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Research Article | DOI: https://doi.org/10.31579/2578-8965/197
1 Khan-Uul district, 11 horoo, Marshal town 113-14, Ulaanbaatar, Mongolia.
2 Praxis für Frauenheilkunde und Geburtshilfe, Kirchenweg 2, 24143 Kiel, Germany.
3 Urologisches Zentrum Schweinfurt, Jägersbrunnen 4, 97421 Schweinfurt, Germany.
4 Proktologie, Kontinenz- und Beckenbodenchirurgie, Niels-Stensen-Kliniken, Franziskus-Hospital Harderberg, Alte Rothenfelder Strasse 23, 49124 Georgsmarienhütte, Germany.
*Corresponding Author: Bolor Choidogjamts, Consultant surgeon, Khan-Uul district, 11 horoo, Marshal town 113-14, Ulaanbaatar, Mongolia. Tel: +976-91912322; E-mail: [email protected].
Citation: Bolor Choidogjamts, Marit Bauer, Christian Vollmer, Erik Allemeyer, (2024), Sacral Neuromodulation in Male Sexual Dysfunction - a Systematic Review. J. Obstetrics Gynecology and Reproductive Sciences, 8(1) DOI:10.31579/2578-8965/197
Copyright: © 2024, Bolor Choidogjamts. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 04 January 2024 | Accepted: 15 January 2024 | Published: 24 January 2024
Keywords: sexual dysfunction; arousal; orgasm; erectile dysfunction; sacral nerve modulation
Introduction: Contemporary patient care requires full consideration of sexual health as well. Sexual dysfunction has a high prevalence and significantly affects quality of life. The cost to the health care system is estimated to be high but has not yet been calculated with certainty. Therapy considers sexual appetence, sexual arousal, orgasmic experience in both genders, lubrication in women and erection in men. Sacral nerve stimulation (SNS) has been used primarily for neurogenic bladder dysfunction, idiopathic pelvic pain, nonobstructive urinary retention, and fecal incontinence. Effects have also been observed on various components of sexual function. Sexual function as a primary outcome parameter of SNS has not been studied to date.
Methods: For a systematic literature search, the Healthcare Databases Advanced Search (HDAS) platform was used, employing the Medline, EMBASE, and CINHAL search engines, and considering only publications from international peer-reviewed journals.
Results: We identified 16 studies with inclusion of a total of 662 women and 40 men in which potential effects of SNS on sexual function were noted when used in other indications. For the female sex, there was evidence for significant improvements in sexual function. The very weak data situation for the male sex so far only allows to assume similar effects. In any case, it remains unclear whether these effects are primary or secondary to SNS.
Discussion: SNS affects urinary bladder emptying, urinary bladder continence, pelvic pain, and fecal continence and defecation. The direct anatomical and physiological relationship between these organ systems and sexual function raises the question of whether there is a primary effect of SNS on sexual function. High-quality studies with sexual function as the primary endpoint should verify this.
Sexual function includes physiological and psychological components [1]. In women, sexual appetence, sexual arousal, orgasmic experience, and lubrication can be distinguished; in men, libido, erection and ejaculation, and orgasmic experience are commonly defined [2,3]. Accordingly, disorders of sexual function may affect any or all aspects of sexual function. The WHO defines sexual health as the physical, emotional, mental, and social well-being related to sexuality [4]. Therefore, contemporary patient care requires full consideration of sexual health as well. In both gynecology and urology, sexual function is an integral part of diagnosis and treatment. However, sexual function should also be considered in specialties that have an anatomical and also functional relation to sexual function (colorectal surgery, oncology, radiotherapy).
Sexual function has a high impact on quality of life [5]. Data on the overall costs of treating sexual dysfunction are open [6]. Extensive data exist on the treatment costs of erectile dysfunction, and these are estimated to be high overall [7].
Data on the incidence of sexual dysfunction show high variance for both genders due to different study designs. For example, estimated prevalences for orgasmic dysfunction in women are 16-25%, and premature ejaculation and erectile dysfunction are the most common impairments in men [8,9]. A summary in Anderson D et al provides some guidance: 52% of all men between 40 and 70 years of age report erectile dysfunction of varying degrees [2].
Tanagho et al. first described chronic sacral nerve stimulation (SNS) as a therapeutic alternative for neurogenic bladder in 1988 [10].
The therapy has been approved in Europe since 1994. As a minimally invasive therapy for urinary urge incontinence [11] of idiopathic 5 pelvic pain [12-14] and nonobstructive urinary retention, there is now a wide therapeutic spectrum for sacral nerve stimulation (SNS) in urology/urogynecology. Since the initial description of the successful treatment of fecal incontinence in 1995 by Matzel et al [15], its dissemination in coloproctology has also been taking place with high dynamics. In contrast, SNS for the indication "non-obstructive defecation disorder" [16] has shown only limited success and is now rarely used for this indication.
SNS involves permanent subsensory electrical stimulation of the S 3 or S 4 nerve roots. This is achieved by placing a percutaneously implantable electrode immediately presacral to the S 3 or S 4 spinal nerves. The effect is checked in a test phase lasting several weeks using a test electrode and an external pulse generator. The indication for full implantation is then only given if there is significant symptom relief under the test stimulation. In this case, a pacing device is then implanted ipsi- or contralaterally, below the dorsal iliac crest, and continuous pacing is started [17]. Both a lithium battery-powered implant (INTERSTIM II 3058, Medtronic, Minneapolis, MN, USA) and rechargeable systems (Axonics r-SNM System, Axonics Modulation Technologies, Inc., Irvine, CA, USA; INTERSTIM 3058 (Micro 97810), Medtronic, Minneapolis, MN, USA) are approved.
Extensive studies exist on the question of the mechanism of action, but a definitive clarification is not yet available. Nerve modulation of somatic and autonomic efferents as well as afferents [18, 19], but also modulation of central areas responsible for continence function [20-22] appear to be the essential basis.
When SNS is used for the treatment of urinary and fecal continence and idiopathic pelvic pain, improvements in sexual function have also been observed from the beginning [23]. However, it has not yet been clarified whether this is a secondary effect of improvement in 6 the aforementioned conditions or direct effects on sexual function [24, 25]. Therefore, we would like to summarize the current state of research on possible effects of SNS on sexual function in this review. Since, on the one hand, anatomical and physiological similarities exist between the genders and thus findings can be derived independent of sex, and, on the other hand, internationally sex-segregated data are only available on a total of 22 men, we include studies on both genders. We discuss possible perspectives for a targeted use of SNS for the therapy of sexual dysfunction then with a focus on the male gender.
To date, sacral nerve stimulation (SNS) has been used primarily for neurogenic bladder dysfunction, idiopathic pelvic pain, non-obstructive urinary retention and fecal incontinence. Effects on various components of sexual function have also been observed. We aim to evaluate whether sexual function is a primary outcome parameter of SNS, as it has not been studied so far.
A literature search was performed using the Healthcare Databases Advanced Search (HDAS) platform. The search engines Medline, EMBASE and CINHAL were used. Only publications from international journals that use a peer-review process were considered. The terms "sex", "neuromodulation", "nerve stimulation", and "sacral" were used for the search query. Case reports were not included. The last update of the literature search was on 07/01/2023. Both genders were considered in the literature search. An ethics vote was not required.
Sexual function as a primary outcome parameter of SNS has not been studied previously. However, evidence of improvements in sexual function in both genders during the use of SNS has been repeatedly published since 2005 for the indications of urinary urgency incontinence and urinary bladder voiding dysfunction [22-34], fecal incontinence [23, 34, 35], and idiopathic pelvic pain [27, 28, 36]. After few reviews could only provide a rough overview of the impact of SNS on sexual function [36, 37, 38], Khunda et al. published the first high-quality meta-analysis in 2019 [39].
Overall, there are evaluated results from all 16 studies reviewed on 706 patients (662 women and 40 men). The vast majority of data exists on urologic indications for SNS "urinary bladder voiding dysfunction (overactive bladder, chronic retention, and idiopathic pelvic pain). Only 9.1% of indications for SNS are for fecal incontinence (61 patients).
The most commonly used instrument for evaluation in the men studied was the International Index of Erectile Function (IIEF-5) [40]. In women, the validated female sexual function index (FISI) [42], in rare cases the Questionnaire for Screening for Sexual Dysfunctions, QSD; [43], the Golombok Rust Inventory of Sexual Satisfaction (GRISS) [44], the Symptom Checklist-90 (SCL-90) [45], the Maudsley Marital Questionnaire (MMQ) [46] and the McGill-Mah Orgasm Questionnaire) [47] were predominantly used. In one paper [22], the Pelvic Floor Distress Short Form (PFIQ-7), Pelvic Floor Impact Questionnaire Short Form (PFD-20), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire Short Form (PISQ-12) instruments were used as a supplement. Jadav et al applied the 9 electronic Personnel Assessment Questionnaire - Pelvic Floor (ePAQ-PF) [51]. Sexual satisfaction before and during SNS was the focus in each case.
Because there is explicitly no evidence for a primary effect of SNS on sexual function, all publications attempted to identify possible circumstantial evidence for a primary relationship between neuromodulation and the almost universally observed improvement in sexual function.
The meta-analysis by Khunda et al [39] distinguishes between primary and secondary outcome parameters. For the primary outcome parameters, significant improvements in the standardized mean difference (SMD) of sexual function (-0.39; 95% CI: -0.58 to -0.19; p = 0.0001) and a significant reduction in sexual complaints (OR 0.22 (0.09, 0.53); p = 0.0009; heterogeneity I2 = 0%) were found for SNS. Subgroup analysis revealed significant effects of SNS on sexual function when using only the 5 highest quality studies (SMD = -0.40 (-0.59, -0.21); p less than 0.0001; I2 = 0%), when excluding all studies with neuropathic patients (SMD = -0.34 (-0.57, -0.11); p = 0.004; I2 = 49%), when excluding all studies with pelvic pain (SMD = -0.42 (-0.68, -0.17); p = 0. 001, I2 = 28%), when excluding all studies with use of a modified stimulation method (SMD = -0.40 (-0.62, -0.19); p = 0.0002; I2 = 18%), when excluding all studies with industry support (SMD = -0. 49 (-0.88, -0.11); p = 0.01; I2 = 38%), and only marginally significant when using only those studies with a mean patient age less than 51 years (SMD = -0.75 (-1.49, 0.00); p = 0.05; I2 = 68%). Significant improvements in sexual function were seen in all studies using SNS for urinary bladder dysfunction (SMD = -0.42 (-0.65, -0.20); p = 0.0003; I2 = 44%), but not in the two studies included by Khunda et al. using SNS for fecal incontinence (SMD = -0.16 (-0.60, 0.27); p = 0.46; I2 = 0%). A subgroup analysis 10 included only studies that used the FSFI: there was a significant improvement for sexual function during SNS (SMD = -0.44 (-0.75, -0.14); p = 0.004; I2 = 49%). For secondary outcome parameters, according to the FSFI, there was a significant trend for improvement in the "appetence" domain, significant improvement in the "desire," "arousal," "satisfaction," and "pain" domains, but not for the "lubrication" and "orgasm" domains. Components of the "electronic Pelvic Assessment Questionnaire" (ePAQ) were examined
supplementally: The effects of urinary bladder symptoms, vaginal symptoms, and dyspareunia on sexual function did not change significantly after SNS (SMD = 0.38; -0.06 to 0.82; p = 0.09; I2 = 0%, (SMD = 0.05; -0.80 to 0.91; p = 0.90; I2 = 53%, SMD = 0.03; -0.41 to 0.46; p = 0.90; I2 = 0%). The meta-analysis by Khunda et al. thus confirmed the conclusions of previous research groups dealing with this topic [36, 37] with regard to female sex. All reviews on the topic [36-38] concluded that there was evidence for efficacy of SNS on sexual function when used to treat other indications. A recent original paper from Saudi Arabia found significant
improvement in sexual function in patients of both genders regardless of age and diagnosis [40]. Since it cannot be differentiated whether these are only secondary effects, high-quality studies with the primary outcome parameter sexual function are required to clarify this issue.
The original papers are summarized in Table 1.
Table 1: Overview of existing studies (modified according to (41))
| Study | Study type | Number of patients w: m with complete evaluation | Age in mean (rounded without comma) | Method | Mean duration of follow-up in months | Indication for SNS | Result regarding SF | p-Value |
Banakhar et al. 2021 [40] | Prospective cohort study | w: m 8: 5 | 47 | FSFI IIEF-5 | 4 (exactly dated programmed order) | Urinary bladder voiding dysfunction (overactive bladder and chronic retention) and idiopathic pelvic pain, impotence (1 patient m) | Significant improvement in FSFI score in all female patients p=0.013 and IIEF-5 in all males p=0.003 4 months after surgery | Desire p = 0,002 Arousal p = 0,01 Orgasm p = 0,012 Satisfaction p = 0,015 |
De Oliveira et al. 2018 [23] | before/after prospective clinical study | w: m 15: 9 | 41 | FSFI IIEF-5 | 20,7 Median | Urinary bladder voiding dysfunction (overactive bladder and chronic retention) and idiopathic pelvic pain, fecal incontinence (1 patient). | Improvement in all domains of the FSFI - but not all significant. Total Score IIEF-5 improved in 4 men (p 0.06) | Desire p = 0,18 Arousal p = 0,11 Lubrication p = 0,04 Orgasm p = 0,13 Satisfaction p = 0,46 Pain p = 0,67 |
Banakhar et al. 2014 [24] | before/after prospective clinical study | 23 Women | 51 | FSFI | 4 Mean
(queried by Khunda et al., see there). | Urinary bladder voiding dysfunction (overactive bladder and chronic retention and "frequency urgency syndrome") | Total score significantly improved P = 0,011 | Desire p = 0,014 Arousal p = 0,067 Lubrication p = 0,625 Orgasm p = 0,035 Satisfaction p = 0,076 Pain p = 0,134 |
Gill et al. 2011 [25] | before/after prospective clinical study | 10 women (after exclusion of sexually inactive women) | 59 | FSFI (+FSHQ) | 3,2 Mean | Urinary bladder voiding dysfunction (overactive bladder and chronic retention) | Total score significantly improved P = 0,023 | Desire p = 0,25 Arousal p = 0,047 Lubrication p = 0,313 Orgasm p = 0,688 Satisfaction p = 0,031 Pain p = 0,375 |
Parnell et al. 2015 [22] | before/after prospective clinical study | 33 Women | 67 | FSFI (+ PFIQ-7, PFD-20, PISQ-12) | 1,5 | Urinary bladder voiding dysfunction (overactive bladder and chronic retention) | Improvement of sexual function in sexually active women | PISQ-12: Sexualfunktion verbessert p = 0,034 PFDI-20 verbessert p = 0,05 PFIQ-7 verbessert p = 0,05 |
Van Voskuilen et al.2012 [34] | before/after prospective clinical study | 8 Women | 54 | QSD (+SCL-90) | Routine Follow-up ? | Urinary bladder voiding dysfunction (overactive bladder and chronic retention, urgency-frequency syndrome) and fecal incontinence (1 patient) | Weak improvement overall | Improved orgasm rating but not significant |
Lombardi et al.2008 [33] | before/after prospective clinical study | 31 Women | 38 | FISFI | 3 | "Lower urinary tract symptoms" (LUTS). | Over all significant improvement in sexual function | Total Score bei neurogenics p = 0,018 Total Score bei idiopathics p = 0,024 Female sexual distress scale FSDS toal score neurogenics p = 0,02 FSDS total score idiopathics p = 0,032 |
| Lombardi et al. 2008 [64] | before/after prospective clinical study | 22 Men | 43 | IIEF-5 | 3 | „Lower urinary tract symptoms “(LUTS | „Remarkable and long-lasting improvement of erectile function in 30 % of patients“ | Median IIEF-5 score of group A (Neurogenics) shifted from 14.6 (range 11–18) to 18 (range 12–23) (P < 0> Five of group A (35.7%) (non-obstructive retention) median score of 14.6 presurgery vs. 22.2 postSNM, with an average increase of 52% (range 27.8–100%). The median IIEF-5 score for group B (Idiopathics) varied from 15.5 to 18. Two of them (25%) reached a median score of 22.5 (range 22–23) compared to 15.5 (range 15–16) presurgery, with a median difference of 45.2% (range 43.6–46.7%). |
Pauls et al. 2007 [30] | before/after prospective clinical study | 7 Women | 50 | FISFI | 5,7 | Urinary incontinence and urgency frequency | Sexual frequency increased p 0,047 FSFI total score significant verbessert p = 0,002 | Desire p = 0,004 Arousal unverändert Lubrication p = 0,005 Orgasm p = 0,043 Satisfaction 0,007 Pain p = 0,015 |
Yih et al. 2013 [28] | before/after prospective clinical study | 167 Women | 54 | FISFI (+ ICSI-PI GRA) | 6 | Urinary bladder voiding dysfunction (overactive bladder and chronic retention), painful bladder syndrome/interstitial cystitis, pelvic pain | FSFI total score significantly improved p = 0.0044 | Patients with FSFI < 26 xss=removed> Desire p = 0,047 Orgasmus p = 0,0051 Satisfaction p = 0,0001 Pain p = 0,011 Patients with FSFI >26 in the total score slight but significant deterioration |
Signorello et al. 2011 [29] | before/after prospective clinical study | 12 Women | 62 | FISFI | 36,3 | Urinary bladder voiding dysfunction (overactive bladder and chronic retention) | Significant improvement of FSFI total score p = 0.012 | Desire p = 0,019 Arousal p = 0,031 Lubrication p = 0,01 Orgasm p = 0,052 Satisfaction p = 0,040 Pain p = 0,198 |
Zabihi et al. 2008 [27] | before/after prospective clinical study | 36 Women | 50 | FISFI | 6 | Urinary bladder voiding dysfunction (overactive bladder and chronic retention) and idiopathic pelvic pain. | Total FSFI score improved p = 0.05 | Desire p = 0,35 Arousal p = 0,03 Lubrication p = 0,03 Orgasm p = 0,04 Satisfaction p = 0,06 Pain p = 0,11 |
Siegel et al. 2016 [31] | before/after prospective clinical study | 189 Women | 57 | OABqol | 36 | Urinary incontinence (overactive bladder) and "urgency frequency". | In women, significantly better sexual function after SNS than after drug therapy p < 0> | - |
Ferhi et al. 2008 [26] | before/after prospective clinical study | w: m 37: 4 | 53 | Telephone interview with own questionnaire | Urinary bladder voiding dysfunction (overactive bladder and chronic retention) | 41.5% of patients reported improved sexual function | - | |
Ingber et al. 2009 [50] | before/after prospective clinical study | 27 Women | 50 | FISFI | 6 | Urinary incontinence (overactive bladder) and urgency frequency Pelvic pain (painful bladder syndrome) | FSFI total score improved but not significant p = 0.220 | Overall, no significant improvement in SF by SNS in heterogeneous population. |
Jadav et al. 2013 [51] | before/after prospective clinical study | 43 Women | 57 | e-PAQ | 6,8 | Fecal incontinence | 53.3% of patients reported improved sexual function | Significant improvement in vaginal and bowel-related sexual health p = 0.005 |
Jarrett et al. 2005 [35] | Retrospective clinical study | 16 Women | 56 (median) | Sex Life Questionnaire | Routine follow-up | Fecal incontinence | Median % improvement in sex life: 40 | - |
e PAQ electronic Personal Assessment Questionnaire, FSDS female sexual distress scale, FSFI The Female Sexual Function Index, PFDI-20 Pelvic Floor Distress Inventory short form 2, PFIQ 7 Pelvic Floor Impact Questionnaire—short form 7, PISQ Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, QSD Questionnaire for Screening for Sexual Dysfunctions, SNS Sakralnervenstimulation, MW Mittelwert, ICSI-PI GRA Interstitial Cystitis Symptom-Problem Indices with patients rating overall change in sexual functioning on scaled global response assessments, IIEF International Index of Erectile Function, OAB-qol International Consultation on Incontinence Modular Questionnaire.
SNS has been firmly established for the treatment of urinary bladder dysfunction, idiopathic pelvic pain, and fecal incontinence. Clinical prospective studies on this since 2005 also investigated possible effects on sexual function. Improvements in sexual function during the use of SNS were predominantly found. In contrast, no results are yet available on the primary use of SNS for the improvement of sexual function. In addition, the existing studies have significant limitations: the number of patients included is small overall, and this is especially true for the male gender. Individual sections of the questionnaires remained open, as some studies included sexually inactive women. Other methodological shortcomings were the lack of baseline values for blood hormone concentrations [33], a lack of concordance between two applied measurement tools [30], an insufficient discussion of the clinical relevance of changes in survey results in most studies, only reporting of score results in follow-up without baseline values, missing data of age and type of voiding disorder [25, 29]. Interpretation of the FSFI used in most studies is not standardized [52].
Further considerations of efficacy in both genders are initially based on neurophysiological similarities in sexual function in both genders. In both men and women, high co-incidences with sexual dysfunction are observed for urinary incontinence and fecal incontinence or defecation disorders [8, 54-56]. Because these underlying conditions are treatment indications for SNS, when sexual function improves, it is difficult to differentiate whether the improvement is a primary effect of SNS or secondary to relief/cure of the underlying condition. Observations exist of significant correlations between improvements in urinary bladder function and sexual function [29]. However, other studies have not confirmed this correlation [24, 30].
An association of urinary tract disorders with impaired sexual arousal and pain during sexual intercourse [57] as well as between fecal incontinence and reduced sexual appetence, lubrication disorders, impaired orgasmic experience, pain and discomfort during sexual intercourse [55] could be clearly demonstrated. For example, 60% of 350 women with urinary incontinence surveyed reported urine leakage during intercourse and described it as significantly affecting sexual life [56]. A review of 21 studies demonstrated improvements in sexual function after surgical therapy for stress incontinence [55]. Positive effects of drug therapy for urinary urge incontinence on sexual function were shown in another review [58].
Patel et al [59] found lower correlations between impairments in sexual function in patients with rectal/sphincter dysfunction compared to those observed in urinary bladder dysfunction. In contrast, Imhof et al [54] presented a clear correlation also to fecal incontinence. Only two studies with a total of 59 participants receiving SNS for fecal incontinence examined the impact on sexual function. Jadav et al. demonstrated significant improvement in vaginal and bowel-related sexual health [51]. However, the study group used an online questionnaire (ePAO) without sufficient validation for sexual function. Jarret et al. also found evidence for improvements in sexual function in patients with SNS for fecal incontinence therapy [35]. However, due to methodological flaws, the results were also not included in the meta-analysis by Khunda et al. Despite small patient numbers and low-quality data on this issue, possible limitations in improving sexual function in patients with SNS for fecal incontinence can be discussed: As long as a patient has to fear a possible loss of stool, it is conceivable that this concern alone significantly limits sexual experience. Thus, improvements in sexual function may be achieved by SNS only if SNS can completely eliminate fecal incontinence. However, this is the case in only a few patients [35].
Overall, more studies exist with evidence for improvements in sexual function when SNS is used for urinary bladder dysfunction than when used for coloproctologic indications (Table 1).
Considering all the results to date, confounding should be discussed: Improvements in sexual function during SNS for other indications could arise as secondary effects.
Considerations of the mode of action in improving sexual function can so far only be speculative, since the mechanism of action of SNS for improving the indication of urinary bladder function, stool retention, defecation function, and pelvic pain, which has been used so far, has not been fully elucidated. However, an effect of neuromodulation in the pelvis on the complex processes of sexual function is suggested. Sympathetic nerve fibers from the hypogastric plexus inhibit urinary bladder contraction and excite urethral and urinary bladder base smooth muscle. The sympathetic nervous system controls pelvic contraction during orgasm [60]. Parasympathetic nerves reach the pelvic plexus and urinary bladder wall via the pelvic nerves. These cause urinary bladder contraction [61]. In both genders, parasympathetic nerves are involved in smooth muscle relaxation. The vasodilation thus caused causes lubrication as well as swelling of the vagina and clitoris [60, 62] and erection in males [59, 61]. The pudendal nerve contains sensory and motor fibers of the pelvic floor [57]. Afferents from all pelvic organs as well as the clitoris, perineum, penis, and lower rectum reach the central nervous system via S2-4 [60, 62, 63]. These neural pathways are stimulated by the SNS. The afferent and efferent innervation of female sexual response could be addressed by neuromodulation in S2-4 [62-63].
Due to limited data and partly insufficient study quality, no selection can be made for the indication of SNS for individual components of sexual dysfunction (loss of libido, premature ejaculation, erectile dysfunction, anorgasmia, lubrication disorders, vaginismus, etc.).
Data on the improvement of erections in men are very limited. To date, there are very few studies that have collected this in small cohorts [64]. It is not possible to make a statement about potential causal relationships based on the existing literature. Further studies with significantly higher case numbers are needed here.
Sexual function is an essential component of overall health.
Sacral nerve stimulation can be used very effectively in the treatment of urinary bladder dysfunction, fecal incontinence, and idiopathic pelvic pain.
There is preliminary evidence of a possible improvement in erection in men as well, but the data are still very limited.
It is unclear whether this is a primary or secondary effect.
We are planning a study to investigate primary effects of sacral nerve stimulation on sexual function in both genders.
The authors declare no conflict of interest.
This paper does not include studies on humans or animals.
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Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
