Introduction For many years, reports in the literature have implicated bicycle riding as causing increased risk of erectile dysfunction (ED). Perineal compression during cycling has been associated with the development of sexual complications. Aim To review current literature on the rationale for ED from bicycle riding and outcome of bicycle riding on erectile function and to present available research on preventative measures specifically regarding bicycle riding. Methods A systematic comprehensive literature review. Results There is a significant relationship between cycling-induced perineal compression leading to vascular, endothelial, and neurogenic dysfunction in men and the development of ED. Research on female bicyclists is very limited but indicates the same impairment as in male bicyclists. Preventative measures including use of a properly fitted bicycle, a riding style with a suitable seat position and an appropriate bicycle seat can help prevent impairment of erectile function. Conclusions There is a need for further research on safe bicycle and bicycle seat design and investigations that address the underlying mechanisms leading to cycling-related sexual dysfunction in both male and female bicyclists.

Introduction The existence of female ejaculation and the female prostate is controversial; however, most scientists are not aware that historians of medicine and psychology described the phenomenon of female ejaculation approximately 2,000 years ago. Aim To review historical literature in which female ejaculation is described. Methods A comprehensive systematic literature review. Main Outcome Measure Emission of fluid at the acme of orgasm and/or sexual pleasure in females was considered as a description of female ejaculation and therefore all documents referring to this phenomenon are included. Results Physicians, anatomists, and psychologists in both eastern and western culture have described intellectual concepts of female ejaculation during orgasm. In ancient Asia female ejaculation was very well known and mentioned in several Chinese Taoist texts starting in the 4th century. The ancient Chinese concept of female ejaculation as independent of reproduction was supported by ancient Indian writings. First mentioned in a 7th century poem, female ejaculation and the Gräfenberg spot (G-spot) are described in detail in most works of the Kāmaśāstra. In ancient Western writings the emission of female fluid is mentioned even earlier, depicted about 300 B.C. by Aristotle and in the 2nd century by Galen. Reinjier De Graaf in the 16th century provided the first scientific description of female ejaculation and was the first to refer to the periurethral glands as the female prostate. This concept was held by other scientists during the following centuries through 1952 A.D. when Ernst Gräfenberg reported on “The role of the urethra in female orgasm. Current research provides insight into the anatomy of the female prostate and describes female ejaculation as one of its functions. Conclusions Credible evidence exists among different cultures that the female prostate and female ejaculation have been discovered, described and then forgotten over the last 2,000 years.

Introduction Persistent genital arousal disorder (PGAD) in women is associated with feelings of persistent, spontaneous, intrusive, unrelenting, and unwanted physical arousal in the absence of conscious thoughts of sexual desire or sexual interest. Aim To report the case of a 49-year-old woman with lifelong PGAD who was recently prescribed varenicline for smoking cessation and who subsequently experienced amelioration of PGAD symptoms. Methods Patient self-report and literature review. Written consent was obtained from the patient. Results Abatement of lifelong PGAD symptoms occurred within approximately two weeks each time varenicline treatment was initiated. PGAD symptoms returned in approximately 2 weeks each time treatment was suspended. Conclusions Varenicline is a partial agonist of the α2β4 subtype of nicotinic cholinergic receptor. Its unique pharmacological action stimulates a small amount of brain dopamine release while antagonizing the ability of nicotine to stimulate much larger dopamine release. Genital sexual arousal is controlled in part by the action of hypothalamic and limbic dopamine systems. Based on the mechanism of action of varenicline and the observation of its effectiveness in this case, we hypothesize that: (i) central hyperactive dopamine release is an important component in the pathophysiology of PGAD in this patient; and (ii) use of varenicline resulted in lowering of this hyperstimulated central dopamine release. Objective testing of varenicline’s safety and efficacy in the treatment of other women with PGAD is suggested.

Introduction This is the second case report of a woman with bipolar disorder type I who noted the onset of persistent genital arousal disorder (PGAD) symptoms after abrupt cessation of paroxetine. With the worsening of PGAD symptoms, she developed severe depression and suicidal thoughts, resulting in her undergoing electroconvulsive therapy (ECT) as management. Aim To describe a case of PGAD and develop hypotheses to explain the beneficial actions of ECT on PGAD based on 4 years of ECT administration. Methods Patient self-report after obtaining consent, as well as literature review. Results After the fourth ECT, the patient’s PGAD symptoms abated serendipitously. She was placed on ECT on demand for the treatment of her PGAD. With each ECT treatment, PGAD symptoms immediately disappeared, relapsing slowly over time until the next ECT was administered. The patient has, thus far, received a total of 30 treatments of ECT. Side effects continue to be minimal and include brief short-term memory loss, headache, and muscle aches. Conclusion ECT is known to induce cerebral excitatory and inhibitory neurotransmitter changes after acute and chronic administration. Sexual arousal is stimulated by the action of hypothalamic and limbic dopamine, noradrenaline, melanocortin, and oxytocin, and inhibited by serotonin, cerebral opioids, and endocannabinoids. Based on the patient’s bipolar disorder, the mechanism of action of ECT and the observation of ECT effectiveness on her PGAD, we hypothesize the following: (i) bipolar disorder led to central hyperactive dopamine release, an important component in the pathophysiology of her PGAD; (ii) central serotonin deficiency after selective serotonin-reuptake inhibitor (SSRI) withdrawal resulted in a lack of inhibition of sexual excitement; (iii) ECT resulted in lowering of the hyperstimulated central dopamine release; and (iv) ECT led to an increase in sexual inhibition by stimulating serotonin activity. Further research in the central control of sexual arousal is needed.