- Email: [email protected]
Perspectives on Priapism Education in Emergency Medicine
BRIEF COMMUNICATION
Perspectives on Priapism Education in Emergency Medicine Jessica C. Dai, MD,1 Douglas S. Franzen, MD, MEd,2 Thomas S. Lendvay, MD,3 Kevin A. Ostrowski, MD,1 and Thomas J. Walsh, MD, MS1
ABSTRACT
Introduction: Priapism is a urologic emergency managed by both emergency medicine (EM) providers and urologists. Attitudes regarding its management and understanding of education of non-urology trainees in this area are poorly defined. Aim: The aim of this study was to describe attitudes toward priapism management among multiple stakeholders and define the current state of priapism education among EM residency programs. Methods: Surveys were developed and distributed online to EM residency leadership, EM residents, and urology providers. Each solicited attitudes and preferences regarding independent priapism management by EM providers. EM residents were further queried about their educational and clinical experiences in priapism management, and EM residency leadership were surveyed about their educational curricula. Responses among all 3 groups were compared using Fisher’s exact tests. Main Outcome Measure: Quantitative and descriptive responses were solicited regarding EM providers’ management of acute ischemic priapism and current priapism curricula for EM residents. Results: 91 EM residency program directors and assistant program directors (31.6% of programs), 227 EM residents (14.7% of programs), and 94 urologists (6.3% of survey recipients) responded. All geographic regions and all years of EM training were represented. Over 90% of all surveyed groups felt that EM providers should independently manage priapism in practice. 17% of senior EM residents felt “not at all” confident in managing priapism; and 25.5% had never primarily managed this entity in training. 81% of programs had a formalized priapism curriculum, of which 19% included treatment simulation. However, 36% of residents felt that current curricula were insufficient. Clinical Implications: Widespread approval from both EM providers and urologists support EM-based management for uncomplicated cases of acute ischemic priapism. Current educational curricula for EM trainees may not be sufficient to prepare them to manage this entity in practice. Strengths & Limitations: This is the first study to examine provider attitudes toward EM-based management of priapism and assess the current state of education in this area with input from all key stakeholders. This survey was limited in its scope and the response rate was lower than desired. Conclusion: Urologists support independent priapism management by EM providers, but an educational gap remains for EM trainees who do not feel adequately trained to manage this independently in practice. Dai JC, Franzen DS, Lendvay TS, et al. Perspectives on Priapism Education in Emergency Medicine. J Sex Med 2019;XX:XXXeXXX. Copyright 2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Priapism; Education; Emergency Medicine; Simulation; Practice Patterns
Received August 3, 2019. Accepted October 9, 2019. 1
Department of Urology, University of Washington, Seattle, Washington, USA;
2
Department of Emergency Medicine, Harborview Medical Center, Seattle, Washington, USA;
3
Division of Pediatric Urology, Seattle Children’s Hospital, Seattle, Washington, USA
Copyright ª 2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsxm.2019.10.011
J Sex Med 2019;-:1e4
INTRODUCTION Priapism is a medical emergency requiring rapid treatment.1 Although primarily managed by urologists, emergency medicine (EM) providers may be first-line providers.2 Thus, EM providers must be competent in managing this entity. Although included on the Model of Clinical Practice of EM,3 priapism experience in EM residents is poorly described. Moreover, urologists’ and EM providers’ attitudes regarding EM 1
2
provider roles in priapism management are unknown. Understanding regarding each specialty’s preferences is critical given the collaborative nature of care for patients with priapism. We evaluate attitudes on EM-based priapism management and describe the current state of priapism education in EM residency programs. We anticipate support for EM management of straightforward priapism from urologists and EM physicians, but hypothesize that academic urologists may be less supportive. We also hypothesize that current educational paradigms may not sufficiently prepare EM trainees for practice.
MATERIALS AND METHODS A panel of content experts (andrology-trained urologist, associate EM program director, simulation education leader, and urology resident) generated 3 unique surveys to query key stakeholders in management of straightforward priapism: EM residency leadership (Appendix A), EM residents (Appendix B), and urologists (Appendix C). “Straightforward” priapism was defined as a first occurrence of priapism unrelated to sickle-cell disease in a patient with no urologic history. All surveys included a description of the study purpose, intent for data use, and primary author’s credentials. Surveys to EM residency leadership and residents were distributed to Accreditation Council for Graduate Medical Education-accredited programs through the Council of Emergency Medicine Residency Directors. Surveys to urologists were distributed through the Society for the Study of Male Reproduction, the Sexual Medicine Society of North America, state urological societies, and e-mail solicitation. All surveys were completed anonymously online. Pediatric urologists were excluded. Chi-square tests were used to compare groups and Fisher’s exact test to compare academic and nonacademic urologists Qualitative responses were examined for recurring thematic elements. The study received Institutional Review Board exemption.
RESULTS 91 EM program directors from 73 of 231 EM programs (31.6%) and 227 EM residents from 34 programs (14.7%) responded. All United States geographic regions were represented. Residents from all training years responded (29.5% postgraduate year [PGY]-1 ¼ 29.1%; PGY-2 ¼ 33.9%; PGY3 ¼ 7.5%; and PGY-4). Surveys were sent to 1,502 urologists and 94 responded (6.2% response rate). 3 pediatric urologists were excluded. Of the respondents, 35% were nonacademic urologists. All American Urological Association sections were represented (7.4% Northeast, 3.2% New York, 4.3% Mid-Atlantic, 10.6% Southeast, 7.4% South Central, 25.6 North Central, 29.8% Western, and 3.2% unknown).
Dai et al
Table 1. Current state of priapism training education in EM residency Current priapism educational curricula Programs with formalized priapism curricula Collaborate with urology in priapism education Desire collaboration with urology in priapism education Incorporate simulation in priapism curricula Expressed preference for simulation in priapism education EM residents (n ¼ 227) EM leadership (n ¼ 91)
Number of respondents (%) 59 (81%) 13 (22%) 38 (64%) 11 (19%)
125 (55%) 39 (43%)
EM ¼ emergency medicine.
Among EM providers, 90.3% of residents and 92.3% of program directors felt they would be able to independently manage priapism. Most residents (69.2%) planned to practice in the community and 79.3% planned to manage priapism independently in practice. However, 49% of residents had never managed a case of priapism in training. Among PGY-3 and PGY4 residents (n ¼ 94), 25.5% had not, and 17% felt “not at all” confident doing so in practice. Few programs (22%) collaborated with urologists in educating residents, although 64% desired this (Table 1). Only 19% incorporated simulation despite preferences from both residents (59%) and leadership (43%) for this. 36% of residents felt their educational curriculum was “insufficient.” Similar to EM providers, 91% of urologists felt EM providers should be able to independently manage straightforward priapism (P ¼ .85). There was no difference in attitudes between academic and nonacademic urologists (EM providers, P ¼ .71 and EM trainees, P ¼ .56). Urologists’ comments reiterated key themes. Adequate experience was deemed critical: “ED physicians should be capable of attempting management of straightforward priapism [.] ED residents should have exposure to aspiration, irrigation, phenylephrine injection, and T shunts if they anticipate working in a low resource area [.].” Interdisciplinary collaboration was also highlighted: “Emergency Department Physicians and Urologists should evaluate their respective role in treating priapism and arrive at a program or protocol they together agree is effective and useful for the best patient care, including the residents’/trainees’ roles [.]”
DISCUSSION The preparation of EM trainees to competently manage priapism and the attitudes of EM providers, trainees, and urologists were not well-defined. We find that all stakeholders agree that EM providers should be both competent and empowered to independently manage straightforward priapism.3,4 J Sex Med 2019;-:1e4
3
Perspectives on Priapism Education in EM
In this study, many senior EM residents feel insufficiently prepared to manage priapism in practice. It is difficult to determine whether these responses extrapolate to all EM residents, as corporal aspiration, irrigation, and injection for priapism management are not “key index procedures” for EM by the Accreditation Council for Graduate Medical Education and are not tracked.5 However, as EM procedural experiences do not vary significantly by program setting or size,6 our findings are likely representative of the global EM training experience. Therefore, a gap may exist between the current educational paradigm and preparedness of senior residents to manage priapism after graduation. Few EM programs collaborate with urologists to educate trainees about priapism, although most desire this. This represents an opportunity for quality improvement through interdisciplinary education. Barriers may include a lack of pre-existing relationships with urologists, or well-entrenched local practice patterns. Departmental “Grand Rounds” may be useful forums to forge partnerships. Institutional champions, departmental support, and careful attention to learning needs of both urology and EM trainees will also be critical. Simulation represents another area for improvement. EM residents’ and program leaders’ preferences for simulation-based priapism education mirrors a broader movement toward simulation-based education within EM.7 Only 2 published simulation models for priapism education exist in the literature; thus, lack of affordable, commercially available models may be a significant barrier.8,9 This study was limited by sampling and nonresponse bias and low response rates. Additionally, surveys were not validated or standardized. These limitations notwithstanding, this is the first study to our knowledge to describe provider attitudes regarding priapism management, define EM residents’ educational experiences, and identify opportunities for quality improvement.
CONCLUSIONS EM residency leadership, residents, and urologists agree that EM providers should be capable of independently managing straightforward priapism. Few EM training programs have priapism curricula incorporating simulation or urologic collaboration despite expressed preferences for both. These are opportunities for quality improvement.
ACKNOWLEDGMENTS The authors would like to acknowledge Dr. Stephen Mitchell and Dr. Martin Makela of the University of Washington Emergency Medicine Department for their help in facilitating the creation and distribution of this survey, as well as their support of interdisciplinary priapism care at our institution.*
J Sex Med 2019;-:1e4
Corresponding Author: Jessica C. Dai, MD, Department of Urology, University of Washington, 1959 NE Pacific Street, Box 356510, Seattle, WA 98195, USA. Tel: 845-536-2901; Fax: 206-543-3272; E-mail: [email protected] Conflict of Interest: T.S.L. is an equity owner of C-SATS, Inc., which does not present a relevant conflict of interest to the material within this manuscript. T.J.W. is a consultant for Boston Scientific, which does not present a relevant conflict of interest to the material within this manuscript. The other authors, J.C.D., D.S.F., and K.S.O. have no conflicts of interest to declare. Funding: This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.
STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design XXX (b) Acquisition of Data XXX (c) Analysis and Interpretation of Data XXX Category 2 (a) Drafting the Article XXX (b) Revising It for Intellectual Content XXX Category 3 (a) Final Approval of the Completed Article XXX
REFERENCES 1. Montague DK, Jarow J, Broderick GA, et al. American Urological Association guideline on the management of priapism. J Urol 2003;170(4 Pt 1):1318-1324. 2. Stein DM, Flum AS, Cashy J, et al. Nationwide emergency department visits for priapism in the United States. J Sex Med 2013;10:2418-2422. 3. Counselman FL, Babu K, Edens MA, et al. The 2016 Model of the Clinical Practice of Emergency Medicine. J Emerg Med 2017;52:846-849. 4. Vilke GM, Harrigan Ra, Ufberg JW, et al. Emergency evaluation and treatment of priapism. J Emerg Med 2004;26:325-329. 5. Accreditation Council for Graduate Medical Education (ACGME) Review Committee for Emergency Medicine. Emergency Medicine Defined Key Index Procedure Minimums. [Online]. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramResources/ EM_Key_Index_Procedure_Minimums_103117.pdf?ver=2017-11-10 -130003-693. Accessed March 9, 2019.
4 6. Hayden SR, Panacek EA. Procedural competency in emergency medicine: The current range of resident experience. Acad Emerg Med 1999;6:728-735. 7. Okuda Y, Bond W, Bonfante G, et al. National growth in simulation training within emergency medicine residency programs, 2003-2008. Acad Emerg Med 2008;15:1113-1116. 8. Ruest AS, Getto LP, Fredette JM, et al. A novel task trainer for penile corpus cavernosa aspiration. Simul Healthc 2017; 12:407-413.
Dai et al 9. Dai JC, Ahn JS, Cannon ST, et al. Acute ischemic priapism management: An educational and simulation curriculum. MedEdPORTAL 2018;14:10731.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi.org/10.1016/j.jsxm.2019.10.011.
J Sex Med 2019;-:1e4
Perspectives on Priapism Education in Emergency Medicine Jessica C. Dai, MD,1 Douglas S. Franzen, MD, MEd,2 Thomas S. Lendvay, MD,3 Kevin A. Ostrowski, MD,1 and Thomas J. Walsh, MD, MS1
ABSTRACT
Introduction: Priapism is a urologic emergency managed by both emergency medicine (EM) providers and urologists. Attitudes regarding its management and understanding of education of non-urology trainees in this area are poorly defined. Aim: The aim of this study was to describe attitudes toward priapism management among multiple stakeholders and define the current state of priapism education among EM residency programs. Methods: Surveys were developed and distributed online to EM residency leadership, EM residents, and urology providers. Each solicited attitudes and preferences regarding independent priapism management by EM providers. EM residents were further queried about their educational and clinical experiences in priapism management, and EM residency leadership were surveyed about their educational curricula. Responses among all 3 groups were compared using Fisher’s exact tests. Main Outcome Measure: Quantitative and descriptive responses were solicited regarding EM providers’ management of acute ischemic priapism and current priapism curricula for EM residents. Results: 91 EM residency program directors and assistant program directors (31.6% of programs), 227 EM residents (14.7% of programs), and 94 urologists (6.3% of survey recipients) responded. All geographic regions and all years of EM training were represented. Over 90% of all surveyed groups felt that EM providers should independently manage priapism in practice. 17% of senior EM residents felt “not at all” confident in managing priapism; and 25.5% had never primarily managed this entity in training. 81% of programs had a formalized priapism curriculum, of which 19% included treatment simulation. However, 36% of residents felt that current curricula were insufficient. Clinical Implications: Widespread approval from both EM providers and urologists support EM-based management for uncomplicated cases of acute ischemic priapism. Current educational curricula for EM trainees may not be sufficient to prepare them to manage this entity in practice. Strengths & Limitations: This is the first study to examine provider attitudes toward EM-based management of priapism and assess the current state of education in this area with input from all key stakeholders. This survey was limited in its scope and the response rate was lower than desired. Conclusion: Urologists support independent priapism management by EM providers, but an educational gap remains for EM trainees who do not feel adequately trained to manage this independently in practice. Dai JC, Franzen DS, Lendvay TS, et al. Perspectives on Priapism Education in Emergency Medicine. J Sex Med 2019;XX:XXXeXXX. Copyright 2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Priapism; Education; Emergency Medicine; Simulation; Practice Patterns
Received August 3, 2019. Accepted October 9, 2019. 1
Department of Urology, University of Washington, Seattle, Washington, USA;
2
Department of Emergency Medicine, Harborview Medical Center, Seattle, Washington, USA;
3
Division of Pediatric Urology, Seattle Children’s Hospital, Seattle, Washington, USA
Copyright ª 2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsxm.2019.10.011
J Sex Med 2019;-:1e4
INTRODUCTION Priapism is a medical emergency requiring rapid treatment.1 Although primarily managed by urologists, emergency medicine (EM) providers may be first-line providers.2 Thus, EM providers must be competent in managing this entity. Although included on the Model of Clinical Practice of EM,3 priapism experience in EM residents is poorly described. Moreover, urologists’ and EM providers’ attitudes regarding EM 1
2
provider roles in priapism management are unknown. Understanding regarding each specialty’s preferences is critical given the collaborative nature of care for patients with priapism. We evaluate attitudes on EM-based priapism management and describe the current state of priapism education in EM residency programs. We anticipate support for EM management of straightforward priapism from urologists and EM physicians, but hypothesize that academic urologists may be less supportive. We also hypothesize that current educational paradigms may not sufficiently prepare EM trainees for practice.
MATERIALS AND METHODS A panel of content experts (andrology-trained urologist, associate EM program director, simulation education leader, and urology resident) generated 3 unique surveys to query key stakeholders in management of straightforward priapism: EM residency leadership (Appendix A), EM residents (Appendix B), and urologists (Appendix C). “Straightforward” priapism was defined as a first occurrence of priapism unrelated to sickle-cell disease in a patient with no urologic history. All surveys included a description of the study purpose, intent for data use, and primary author’s credentials. Surveys to EM residency leadership and residents were distributed to Accreditation Council for Graduate Medical Education-accredited programs through the Council of Emergency Medicine Residency Directors. Surveys to urologists were distributed through the Society for the Study of Male Reproduction, the Sexual Medicine Society of North America, state urological societies, and e-mail solicitation. All surveys were completed anonymously online. Pediatric urologists were excluded. Chi-square tests were used to compare groups and Fisher’s exact test to compare academic and nonacademic urologists Qualitative responses were examined for recurring thematic elements. The study received Institutional Review Board exemption.
RESULTS 91 EM program directors from 73 of 231 EM programs (31.6%) and 227 EM residents from 34 programs (14.7%) responded. All United States geographic regions were represented. Residents from all training years responded (29.5% postgraduate year [PGY]-1 ¼ 29.1%; PGY-2 ¼ 33.9%; PGY3 ¼ 7.5%; and PGY-4). Surveys were sent to 1,502 urologists and 94 responded (6.2% response rate). 3 pediatric urologists were excluded. Of the respondents, 35% were nonacademic urologists. All American Urological Association sections were represented (7.4% Northeast, 3.2% New York, 4.3% Mid-Atlantic, 10.6% Southeast, 7.4% South Central, 25.6 North Central, 29.8% Western, and 3.2% unknown).
Dai et al
Table 1. Current state of priapism training education in EM residency Current priapism educational curricula Programs with formalized priapism curricula Collaborate with urology in priapism education Desire collaboration with urology in priapism education Incorporate simulation in priapism curricula Expressed preference for simulation in priapism education EM residents (n ¼ 227) EM leadership (n ¼ 91)
Number of respondents (%) 59 (81%) 13 (22%) 38 (64%) 11 (19%)
125 (55%) 39 (43%)
EM ¼ emergency medicine.
Among EM providers, 90.3% of residents and 92.3% of program directors felt they would be able to independently manage priapism. Most residents (69.2%) planned to practice in the community and 79.3% planned to manage priapism independently in practice. However, 49% of residents had never managed a case of priapism in training. Among PGY-3 and PGY4 residents (n ¼ 94), 25.5% had not, and 17% felt “not at all” confident doing so in practice. Few programs (22%) collaborated with urologists in educating residents, although 64% desired this (Table 1). Only 19% incorporated simulation despite preferences from both residents (59%) and leadership (43%) for this. 36% of residents felt their educational curriculum was “insufficient.” Similar to EM providers, 91% of urologists felt EM providers should be able to independently manage straightforward priapism (P ¼ .85). There was no difference in attitudes between academic and nonacademic urologists (EM providers, P ¼ .71 and EM trainees, P ¼ .56). Urologists’ comments reiterated key themes. Adequate experience was deemed critical: “ED physicians should be capable of attempting management of straightforward priapism [.] ED residents should have exposure to aspiration, irrigation, phenylephrine injection, and T shunts if they anticipate working in a low resource area [.].” Interdisciplinary collaboration was also highlighted: “Emergency Department Physicians and Urologists should evaluate their respective role in treating priapism and arrive at a program or protocol they together agree is effective and useful for the best patient care, including the residents’/trainees’ roles [.]”
DISCUSSION The preparation of EM trainees to competently manage priapism and the attitudes of EM providers, trainees, and urologists were not well-defined. We find that all stakeholders agree that EM providers should be both competent and empowered to independently manage straightforward priapism.3,4 J Sex Med 2019;-:1e4
3
Perspectives on Priapism Education in EM
In this study, many senior EM residents feel insufficiently prepared to manage priapism in practice. It is difficult to determine whether these responses extrapolate to all EM residents, as corporal aspiration, irrigation, and injection for priapism management are not “key index procedures” for EM by the Accreditation Council for Graduate Medical Education and are not tracked.5 However, as EM procedural experiences do not vary significantly by program setting or size,6 our findings are likely representative of the global EM training experience. Therefore, a gap may exist between the current educational paradigm and preparedness of senior residents to manage priapism after graduation. Few EM programs collaborate with urologists to educate trainees about priapism, although most desire this. This represents an opportunity for quality improvement through interdisciplinary education. Barriers may include a lack of pre-existing relationships with urologists, or well-entrenched local practice patterns. Departmental “Grand Rounds” may be useful forums to forge partnerships. Institutional champions, departmental support, and careful attention to learning needs of both urology and EM trainees will also be critical. Simulation represents another area for improvement. EM residents’ and program leaders’ preferences for simulation-based priapism education mirrors a broader movement toward simulation-based education within EM.7 Only 2 published simulation models for priapism education exist in the literature; thus, lack of affordable, commercially available models may be a significant barrier.8,9 This study was limited by sampling and nonresponse bias and low response rates. Additionally, surveys were not validated or standardized. These limitations notwithstanding, this is the first study to our knowledge to describe provider attitudes regarding priapism management, define EM residents’ educational experiences, and identify opportunities for quality improvement.
CONCLUSIONS EM residency leadership, residents, and urologists agree that EM providers should be capable of independently managing straightforward priapism. Few EM training programs have priapism curricula incorporating simulation or urologic collaboration despite expressed preferences for both. These are opportunities for quality improvement.
ACKNOWLEDGMENTS The authors would like to acknowledge Dr. Stephen Mitchell and Dr. Martin Makela of the University of Washington Emergency Medicine Department for their help in facilitating the creation and distribution of this survey, as well as their support of interdisciplinary priapism care at our institution.*
J Sex Med 2019;-:1e4
Corresponding Author: Jessica C. Dai, MD, Department of Urology, University of Washington, 1959 NE Pacific Street, Box 356510, Seattle, WA 98195, USA. Tel: 845-536-2901; Fax: 206-543-3272; E-mail: [email protected] Conflict of Interest: T.S.L. is an equity owner of C-SATS, Inc., which does not present a relevant conflict of interest to the material within this manuscript. T.J.W. is a consultant for Boston Scientific, which does not present a relevant conflict of interest to the material within this manuscript. The other authors, J.C.D., D.S.F., and K.S.O. have no conflicts of interest to declare. Funding: This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.
STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design XXX (b) Acquisition of Data XXX (c) Analysis and Interpretation of Data XXX Category 2 (a) Drafting the Article XXX (b) Revising It for Intellectual Content XXX Category 3 (a) Final Approval of the Completed Article XXX
REFERENCES 1. Montague DK, Jarow J, Broderick GA, et al. American Urological Association guideline on the management of priapism. J Urol 2003;170(4 Pt 1):1318-1324. 2. Stein DM, Flum AS, Cashy J, et al. Nationwide emergency department visits for priapism in the United States. J Sex Med 2013;10:2418-2422. 3. Counselman FL, Babu K, Edens MA, et al. The 2016 Model of the Clinical Practice of Emergency Medicine. J Emerg Med 2017;52:846-849. 4. Vilke GM, Harrigan Ra, Ufberg JW, et al. Emergency evaluation and treatment of priapism. J Emerg Med 2004;26:325-329. 5. Accreditation Council for Graduate Medical Education (ACGME) Review Committee for Emergency Medicine. Emergency Medicine Defined Key Index Procedure Minimums. [Online]. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramResources/ EM_Key_Index_Procedure_Minimums_103117.pdf?ver=2017-11-10 -130003-693. Accessed March 9, 2019.
4 6. Hayden SR, Panacek EA. Procedural competency in emergency medicine: The current range of resident experience. Acad Emerg Med 1999;6:728-735. 7. Okuda Y, Bond W, Bonfante G, et al. National growth in simulation training within emergency medicine residency programs, 2003-2008. Acad Emerg Med 2008;15:1113-1116. 8. Ruest AS, Getto LP, Fredette JM, et al. A novel task trainer for penile corpus cavernosa aspiration. Simul Healthc 2017; 12:407-413.
Dai et al 9. Dai JC, Ahn JS, Cannon ST, et al. Acute ischemic priapism management: An educational and simulation curriculum. MedEdPORTAL 2018;14:10731.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi.org/10.1016/j.jsxm.2019.10.011.
J Sex Med 2019;-:1e4