On Saturday, October 10, at the 27th Annual SMSNA Fall Scientific Meeting, Dr. Sarah Cigna detailed a practical, region-based algorithm for evaluating and managing persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) in men and women. PGAD involves persistent or recurrent, unwanted sensations of genital arousal that are not necessarily associated with sexual desire, while GPD encompasses other uncomfortable or unwanted genito-pelvic sensations. These conditions can cause significant distress and negatively affect sexual function and daily activities. Dr. Cigna emphasized that identifying where symptoms originate can help clinicians determine which areas to evaluate and target for treatment.

The region-based approach recognizes that PGAD/GPD symptoms may originate from five different regions, even when the sensations are experienced in the genitals:

• Region 1: End organ. Symptoms may arise from local conditions, including skin changes, irritation, or genital adhesions. The key is to identify where the sensations originate and whether a local condition is contributing.

• Region 2: Pelvis/perineum. Pelvic floor dysfunction, pudendal neuropathy, and vascular conditions may contribute to symptoms. Dr. Cigna emphasized the importance of considering pelvic structures and organs when evaluating PGAD/GPD.

• Region 3: Cauda equina. Conditions affecting the sacral spinal nerve roots, including nerve compression, may contribute to genitopelvic symptoms.

• Region 4: Spinal cord. Spinal cord abnormalities may contribute to symptoms and warrant evaluation by a spine specialist when indicated.

• Region 5: Brain. Brain pathways involved in processing genital sensations may contribute to PGAD/GPD symptoms, making this region particularly complex to evaluate.

Dr. Cigna explained that the numbered regions provide a systematic way to identify potential causes of symptoms. Clinicians should begin with the end organ and pelvis before considering more central neurological causes. Depending on the patient's symptoms, topical anesthetics or diagnostic nerve blocks may help identify the source of the sensations. She recommended the International Society for the Study of Women's Sexual Health (ISSWSH) Process of Care document for PGAD/GPD as a starting point for clinicians evaluating and managing these conditions.

On Saturday, October 10, at the 27th Annual SMSNA Fall Scientific Meeting, Drs. Irwin Goldstein and Barry Komisaruk, along with Sue Goldstein, all members of the International Society for the Study of Women's Sexual Health (ISSWSH), presented a panel discussion on redefining orgasm. The panel explained that ISSWSH's original definition, which emphasized intense pleasure, did not fully account for the neurological and physiological processes involved in orgasm. Sue Goldstein explained that the updated ISSWSH definition recognizes three stages: pre-orgasm, orgasm, and post-orgasm. "Four years! It took us four years to get here," Dr. Irwin Goldstein remarked. However, the definition of female orgasmic disorder has not yet changed.

Dr. Komisaruk discussed the major sensory nerves connecting the genitals to the brain. The clitoris, cervix, and vagina project to overlapping regions of the brain's sensory cortex through different nerve pathways. He explained that women describe orgasms associated with these areas differently, with clitoral stimulation often producing more localized sensations and vaginal stimulation producing deeper sensations. Stimulation of multiple regions may contribute to a more intense orgasm. Interestingly, nipple stimulation also activates similar regions of the brain. Dr. Komisaruk noted that orgasm intensity may be related to muscle contraction intensity. Different areas of the brain become active at different times during orgasm, with activity subsiding shortly afterward. His research also suggests that excitation and inhibition occur together, with increased pain tolerance during orgasm. He described an "orgasm faucet model," in which different sources of stimulation can contribute to orgasm independently or simultaneously.

Dr. Irwin Goldstein explained how this understanding may help clinicians recognize six categories of female orgasmic dysfunction:

• Excitation insufficiency: Difficulty becoming sufficiently aroused to reach orgasm. Potential treatments may include medications that affect dopamine or serotonin signaling.

• Inhibition insufficiency: Difficulty regulating the inhibitory processes associated with orgasm, potentially involving pain. Treatments discussed included SSRIs, SNRIs, analgesics, and progesterone.

• Delayed orgasm: Orgasm develops slowly or takes longer than desired to occur. Treatment may involve approaches to increase sensitivity.

• Muted or prematurely muted orgasm: Arousal develops, but the orgasmic response is diminished or ends prematurely.

• Anhedonic orgasm: Orgasm occurs without the expected sensation of pleasure, potentially following surgery. Medication may be considered depending on the underlying cause.

• Post-orgasmic illness syndrome (POIS): Symptoms of illness following orgasm that may persist for an extended period. Dr. Goldstein discussed potential approaches involving psychotherapy and hormonal or neurotransmitter-related treatments.

Dr. Irwin Goldstein emphasized that a single definition or classification cannot fully capture the range of women's orgasmic experiences. He suggested that the traditional approach of placing women into one diagnostic category may eventually give way to more specific classifications that better reflect individual experiences.

Sue Goldstein noted that these concepts may also apply beyond women. All three panelists agreed that further research is needed to better understand orgasm and refine the classification of orgasmic disorders.

On Saturday, October 10, at the 27th Annual SMSNA Fall Scientific Meeting, Dr. Sage Bolte discussed the challenges cancer survivors face when navigating dating and disclosure. How can clinicians counsel patients on telling a potential partner about cancer-related sexual dysfunction? Dr. Bolte emphasized that disclosure is a personal process, and patients should remain in control of how and when they share their cancer experiences.

Dr. Bolte began by sharing the story of a patient who asked, "When do I tell someone?" The patient feared that disclosing their cancer history would discourage potential partners from pursuing a relationship. Disclosure involves considering whether, when, why, what, and whom to tell. "Because I had cancer" can become the starting point for conversations about body image, fertility, sexual function, and concerns about the future.

Dr. Bolte encouraged clinicians to consider the specific developmental and relationship goals a patient is trying to accomplish. There is a difference between owning your cancer story and making that story visible, particularly when navigating online dating. When patients feel unable to disclose their experiences, understanding what their lives were like before cancer can help guide counseling. For some, there is no "after cancer," as they continue to live with chronic or lifelong diagnoses that may create feelings of guilt or uncertainty in romantic relationships.

Fear of rejection can be one of the biggest barriers to disclosure. Dr. Bolte encouraged clinicians to help patients consider questions such as "Why now?", "What now?", "Who?", and "Where?" The timing, stage of the relationship, person receiving the information, and whether disclosure happens online can all influence the process.

Clinicians can create a comfortable environment for discussing disclosure by:

• Opening the door to conversations about dating and relationships.

• Normalizing patients' concerns and respecting their decision not to disclose.

• Protecting patient privacy.

• Exploring what patients want from a relationship before offering advice.

• Referring patients to specialists who can address specific concerns, such as sexual dysfunction.

Dr. Bolte encouraged clinicians to give patients the space to discuss dating and the desire to be known without fear of rejection. Her message was to consider the person behind the cancer diagnosis and support their decisions about disclosure. For patients navigating dating after cancer, the goal is to feel comfortable being known while remaining in control of their own story.

On Saturday, October 10, at the 27th Annual SMSNA Fall Scientific Meeting, Dr. Juan Andino discussed the surgical challenges of prolonged ischemic priapism, emphasizing the importance of early intervention and the potential benefits of penoscrotal decompression. Dr. Andino suggested that patients with ischemic priapism lasting 20 hours should already be considered complex cases, rather than waiting until 24 hours. He emphasized that his primary goal is immediate decompression, with penile prosthesis placement considered depending on the duration of priapism and the likelihood of erectile function recovery.

Dr. Andino began by examining the different international recommendations based on the duration of priapism, including thresholds of 24 and 36 hours. The goal of traditional shunt surgery is to create a passage between the corpora cavernosa and the glans to drain trapped blood. Dr. Andino highlighted penoscrotal decompression as a promising alternative, which drains blood through an opening in the proximal corpora cavernosa while sparing the glans. A systematic review found that penoscrotal decompression achieved detumescence in 89.3% of cases, with some patients preserving erectile function.

Dr. Andino also discussed the importance of preserving penile structures and understanding how surgical decisions may affect erectile function and quality of life. He referenced the European Association of Urology (EAU) guidelines and the AUA/SMSNA recommendations, noting the evolving evidence surrounding penoscrotal decompression. Another study identified the duration of priapism as the strongest predictor of erectile dysfunction. Current AUA/SMSNA guidelines allow clinicians to consider penile prosthesis placement after more than 36 hours of untreated ischemic priapism or when shunting procedures have failed. However, Dr. Andino emphasized the importance of earlier intervention to improve the chances of preserving erectile function.

On Friday, October 9, at the 27th Annual SMSNA Fall Scientific Meeting, Drs. Martin Gross and Laurence Levine engaged in a debate surrounding the management of erectile dysfunction (ED) with Peyronie's disease (PD) using inflatable penile prostheses (IPP). Is less truly more, or is maximal therapy the best option?

Dr. Gross argued that less is more, citing the recent PUMP study, which found that implantation alone was often sufficient. Specifically, the study reported that grafting was needed in only about 2% of cases. He stated that the preferred choice is often the simplest approach, with modeling and the scratch technique used as needed when curvature is under 45 degrees. Manual modeling can often reduce the curvature enough for the implant to provide further correction. The scratch technique is typically used as an adjunct procedure to disrupt plaque. When curvature exceeds 45 degrees, the implant can still provide much of the correction, with plaque incision using the Brock technique when necessary. This approach may mitigate some of the risks associated with multiple adjunctive procedures, such as hematoma, sensation loss, and glans necrosis.

Dr. Levine argued for a more extensive approach to achieve maximum correction. He emphasized that this approach may help address patients' concerns about lost penile length. The question is whether surgeons can safely and effectively restore length to its pre-PD state. If the goal of IPP surgery in patients with PD and ED is to recover lost length and girth, correct curvature or deformity, and make the penis functionally straight and rigid, the challenge may lie in the unpredictable anatomy of the neurovascular bundle within Buck's fascia. Unfortunately, the risks of IPP surgery may limit the ideal result. Dr. Levine highlighted the tunica expansion procedure (TEP), which uses small incisions in the tunica albuginea to allow the penis to expand during prosthesis implantation. Using TEP, patients experienced an average improvement of 1.7 cm in stretched penile length, with relatively few complications reported. Dr. Levine concluded that TEP is a reasonable option for patients who experience significant distress from penile length or girth loss.

On Friday, October 9, at the 27th Annual SMSNA Fall Scientific Meeting, Dr. Aruna Sarma discussed sexual dysfunction and lower urinary tract symptoms (LUTS) in diabetes, specifically the opportunities and information that can be gathered from UroEDIC. She explained that erectile dysfunction (ED) is one of the leading complications of diabetes, and that glycemia and autonomic neuropathy drive the onset of diabetes-related dysfunction.

Forty years of large diabetes studies have provided some of the richest databases on diabetes. Dr. Sarma says her team has been leveraging existing data to identify urologic complications. Early control of glycemic exposure can positively impact ED and urinary tract infections (UTIs). Despite differences in ED trajectories, autonomic neuropathy appeared to be the biggest predictor of ED in men with diabetes. Type 1 diabetes, specifically, is considered a "clean" model. People with type 1 diabetes may be studied without other comorbidities, such as obesity, and may now be experiencing some of the urologic complications as adults. Dr. Sarma says the key is knowing what questions to ask and how to find the answers.

An interesting part of her research, she says, is that LUTS and ED do not always coexist. LUTS and ED can affect a person independently or together. For 75% of her study population, ED tended to come first. She states that once LUTS develops, it is difficult to eliminate. However, when treating both ED and LUTS, LUTS may improve while ED does not. In women, depression accounts for about half of the association between LUTS and female sexual dysfunction (FSD). A major part of their FSD assessment included pain, which can contribute to depression and further LUTS.

Dr. Sarma concluded with several key takeaways:

• ED is one of the leading complications of diabetes.

• LUTS can wax and wane, so treat symptoms and reassess the patient.

• Glycemia and autonomic neuropathy drive the onset of diabetes-related dysfunction.

• Routine check-ups should include questions about sexual function.

• Researchers should combine data sources and large, deeply characterized cohorts to expand the scale of their research.

On Friday, October 9, at the 27th Annual SMSNA Fall Scientific Meeting, Drs. Raevti Bole, Lawrence Jenkins, and Matthew Ziegelmann discussed the management of penile shortening, pain, and indentation deformity in Peyronie's disease (PD).

Dr. Ziegelmann presented a case study of a 54-year-old patient with PD who experienced penile shortening. He explained that many patients report dissatisfaction with their penile length, sexual performance, and self-image. One of the most challenging yet important aspects of PD treatment is patient counseling, particularly helping men understand that their penis may not return to its original length. Although several oral therapies are available, oral monotherapy is generally not recommended for treating PD deformity. However, pentoxifylline may be used off-label to address fibrosis, while tadalafil is commonly used to treat PD-related erectile dysfunction (ED). Nonsurgical options also include penile traction therapy and vacuum erection devices, although improvements in length may not meet patient expectations. Injections have not been proven to restore penile length, and surgery is not generally the preferred approach for shortening alone. For his patient, Dr. Ziegelmann recommended tadalafil, traction therapy, and realistic expectations about treatment outcomes.

Dr. Jenkins presented a case involving pain during erections or penetration. He explained that pain may resolve as PD progresses beyond its active phase, although penile curvature may persist. He recommended first identifying the location of the pain and plaque, along with reviewing the patient's history of injections, traction therapy, or other treatments. Several treatment options are available, although not all are supported by sufficient evidence or FDA approval. Dr. Jenkins noted that pain persisting beyond the inflammatory phase of PD may indicate another underlying condition. He also emphasized the importance of early intervention for pain, as surgery is generally considered once the disease has stabilized and curvature is no longer changing. In his patient's case, addressing the pain within the first year may have been beneficial.

Dr. Bole discussed a patient with penile deformity resulting in loss of girth and length. She explained that volume loss and indentation deformities are common concerns in PD and may reduce sexual activity independently of penile curvature. Hinge deformities, which can cause instability during penetration, are particularly challenging. Dr. Bole recommended assessing erectile function and using structured questions to better understand how the deformity affects the patient. Although traction therapy may provide benefits, it may not be sufficient on its own. For her patient, plication alone was unlikely to adequately address the deformity. Dr. Bole reviewed several surgical grafting techniques and emphasized that treatment selection should account for erectile function and other health conditions. Patients with ED that does not respond to treatment may require a different surgical approach. In her case study, the surgical team used grafting to address the deformity and instability of the tunica albuginea, with appropriate patient counseling about expected outcomes.

On Friday, October 9, at the 27th Annual SMSNA Fall Scientific Meeting, Drs. Jasper Bash and Blaire Stocks engaged in a lively debate about whether testosterone should remain a controlled substance.

Dr. Stocks argued for maintaining testosterone's controlled-substance status to help mitigate misuse. He emphasized that testosterone treatment should not be stopped altogether, but that there are opportunities to reduce abuse. He drew attention to the use of anabolic-androgenic steroids (AAS) and related substances among young men, with some gym-goers reporting that they began using AAS as young as 19 years old. Potential side effects of AAS misuse include acne, sexual dysfunction, mood changes, insomnia, fluid retention, testicular atrophy, and excess breast tissue. Testosterone misuse may also affect fertility, potentially impacting future family planning. Outside of medical care, individuals may obtain testosterone from unreliable sources. However, Dr. Stocks concluded with a surprising admission: "I also don't really agree with what I talked about."

Dr. Bash argued for removing testosterone's controlled-substance classification, emphasizing its therapeutic benefits. Testosterone can improve sexual symptoms in men with testosterone deficiency, support masculinizing gender-affirming care, and help treat hypoactive sexual desire disorder in women. He also pointed to its stability, joking that he was able to carry it through airport security in his TSA-approved quart-sized bag. Testosterone has been classified as a Schedule III controlled substance since 1990, alongside medications such as ketamine. With testosterone increasingly available online, Dr. Bash questioned why physicians continue to face so many restrictions when prescribing it. He argued that removing these restrictions could improve access for patients who may otherwise struggle to receive treatment. "Testosterone is a medication. I should be able to prescribe it as I do anything else. The potential for abuse is so low that it should be treated that way."

Should testosterone remain a controlled substance to prevent misuse, or are current restrictions creating unnecessary barriers to patient care?

On Thursday, October 8, at the 27th Annual SMSNA Fall Scientific Meeting, Drs. Amy Pearlman and Kevin Chu engaged in a lively debate about whether sexual health professionals should prescribe GLP-1 medications.

Dr. Pearlman argued that sexual health professionals should prescribe GLP-1s. She cited a systematic review of 10 studies showing that GLP-1s may improve erectile dysfunction (ED), likely indirectly through weight loss. Dr. Pearlman also presented a case in which fertility improved with GLP-1 use. Other data showed that men with diabetes who were taking semaglutide experienced improvements in ED, while the same was not observed in men without diabetes. Maintaining a healthy weight and muscle mass can contribute to overall sexual health and vitality. Dr. Pearlman pointed out that many of the necessary procedures are already in place and may simply need to be adapted. She asked Dr. Chu: If sexual health professionals already prescribe treatments for conditions associated with metabolic disease, why shouldn't they treat metabolic disease itself?

Dr. Chu argued that sexual health professionals should not prescribe GLP-1s. He explained that ED is often the "canary in the coal mine" for other health concerns. However, most sexual medicine professionals do not directly manage conditions such as hypertension or cardiovascular disease. Dr. Chu noted that the same studies Dr. Pearlman cited could also support his argument, as the evidence remains inconclusive about whether GLP-1s improve ED or fertility. He also raised concerns about adverse events that may be beyond a sexual health professional's scope of practice, potentially creating additional burdens for both providers and patients. Instead, he recommended a multidisciplinary approach in which specialists work together to manage ED, ejaculatory disorders, and underlying metabolic conditions.

Should GLP-1 prescribing become part of sexual medicine practice, or is it best left to other specialists?

On Thursday, October 8, at the 27th Annual SMSNA Fall Scientific Meeting, Drs. Kate Adams and Amy Hoover discussed how mental health practitioners and pelvic floor physical therapists (PTs) can work together to support sexual health. Drs. Adams and Hoover presented a case study of a woman who struggled with penetrative sex, tampon use, and pelvic exams. Using this case as an example, they explained how pelvic floor PTs can determine whether the pelvic floor muscles are tight or weak, which can affect sexual function. PTs primarily aim to address the patient's chief complaint, which may include sexual pain or incontinence. They can use several tools, such as dilators, vibrators, biofeedback, and electrical stimulation, to help improve blood flow, stretching, and muscle strength.

Beyond physical symptoms, a heightened nervous system may also contribute to pelvic floor dysfunction. The brain and pelvic floor are closely connected. If a person has experienced negative events resulting in hypervigilance, their pelvic floor muscles may become tighter and more rigid. Calming these responses may help relax the pelvic floor. In the case study, the patient struggled with anxiety, fear, avoidance, trauma, and sexual confidence. The PTs determined that she would struggle with stretching and muscle exercises but was able to connect with her breathing.

Drs. Adams and Hoover were able to treat the patient by addressing the full picture. Mental health professionals can help address nervous system-related elements of pelvic floor dysfunction that hinder sexual wellness. PTs can help address body confidence concerns and other pelvic floor-related issues that may affect mental health through negative feedback loops. Drs. Adams and Hoover emphasized the importance of time, patience, and education in helping the patient adapt to treatment and home exercises. Through gradual treatment and patient education, the woman was eventually able to tolerate dilators, use tampons, and complete a pelvic exam.

Drs. Adams and Hoover recommended shifting the focus to how a patient's brain and environment may be interfering with sexual function.

On Thursday, October 8, at the 27th Annual SMSNA Fall Scientific Meeting, Aleece Fosnight, MSPAS, PA-C, CSE, MSCP, IF, HAES, explained the evidence supporting interventions that can be individualized for each menopausal person. Fosnight invited attendees to consider menopausal sexual function differently. All systems interact to create sexual function, and nonhormonal strategies can help target the "bottleneck" that may be preventing satisfying sex. She emphasized that menopause care is outcome-specific and that not every nonhormonal treatment will be beneficial for everyone.

Fosnight encouraged providers to ask better questions when taking a patient's history. Was there a medication change? Are there new or existing symptoms? What kind of distress may be causing problems, and which symptoms do not need to be addressed immediately? She explained that if an intervention is beneficial to the patient, it should be considered in treatment recommendations. For example, sleep is important for everyone, but weight gain is not a concern for every woman. Fosnight also reminded attendees that nonhormonal pharmacological treatments should be prescribed for specific conditions, such as hypoactive sexual desire disorder and genitourinary syndrome of menopause.

Fosnight encouraged providers to let what is truly bothering their patients guide treatment decisions. Pelvic floor therapy may work for one woman, but not for everyone. Improving sleep may also benefit some women without making a noticeable difference for others. Her final recommendation for providers was to ask what changed, find the bottleneck, match the intervention, and measure what matters. Outcomes should reflect the patient's specific goals.

On Thursday, October 8, at the 27th Annual SMSNA Fall Scientific Meeting, Dr. Nahid Punjani highlighted differences in life expectancy between men and women, both in the United States and across the globe. His data showed that women tend to live longer than men. He says that introducing a Men's Health Program or an Office of Men's Health may encourage greater engagement between men and the healthcare system. Men's health has fewer dedicated resources within the US government than women's health. A centralized Office of Men's Health would combine resources from other projects related to men's health, creating opportunities to improve men's life expectancy.

Dr. Punjani says this difference may be related to men's and women's healthcare habits. Men tend to use healthcare services and obtain health insurance less often than women. They also tend to sleep less, smoke cigarettes and consume alcohol more often, and visit the doctor less frequently. According to Dr. Punjani, rates of drug- and alcohol-induced diseases are significantly higher in men than in women.

Dr. Punjani says urologists and other healthcare providers are stewards of care because when men come into the office with penile or sexual dysfunction concerns, providers have an opportunity to direct them to appropriate care. Conditions like erectile dysfunction (ED) are associated with cardiovascular disease. If a man presents with ED, he may also have underlying health issues that could reduce his life expectancy.