizes the harm to the youth, while maximizing the opportunity for a good quality of life. Scientific literature shows that gender dysphoric feelings may have an early onset. While GD in childhood is associated with a variability in outcomes and does not persist into adulthood in more than about 25% of cases, adolescents who were gender dysphoric in childhood and present at gender identity clinics soon after puberty rarely refrain from medical gender reassignment (GR- cross-sex hormones and surgeries). There are many clinics worldwide dedicated GD in children and adolescents. Diagnostic protocols and instruments for adolescents have been developed, and medical interventions, including the halting of puberty, have become available. Various professional organizations and clinics have published treatment guidelines. Although the use of GnRHa to suppress puberty in the clinical management of GD in youth is still is object of various ongoing debates and not always an available medical option. Such limit is not without consequence for GD adolescents’ wellbeing. P-03-067 TREATMENT OF PRIAPISM WITH PDE-5 INHIBITORS Romaniuk, M.1 1 Institute of Urology, Sexopathology and Andrology, Kiev, Ukraine Objective: Patient S., 59 years old, first came to the clinic in 2013 with voiding complains. His diagnosis was BPH stage 2 (PSA ¼ 3,5 ng/ml). TURP was perfomed, but histology showed adenocarcinoma of the prostate (6 Glisson, T2N0M0 2 clinical group, 2 stage). 2014 - extraperitoneal radical prostatectomy. At 12 months after surgery - bulbar urethral stricture (perfomed laser optical urethrotomy, urination normalized). J Sex Med 2016;13:S172eS212
Methods: After radical prostatectomy, the patient had normal erection (best during night sleep), and he made two attempts to sex. During both of them he experienced pain during orgasm (postoperative discomfort in the area of urethrotcystoanastomosis). 1 month after the internal optical urethrotomy - patient noted a strong, prolonged, painful erections during the night, the diagnosis - chronic priapism. But he stopped sexual contacts due to the fear of pain.The patient was interviewed in order to normalize his sex life. Attempts of sex were unsuccessful due to the weak erection during sexual intercourse. Assessement of hormonal profile showed normal parameters: testosterone ¼ 15.3 nmol / L, estradiol ¼ 31.0 pg /ml, prolactin ¼ 6.92 ng / ml, LH ¼ 4,06 mIU / ml, FSH ¼ 11.6 vIU / ml. Doppler penile ultrasound with stimulation (intacavernosal injection of 10 mg of prostaglandin E2) showed: peak systolic velocity after stimulation ¼ 45 cm/sec, end diastolic velocity after stimulation ¼ 12 cm/sec., so we could see the signs of venous insufficiency in the penile blood vessels. Results: Given the actuality of sexual relations in the patient’s family, we prescribed the course of sildenafil citrate 25 mg daily in the morning (the dosage and time of admission were associated with the severity of nocturnal erections) plus for need - 25 mg before sex (preferably in the first half of the day), and sertraline 50 mg per day (at night) for 2 months. During this therapy, the main recommendation was to activate the sexual life, but in case of severe delaying of orgasm - to reduce the dosage of sertraline to 25 mg per day. Conclusion: The control visit was after 1 month. The patient was sexually active, IIEF-5 ¼ 24 points, 3-4 intercourses per week. From the second week of therapy he noted decreasing of strength and intensity of nocturnal erections. Pain during orgasm was not sighnificant. After the end of the treatment course the cancellation of sertraline is planned, and using sildenafil for need, in a suitable dosage. Policy of full disclosure: None. P-03-068 SUCCESSFUL MANAGEMENT OF PGAD AND CLITORODYNIA CAUSED BY A CLOSED COMPARTMENT SYNDROME Aerts, L.1 1 Montréal, Canada Objective: Persistent genital arousal disorder (PGAD) and clitorodynia e a chronic unexplained clitoral pain - are rare conditions that are poorly understood [1,2]. Methods: A 20 years old women presented with persistent genital and urethral awareness since the age of 15. The awareness was similar to arousal, increased by the vibrations in a car and often leaded her to urinate. She rated the bother from the constant awareness to be 10/10. Two years ago, she underwent surgery for endometriosis. She took combined oral contraceptives (COC) for a total of 1.5 years, but recently stopped taking COC as she was not sexually active. TSH and prolactin were normal.