Re: indwelling ureteral stents and sexual health: a prospective multivariate analysis . MC Sighinolfi et al. J.Urol 2007, 178 229-31

We read with interest the article by Sighinolfi et al. who prospectively assessed the impact of indwelling ureteral stents on sexual function using the IIEF-5 and Female SFI. At 45 and 60 days after stent insertion 83% of men reported some grade of sexual dysfunction, and 30% of women reported no sexual activity due to stent related anxiety. In recent years there has been an increasing awareness of the need for validated tools to measure objectively the considerable morbidity associated with ureteral stenting, and to address its influence on daily activities. These tools have remained elusive. In this respect the present study significantly adds to the existing literature. Nevertheless we would like to address some issues that we believe deserve scrutiny. Although the authors recognize the robustness of the USSQ developed by Joshi et al. they failed to use it in their study. The USSQ is a validated self-administered instrument with good evaluative and discriminant properties, which explores stent related morbility in 6 areas. The questionnaire has been adopted in several clinical trials and has recently been validated by our group in Italian in a prospective cohort of 66 patients of box sexes with indwelling stents. In the USSQ sexual function for both sexes is investigated with 3 questions evaluating transient but complete sexual dysfunction , pain during intercourse and overall satisfaction for those subjects with a pre-stent active sex life. The 2 specific questionnaires on sexual dysfunction were chosen by Sighinolfi et al. for a more thorough assessment. However one has to recognize that they have not been formally validated in Italian and thus a bias may have been introduced. Moreover with the IEEF-5 the evaluation of pain during intercourse, commonly reported complaint (64% and 45% of men at 1 and 4 weeks after stent insertion, respectively in our series) remains unexplored. Finally a single multidimensional questionnaire with a separate index score for each domain such as the USSQ, would have allowed an easier and more reliable correlation between sexual dysfunction and all other symptoms. Within the same cohort used for our validation study we perform a multivariate analysis to identify predictors of stent related morbidity, including patient age, gender and BMI and stent length, size and location of distal extremity with respect to the midline has determined on abdominal X-ray. Stent distal loop crossing the midline, which was previously shown to impact symptoms negatively , proved to be an independent predictor of morbidity for all USSQ domains including sexual matters. In particular 82% and 100% of original active male and female patients with this condition, respectively reported impaired sexual function at 1 week, compared to 43%and 80% respectively with the stent not crossing the midline (p