Steven D Kleeman

Good Samaritan Hospital, Cincinnati, Ohio, United States

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Publications (55)124.52 Total impact

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    ABSTRACT: In 2011, the Accreditation Council for Graduate Medical Education implemented work restrictions for interns (Postgraduate Year [PGY] 1) to combat potential physical and emotional burdens. We hypothesized resident burnout remains high despite these limitations. This web-based survey queried Ohio-based residents in general surgery, obstetrics-gynecology, family medicine, and internal medicine using general questions, Epworth Sleepiness Scale, Center for Epidemiologic Studies Depression scale, and Maslach Burnout Inventory. One hundred forty-nine residents responded: 39 general surgery (26.2%), 37 obstetrics-gynecology (24.8%), 27 family medicine (18.1%), and 46 internal medicine (30.9%). The majority was PGY-1 (36.2%), female (55%), aged 20-29 years (57.7%), and married (52.3%) with no children (75%). Many reported 5-6 hours of sleep per night (55.7%) and 0-3 days per week of exercise (81.9%). There were no differences between junior and senior residents regarding demographics, sleep, or activity; however, seniors had a higher Maslach Burnout Inventory personal accomplishment domain mean (standard deviation) score (39.0 [5.2] compared with 37.1 [7.2], P=.07). Factors associated with an increased score on the Maslach Burnout Inventory depression domain were more residents per year (P=.015) and graduation from a U.S. medical school (P<.001). Decreased physical activity was related to higher Maslach Burnout Inventory emotional exhaustion (P<.001). Increased Epworth Sleepiness Scale sleepiness and higher Center for Epidemiologic Studies Depression scale depression were associated with more work (P=.03; P=.019) and less sleep (P=.013; P=.007). Although the Accreditation Council for Graduate Medical Education restricts work hours for interns, we found no differences based on PGY level regarding Epworth Sleepiness Scale, Center for Epidemiologic Studies Depression scale, or Maslach Burnout Inventory except for the personal accomplishment domain score. At all levels, programs should encourage and teach coping strategies for sleepiness and depression.
    Obstetrics and Gynecology 05/2014; 123 Suppl 1:117S-8S. · 4.80 Impact Factor
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    ABSTRACT: The female sexual response is dynamic; anatomic mechanisms may ease or enhance the intensity of orgasm. The aim of this study is to evaluate the clitoral size and location with regard to female sexual function. This cross-sectional TriHealth Institutional Board Review approved study compared 10 sexually active women with anorgasmia to 20 orgasmic women matched by age and body mass index (BMI). Data included demographics, sexual history, serum hormone levels, Prolapse/Incontinence Sexual Questionnaire-12 (PISQ-12), Female Sexual Function Index (FSFI), Body Exposure during Sexual Activity Questionnaire (BESAQ), and Short Form Health Survey-12. All subjects underwent pelvic magnetic resonance imaging (MRI) without contrast; measurements of the clitoris were calculated. Our primary outcomes were clitoral size and location as measured by noncontrast MRI imaging in sagittal, coronal, and axial planes. Thirty premenopausal women completed the study. The mean age was 32 years (standard deviation [SD] 7), mean BMI 25 (SD 4). The majority was white (90%) and married (61%). Total PISQ-12 (P < 0.001) and total FSFI (P < 0.001) were higher for orgasmic subjects, indicating better sexual function. On MRI, the area of the clitoral glans in coronal view was significantly smaller for the anorgasmic group (P = 0.005). A larger distance from the clitoral glans (51 vs. 45 mm, P = 0.049) and body (29 vs. 21 mm, P = 0.008) to the vaginal lumen was found in the anorgasmic subjects. For the entire sample, larger distance between the clitoris and the vagina correlated with poorer scores on the PISQ-12 (r = -0.44, P = 0.02), FSFI (r = -0.43, P = 0.02), and BESAQ (r = -0.37, P = 0.04). Women with anorgasmia possessed a smaller clitoral glans and clitoral components farther from the vaginal lumen than women with normal orgasmic function. Oakley SH, Vaccaro CM, Crisp CC, Estanol MV, Fellner AN, Kleeman SD, and Pauls RN. Clitoral size and location in relation to sexual function using pelvic MRI. J Sex Med **;**:**-**.
    Journal of Sexual Medicine 02/2014; · 3.51 Impact Factor
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    ABSTRACT: The objective of this study was to measure and model the passive biomechanics of cadaveric levator ani muscle in the fiber direction at low strains with a moderately slow deformation rate. Nine levator ani samples, extracted from female cadavers aged 64 to 96 years, underwent preconditioning and uniaxial biomechanical analysis on a tensile testing apparatus after the original width, thickness, and length were measured. The load extension data and measured dimensions were used to calculate stress-strain curves for each sample. The resulting stress-strain curves up to 10% strain were fit to four different constitutive models to determine which model was most appropriate for the data. A power-law model with two parameters was found to fit the data most accurately. Constitutive parameters did not correlate significantly with age in this study; this may be because all of the cadavers were postmenopausal.
    Journal of biomechanics 11/2013; · 2.66 Impact Factor
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    ABSTRACT: Despite its central role in sexual function, we lack a description of the nerve distribution and histology for the central components of the clitoris. This study aims to characterize microscopic anatomy of the clitoral-urethral complex (CUC) and aid our understanding of sexual sensation METHODS: The CUC was excised from three female fresh-frozen cadavers en bloc and prepared in 5-μm longitudinal sections with hematoxylin and eosin and S100 immunohistochemistry for neural elements. Approximately 20 sections were obtained from each specimen. On low power microscopy, the 30 most innervated fields on each section were identified. On high power, the total number of nerves per field was quantified, then was averaged. The histologic characteristics of each clitoral component were described. Two investigators evaluated all specimens. Descriptives of large (≥3 fibers) and small nerves based on location in the CUC. Nerve quantification revealed the glans to be the most populated by small nerves (52.1, standard deviation [SD] 26.2). As slices through each specimen moved caudad toward the urethra, the number of small nerves dramatically decreased from 40.4 (SD 10.8) in the body and 29.8 (SD 8.8) (superior CUC) near the bulb to 23.7 (SD 9.8) in the middle CUC and 20.5 (SD 10.4) (inferior CUC) near the urethra. Although the variation in small nerves was striking, large nerves were somewhat uniform and comprised a minority of the overall quantity. Neuroanatomy was consistent for all cadaver specimens. Our study provided a description of the nerve distribution throughout the central CUC. Increased density of small nerves in the glans suggests this is the location of heightened sensation. Decreasing quantity of nerves in segments closer to the urethra may indicate these zones are less important for sexual sensation. Knowledge of human clitoral innervation is important for understanding the complexities of the female sexual response cycle. Oakley SH, Mutema GK, Crisp CC, Estanol MV, Kleeman SD, Fellner AN, and Pauls RN. Innervation and histology of the clitoral-urethal complex: A cross-sectional cadaver study. J Sex Med **;**:**-**.
    Journal of Sexual Medicine 06/2013; · 3.51 Impact Factor
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    ABSTRACT: INTRODUCTION AND HYPOTHESIS: Intra-vaginal diazepam suppositories are commonly prescribed as a treatment option for high-tone pelvic floor myalgia. This triple-blinded placebo-controlled randomized trial sought to determine if 10 mg diazepam suppositories improve resting pelvic floor electromyography (EMG) compared with placebo. METHODS: Women ≥18 years of age with hypertonic pelvic floor muscles on examination, confirmed by resting EMG ≥2.0 microvolts (μv), administered vaginal suppositories containing either diazepam or placebo for 28 consecutive nights. Outcomes included vaginal surface EMG (four measurements), the Female Sexual Function Index (FSFI), the Short Form Health Survey 12 (SF-12), four visual analog scales (VAS), the Patient Global Impression of Severity (PGI-S), and the Patient Global Impression of Improvement (PGI-I). A priori sample size calculation indicated that 7 subjects in each group could detect a 2-μv difference in resting EMG tone with 90 % power. RESULTS: Twenty-one subjects were enrolled. The mean age was 36.1 (SD 13.9) years, mean body mass index was 28.56 (SD 9.4), and the majority (85.7 %) was Caucasian. When evaluating response to therapy, no difference was seen in any of the resting vaginal EMG assessments at any time point within subjects or between groups, nor was an interaction found. Additionally, no differences were noted in any of the validated questionnaires. CONCLUSIONS: When used nightly over 4 weeks, 10 mg of vaginal diazepam was not associated with improvement in resting EMG parameters or subjective outcomes compared with placebo. This suggests such that therapy alone may be insufficient in treating high-tone pelvic floor dysfunction.
    International Urogynecology Journal 05/2013; · 2.17 Impact Factor
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    ABSTRACT: Background/Aims: The Accreditation Council for Graduate Medical Education (ACGME) requires that all Ob/Gyn residents accomplish scholarly activity. We hypothesize resident productivity is poor. Methods: This was a web-based two-survey study using SurveyMonkey®. Surveys queried both program directors and residents regarding their adherence to ACGME guidelines. All 233 accredited Ob/Gyn programs were targeted. Results: 70 program directors responded (30.4%). The majority (99%) felt research was a goal of their program and stated their residents are taught to read current literature (99%), design basic studies (99%), and interpret simple statistics (89%). 17% (53/313) of the residents did not agree that their training environment promoted research, 25% did not feel comfortable discussing basic study designs, and 54% did not feel comfortable interpreting basic statistics. Urban programs demonstrated improved resident attitudes toward research (p = 0.025), better research environments (p = 0.007) and curricula (p = 0.001) compared to rural programs. Furthermore, residents intending to pursue an academic career were more likely to be working with a research mentor (p = 0.038). Conclusion: The ACGME clearly delineates residency research requirements. A dichotomy exists between program director perception and resident compliance. Notwithstanding, it is reassuring that the majority of programs appear to promote scholarly activity and provide necessary support.
    Gynecologic and Obstetric Investigation 03/2013; · 1.10 Impact Factor
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    ABSTRACT: OBJECTIVE: To determine whether patient-controlled analgesia or scheduled intravenous analgesia provides superior pain relief and satisfaction with pain control after vaginal reconstructive surgery. STUDY DESIGN: Fifty-nine women scheduled for vaginal reconstructive surgery were enrolled in this randomized trial. Operative procedures and postoperative orders were standardized. Visual analog scales for pain and satisfaction with pain control were recorded during the hospital stay and 2 weeks after surgery. RESULTS: Patients receiving patient-controlled analgesia had less pain on postoperative day 1, 25 mm vs 39 mm, on visual analog scales (P = .007). Although this group used twice as much hydromorphone (3.57 mg vs 1.48 mg, P < .001), there was no difference in side effects, length of hospital stay, or complications. For the sample overall, larger amounts of narcotic used correlated with higher pain scores (r = 0.364, P = .009) and worse satisfaction scores (r = -0.348, P = .012). CONCLUSION: In patients undergoing vaginal surgery, patient-controlled analgesia offers superior pain relief on postoperative day 1 when compared with scheduled, nurse-administered hydromorphone.
    American journal of obstetrics and gynecology 06/2012; · 3.28 Impact Factor
  • Steven D Kleeman, Mickey M Karram
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    ABSTRACT: This article discusses the tension-free vaginal tape (TVT) procedure, which attempts to recreate urethral support at the level of the pubourethral ligaments by placing a polypropylene sling at the midurethra as opposed to the bladder neck. The procedure has the proposed advantage of being done under local anesthesia and being an outpatient surgery and can be performed transvaginally or suprapubically.
    Urologic Clinics of North America 02/2011; 38(1):39-45, vi. · 1.39 Impact Factor
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    ABSTRACT: The objective of the study was to identify predictors of recurrent urinary incontinence (UI) 1 year after treatment with tension-free vaginal tape (TVT) and transobturator tape (TOT). One hundred sixty-two women with urodynamic stress urinary incontinence (SUI) were included in a clinical trial comparing TVT with TOT with at least 1 year of follow-up were included in this analysis. Potential clinical and urodynamic predictors for development of "any recurrent UI" or "recurrent SUI" 1 year after surgery were evaluated using logistic regression models. Subjects who received concurrent prolapse surgery and those taking anticholinergic medications preoperatively were more likely to develop any recurrent UI. Increasing age was independently associated with recurrent SUI. Risk factors were similar for TVT and TOT for both definitions of treatment failure. Concurrent prolapse surgery and preoperative anticholinergic medication use are associated with increased risk of developing recurrent UI 1 year after TVT or TOT. Increasing age is specifically associated with the recurrence of SUI symptoms.
    American journal of obstetrics and gynecology 01/2009; 199(6):666.e1-7. · 3.28 Impact Factor
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    ABSTRACT: The objective of the study was to evaluate perceptions regarding subspecialty training in female pelvic medicine and reconstructive surgery (FPMRS) in the United States. A 57-item questionnaire was anonymously mailed to fellows and applicants to FPMRS fellowship. Seventy-four American fellowship interviewees and current fellows completed the entire questionnaire (56% response rate). Key factors associated with higher interest in FPMRS compared to general obstetrics and gynecology (OBG) included competitiveness to get into fellowship and new developments. Key factors associated with higher interest in FPMRS compared to other subspecialties in obstetrics and gynecology (SUB) were lower risk of malpractice and higher sense of career satisfaction. Commonly cited attributes of FPMRS that attract to the field relate to the complexity of cases and the quantity of time spent in the operating room. Majority of responders preferred academics over private practice or a mixture (55.4%, 17.6%, and 27%, respectively). The most important reason for interest in FPMRS compared to OBG and SUB is quality time in the operating room and lower risk of malpractice, respectively. Results of this study may help attract medical students to OBG and help mentors with career counseling.
    International Urogynecology Journal 08/2008; 19(11):1523-6. · 2.17 Impact Factor
  • S D Kleeman, M Karram
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    ABSTRACT: The vagina proper extends from the hymen to the cervix and uterus. The anterior wall of the rectum and the posterior vaginal wall are fused for approximately 3 to 4 cm into the vagina. Above this, a plane of dissection is easily created. Plastic repair of the posterior vagina that utilizes ''fascia'' are in fact using the split adventicia and fibromuscular walls of the vagina to support the anterior wall of the rectum. Evaluation of posterior vaginal wall defects requires not only an anatomical description of the prolapse, but also correlation of any functional derangements that may exist. Evaluation may include; defecography, bowel transit studies, manometry, endoluminal ultrasound and magnetic resonance imaging. Surgical correction of posterior vaginal wall prolapse includes vaginal, trans anal and abdominal approaches. Vaginal approaches include site specific repairs and traditional posterior colporrhaphy with levator ani placation. Graft augmentation has been described with both approaches in an effort to improve outcomes and decrease failure rates.
    Minerva ginecologica 05/2008; 60(2):165-82.
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    ABSTRACT: The aim of this study was to correlate the lowest Valsalva or cough leak point pressure (LPP) with clinical measures of incontinence severity and quality of life in women with pure urodynamic stress incontinence (SUI). This is an analysis of the baseline data from a prospective, multicenter, randomized trial comparing the Monarc transobturator sling to the tension-free vaginal tape. One hundred fifty-five women with SUI underwent urodynamic evaluations including abdominal or vesical LPP determinations, and each completed the Sandvik Incontinence Severity Index, a 3-day voiding diary, and quality-of-life questionnaires. In patients with a LPP, there were no significant correlations between LPP and the above clinical measures of incontinence severity or condition-specific quality-of-life questionnaire scores. In this patient population with pure urodynamic SUI, LPP is not a useful urodynamic predictor of baseline SUI severity and its effects on quality of life.
    International Urogynecology Journal 05/2008; 19(9):1193-8. · 2.17 Impact Factor
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    ABSTRACT: To compare the safety and efficacy of the transobturator tape to tension-free vaginal tape (TVT) in the treatment of stress urinary incontinence in patients with and without concurrent pelvic organ prolapse. One-hundred seventy women with urodynamic stress incontinence, including those with and those without pelvic organ prolapse, from three academic medical centers were randomized to receive TVT or transobturator tape. Subjects with detrusor overactivity or previous sling surgery were excluded. The primary outcome was the presence or absence of abnormal bladder function, a composite outcome defined as the presence of any the following: incontinence symptoms of any type, a positive cough stress test, or retreatment for stress incontinence or postoperative urinary retention assessed 1 year after surgery. This study is a noninferiority study design. Of 180 women who enrolled in the study, 170 underwent surgery and 168 returned for follow-up, with a mean follow-up of 18.2+/-6 months. Mean operating time, length of stay, and postoperative pain scores were similar between the two groups. Bladder perforations occurred more frequently in the TVT group (7% compared with 0%, P=.02); otherwise, the incidence of perioperative complications was similar. Abnormal bladder function occurred in 46.6% of TVT patients and 42.7% of transobturator tape patients, with a mean absolute difference of 3.9% favoring transobturator tape (95% confidence interval -11.0% to 18.6%.). The P value for the one-sided noninferiority test was .006, indicating that transobturator tape was not inferior to TVT. The transobturator tape is not inferior to TVT for the treatment of stress urinary incontinence and results in fewer bladder perforations. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00475839.
    Obstetrics and Gynecology 04/2008; 111(3):611-21. · 4.80 Impact Factor
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    ABSTRACT: The objective of the study was to assess sexual function following anal sphincteroplasty and determine associations between sexual function and fecal incontinence. Women 1 year or longer following anal sphincteroplasty with or without other reconstructive surgery were matched to controls. Subjects were mailed the Female Sexual Function Index (FSFI), Fecal Incontinence Quality of Life (FIQOL), Fecal Incontinence Severity Index (FISI), and a general questionnaire. Twenty-six cases and 26 controls responded; 73% were sexually active. Sexual function scores were similar between the groups. Seventeen sphincteroplasty patients and 8 controls complained of fecal incontinence at follow up. Significant correlations were found between FSFI domains and the FIQOL depression/self-perception scale, FISI fecal incontinence of solid stool, and total FISI. Sexual activity and function was similar following anal sphincteroplasty, compared with controls, despite worse symptoms of fecal incontinence. Fecal incontinence of solid stool and depression related to fecal incontinence were correlated with poorer sexual function.
    American journal of obstetrics and gynecology 01/2008; 197(6):618.e1-6. · 3.28 Impact Factor
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    ABSTRACT: The objective of the study was to assess sexual function following vaginal surgery and to determine the impact on postoperative sexual function in women who undergo concurrent antiincontinence procedures, compared with those who do not. Sexually active women undergoing vaginal repairs for prolapse or urinary incontinence were prospectively enrolled. Subjects completed the Female Sexual Function Index (FSFI), Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and a standardized questionnaire. Follow-up occurred at 6 months. Forty-nine subjects (96%) returned their postoperative surveys; 48 were sexually active. Improvements were noted in postoperative prolapse stage, UDI-6, and IIQ-7. However, sexual function and frequency were similar. The most bothersome barrier to sexual activity before repair was vaginal bulging; postoperatively it was vaginal pain. Twelve subjects (25%) commented on the negative impact of vaginal pain postoperatively. Finally, FSFI scores were not different based on performance of antiincontinence surgery. Sexual function was unchanged following vaginal reconstructive surgery despite anatomic and functional improvements; lack of benefit may be attributable to postoperative dyspareunia.
    American journal of obstetrics and gynecology 01/2008; 197(6):622.e1-7. · 3.28 Impact Factor
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    ABSTRACT: The purpose of this study is to compare the feasibility of local anesthesia with IV sedation versus general anesthesia for vaginal correction of pelvic organ prolapse. Patients with pelvic organ prolapse who were scheduled for an anterior or posterior colporrhaphy, or an obliterative procedure, and who did not have a contraindication or preference to type of anesthesia were randomized to one of the two anesthesia groups. Nineteen patients were randomized to the general group and 21 patients were randomized to the local group. Mean operating room, anesthesia, and surgical time were similar in each group, and 10 patients in the local group bypassed the recovery room. Requests and doses of antiemetics, postoperative verbal numerical pain scores and length of hospital stay were similar between the two groups. Mean recovery room and total hospital costs were significantly lower in the local group. Local anesthesia with IV sedation is a feasible alternative for vaginal surgery to correct pelvic organ prolapse.
    International Urogynecology Journal 08/2007; 18(7):807-12. · 2.17 Impact Factor
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    ABSTRACT: The aim of this prospective study was to determine if sacral neuromodulation has an effect on the patient's subsequent sexual function. Sexually active patients that underwent an Interstim Sacroneuromodulator implantation (Medtronic, Minneapolis, MN) for control of bladder symptoms were enrolled. A Female Sexual Function Index (FSFI) was completed before surgery and at a mean of 5.7 months postoperatively. Eleven subjects proceeded to permanent implantation, seven of these were sexually active before and after placement. Three subjects (43%) felt the device impacted on their sexual function in a positive way (1) by decreasing urgency and (2) by increasing desire. Overall sexual frequency increased significantly after the surgery (p=0.047). There were also significant increases in the FSFI total (p=0.002), and domain scores for desire (p=0.004), lubrication (p=0.005), orgasm (p=0.043), satisfaction (p=0.007), and pain (p=0.015). There was no correlation between patient report of urinary symptom improvement and FSFI scores. In conclusion, sacral neuromodulation may improve sexual frequency and sexual function scores in subjects with urgency frequency and urge incontinence.
    International Urogynecology Journal 05/2007; 18(4):391-5. · 2.17 Impact Factor
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    ABSTRACT: To develop a valid and reliable tool to objectively measure surgical skill necessary for repair of fourth-degree perineal lacerations and then to use this tool to measure improvement after a workshop. We measured baseline surgical ability and clinical knowledge of 26 residents (postgraduate year [PGY]-1 to PGY-4) using the Objective Structured Assessment of Technical Skills (OSATS) and a written examination. The OSATS consists of a global surgical skills assessment (OSATS-G), a procedure checklist (OSAT-C), and pass/fail grade. Five weeks after our baseline evaluation, a 1.5-hour workshop was administered to approximately half of the 26 residents (n=14). One week after this intervention, the residents were re-examined using the same assessment tools. The OSATS demonstrated construct validity as scores on the examination increased on both the OSATS-G and the OSATS-C from PGY-1 through PGY-4 (P=.001 and P=.041, respectively). Reliability indices for the OSATS were high. Eighty-one percent of the residents failed the OSATS before intervention because of failure to identify and repair the internal anal sphincter. After educational intervention, senior residents improved on all assessments (OSATS-G, P=.041; OSATS-C, P=.004; written examination, P=.008), and all residents passed the OSATS. A valid and reliable OSATS and written examination were developed to assess surgical skills, knowledge, and judgment necessary to properly manage fourth-degree perineal lacerations. Residents improved on the OSATS and the written examination after undergoing a structured educational workshop. II.
    Obstetrics and Gynecology 03/2007; 109(2 Pt 1):289-94. · 4.80 Impact Factor
  • Steven Kleeman
    International Urogynecology Journal 01/2007; 18(8). · 2.17 Impact Factor
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    ABSTRACT: The purpose of this study was to evaluate sexual function in women referred to a urogynecology practice. All new patients were mailed an optional female sexual function index (FSFI) in conjunction with their history forms; other sexual function information was obtained during the physician interview. Over 6 months, four hundred fifty new patients were enrolled. Of these, 243 (54%) were not sexually active. Reasons listed for sexual inactivity included partner problems/no partner (32%), low desire (14%), prolapse (10%), and pain (10%). There were several differences between sexually active and non-sexually active participants; however, after a multivariate analysis, only age, marital status, and stage/grade 1-2 of prolapse remained significant. One hundred nine sexually active patients completed the FSFI; the majority was sexually active two to four times per month. Female sexual dysfunction was noted in 70 (64%) patients. Lowest scores were noted for the domain of desire, followed by arousal, orgasm, lubrication, satisfaction, and pain. Reduced frequency of intercourse was the only factor significantly associated with dysfunction. Ninety-four percent were not embarrassed by the survey. Overall, sexual inactivity is common in patients presenting for urogynecologic care. Those that are sexually active report low rates of sexual activity and high rates of sexual dysfunction. Most sexually active patients will accept a sexual function questionnaire as part of their routine assessment.
    International Urogynecology Journal 12/2006; 17(6):576-80. · 2.17 Impact Factor

Publication Stats

963 Citations
124.52 Total Impact Points

Institutions

  • 2002–2013
    • Good Samaritan Hospital
      Cincinnati, Ohio, United States
  • 2005–2008
    • University of Cincinnati
      • Department of Obstetrics and Gynecology
      Cincinnati, OH, United States
  • 2006
    • Good Samaritan Hospital
      Suffern, New York, United States
    • Saint Barnabas Medical Center
      Livingston, New Jersey, United States