Measured magnetic noise of “Geoscan-401” quadcopter.
\r\n\t
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More recently his work pertains to spatial adaptation to climate change, spatial responses in wine growing regions to climate change, the geographies of viticulture and wine, artificial intelligence and machine learning to predict patterns of natural processes and hazards, historical ethnic enclaves in American cities and regions, and environmental adaptations of 19th century European immigrants to North America's landscapes.",institutionString:"Texas State University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"6",institution:{name:"Texas State University",institutionURL:null,country:{name:"United States of America"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"12",title:"Environmental Sciences",slug:"environmental-sciences"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"194667",firstName:"Marijana",lastName:"Francetic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/194667/images/4752_n.jpg",email:"marijana@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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First evaluation of magnetic anomalies has been carried out in Sweden in 1640 using a compass for detecting iron ore deposits, but systematic magnetic surveys have started at the end of nineteenth—beginning of twentieth century with invention of magnetometers [1]. Both ground and aeromagnetic surveys are usually carried out in a regular pattern with fixed distances between parallel lines and points of measurements [2]. Aeromagnetic survey is usually being executed at 250–300 m height depending on aircraft characteristics and flight regulations. Unmanned aeromagnetic system (UAMS) can operate lower, starting from few meters. This is important for geological interpretation of magnetic anomalies as the magnetic signal weakens at a distance from the source. Another advantage of UAMS is a pure economic one. A piloted aircraft is ineffective for surveys of areas, which are less than 200–300 km2 due to high expenses on services requesting airport infrastructure and on approach from the airport to the area of survey. Unmanned aerial vehicle (UAV), especially a small one (lighter than 10 kg [3]), does not need an infrastructure and can be easily transported by car or even by operator.
The major issue of UAMS design is elimination of UAV’s magnetic noise. With piloted aircraft, the problem gets resolved by one of two ways: (1) placing the magnetometer at a gondola attached to aircraft either by rope or by special bar or (2) using quite complicated systems of the aircraft’s noise compensation. In traditional aeromagnetic survey, such systems contain additional magnetometers and use special algorithms facilitating results characterized by error well below 2 nT. In UAMS, such system adds sufficient weight to the load and, practically, rejects use of lightweight UAVs, which eliminates UAMS advantages over using a piloted aircraft. Thus, for UAMS, the first way is the most effective way to fight the carrier’s magnetic noise. Miniaturization of equipment theoretically allows the use of compensation in UAMS using existing technologies, but it makes the system much more complex and expensive.
Each measurement in the magnetic survey, besides of the magnetic field components, should contain time and exact positioning of the magnetometer. State-of-the-art professional UAVs are usually equipped with global navigation satellite system (GNSS) and navigation system facilitating programmed flight route.
Choice of magnetometer for UAMS is also important. It should be lightweight, tolerant to the sensor’s orientation, and, preferably, characterized by high frequency of measurements.
Further, we will consider solutions of these issues for fixed-wing and multirotor UAMS and will demonstrate results of magnetic surveys executed with UAMS designed on the basis of a quadcopter drone “Geoscan-401”.
The advisability of using UAVs to carry out aeromagnetic surveys is based on the fact that UAV-based surveys are more cost effective, and their results are comparable with those of conventional aeromagnetic surveying with the use of manned aircraft. The greater the takeoff weight of a UAV is, the more difficult and expensive its development is, and the lower its reliability and operational safety are [4]. Lightweight UAVs need no airfield; they are characterized by low energy consumption. The main problems to be solved are (1) the development of a magnetic sensor to meet a number of requirements and (2) deviation minimization [5]. The requirements for magnetic-field sensors are related to the speed of a UAV (the measurement rate should be more than 10 Hz at a speed of 60 km/h, which corresponds to a 2-m spacing between measurements) and to payload restrictions. For short-range (from 10 to 120 km) lightweight UAVs [4], the payload weight must not exceed 2 kg, which means additional requirements for aeromagnetometers.
Choice of UAV type (fixed-wing, helicopter, and multirotor) for UAMS should be made on the basis of tasks to be resolved. For magnetic survey of large areas (over 150–200 km2) with relatively flat surface, fixed-wing UAV would be the best option because of higher flight speed. For mountains, maneuverability of the UAV is more important, so helicopter and multirotor UAVs will be the favorites for mountain territories. Further, we will consider fixed-wing and multirotor UAVs as possible platforms for UAMS. The helicopters are excluded from consideration, as they are more expensive in operation and, at the same time, do not have clear advantages in comparison with multirotor UAVs.
Typical magnetic signature of a fixed-wing lightweight UAV can be seen in Figure 1 [5].
Magnetic signature ΔTa of “Geoscan-201” for its different orientation at the Earth’s magnetic field: (a) west; (b) north; (c) south; and (d) east.
The magnetic noise induced by UAV “Geoscan-201” components has been measured using special non-magnetic stand 120 × 270 cm (Figure 2) and atomic scalar magnetometers MMPOS-1 (Russia) and Geometrics G-858 (Canada). To remove the background magnetic field, the measurements on the upper level of the stand have been initially executed without UAV by grid 10 × 10 cm. The amplitude of background magnetic anomalies of the stand is below 1 nT/m.
“Geoscan-201” magnetic noise measurement (a) and background magnetic field (b).
As far as use of gondola for distancing magnetic sensor from the UAV is rather impossible for such a lightweight aircraft as “Geoscan-201”, the best option for the sensor placement is the end of wing, where magnetic influence of the aircraft ranges from −4 to +4 nT. Difference between ΔTa measured at the ends of left and right wings varies for different regimes of the engine and servo operation from 7 to 19 nT, which is much more than acceptable for the high-quality magnetic survey [5].
From Figure 1, it is absolutely clear that, for a lightweight UAV:
major sources of magnetic noise are electric engine and servos producing anomalies with amplitude of 600–700 nT;
the most appropriate location of magnetic sensors is at the ends of wings, and, in that case, the servos should be placed in the UAV’s main body instead of wings.
Another obvious conclusion relates with the UAV’s engine type. Replacement of an electric engine with combustion one in accordance with the results of mathematical modeling makes a horizontal gradient of the magnetic field at the end of a wing three to four times lower. However, the combustion engine fitting the task weighs about 700 g versus 284 g of electro engine. This, along with the additional weight of a magnetic sensor (up to 200 g) at the end of a wing, has made UAV “Geoscan-201” unstable in the air because of displacing center of mass.
To comply with the results of the experiment, a new UAV “Geoscan-301”has been designed (Figure 3a) and built (Figure 3b).
Design of “Geoscan-301” (a) and its launch (b).
Aerodynamic modeling and measured magnetic effect (Figure 4) demonstrate compliance of the new UAV with all the requests of high-quality magnetic survey. Nevertheless, the new problem appeared during the flight tests: complicate control of the combustion engine makes flight control extremely difficult, and it requests fundamental changes in the software facilitating UAV operation.
Measured magnetic effect of “Geoscan-301”. Contour interval—25 nT; contour interval in the sidebar—1 nT.
Multirotor UAV can be characterized as easiest-to-control type of unmanned aircrafts. At the same time, its magnetic noise is much more complicated in comparison with a fixed-wing UAV because of minimum four electric engines. And, there is no room for a magnetic sensor in the main UAV body, so we have to consider use of non-magnetic gondola attached to the UAV by rope (cable).
Magnetic noise of “Geoscan-401” quadcopter (Figure 5) measured at different distances from the UAV is given in Table 1.
Quadcopter “Geoscan-401”.
Distance from the UAV, m | Max amplitude of magnetic noise, nT |
---|---|
1 | ≈5 |
2 | ≈1 |
3 | ≈0.1 |
Measured magnetic noise of “Geoscan-401” quadcopter.
It is obvious that at 3 m from the UAV, the magnetic noise is already negligible. Nevertheless, in UAMS built on the basis of “Geoscan-401”, the length of the rope is 20 m, which is reasoned by aerodynamic specifics of this UAV. The lesser distance between gondola and UAV affects stability of the flight. It is necessary to note that for another UAVs, these figures can differ.
At the first tests, the gondola itself was a ring-shaped non-magnetic frame with rubidium vapor magnetometer (RVM) and additional differential GNSS receivers with external antennas [6]. Later, in order to improve UAMS aerodynamic characteristics, a crossbar-shape gondola had been designed (Figure 6). During the flight, the autopilot uses copter’s GNSS for navigation, and GNSS on the outer frame registers the magnetometer’s allocation using time synchronization method. The GNSS horizontal accuracy is about ±2.5 m, and vertical accuracy is about ±3 m.
Unmanned aeromagnetic system (UAMS) on the basis of “Geoscan-401”.
Thus, both fixed-wing and multirotor UAVs can be used as a transport platform for UAMS. For the fixed-wing ones, optimal location of magnetic sensor(s) is at the ends of wings, and for the multirotor UAVs—at a gondola attached to UAV by a rope (cable) not less than 3 m in length, depending on magnetic and aerodynamic characteristics of the aircraft.
Different models of magnetometers have been considered for UAMS. The magnetic sensor for unmanned aeromagnetic survey should be: (a) lightweight, not over 300 g; (b) quite fast, not less than 10 measurements per second; and (c) insensitive to orientation. As far as no one from the magnetometers in the market responded to these requests without a sufficient adaptation, a new rubidium vapor magnetometer (RVM) has been designed and built for the purpose.
The specification of the rubidium vapor magnetometer (RVM; Figure 7) is listed in Table 2. The RVM includes: (i) magnetic sensor with a bulb containing vapor Rb87; (ii) the Electronic Control Unit (ECU) including the optical pumping lamp; and (iii) the power source (not shown in Figure 7). All the parts are designed as separate modules connected by fiber-optic and electric cables, which facilitate distribution of the weight in the UAMS.
Rubidium vapor magnetometer (RVM).
Sensitivity | 10 pT/√Hz |
Field range | 20,000–100,000 nT |
Frequency response | 200 Hz |
Sampling rate | 1000 Hz |
The range sensor angles | ±45° |
Power | 8–35 V, 10 W |
Environment temperature | −20 … + 60°С |
Weight of the sensor/ECU | 120 g/300 g |
Specification of the rubidium vapor magnetometer (RVM).
The RVM’s noise has been checked at the magnetic field stabilizer, and it is about 10 pT/√Hz. The transition process (speed of reaction to a jump field) takes 30 ms.
To evaluate an absolute error of the RVM, a series of comparative tests has been conducted using the commercially available cesium vapor Geometrics G-858 and Overhauser MMPOS magnetometers. The field tests were organized in the area free of industrial noise and anomalous magnetic field gradients (Leningrad region, Russia).
Range of tests has been conducted in order to evaluate an influence of temperature on the measurements. The results demonstrate independence of measurements as well as of the measurement’s error estimation of the temperature of both magnetic sensor and electronic unit of RVM [6].
Another standard test was conducted inside the calibration test station UPTM-4 in order to define the metrological characteristics of the magnetometer. The test had taken place at the facilities of FGUNPP “Geologorazvedka” in Leningrad region, Vsevolozhsk district. Results of the RVM systematic errors ∆se(B) and standard deviation S(B) with a measurement range of magnetic induction module (B) are shown in Table 3.
В, nT | ∆es(B), nT | S(B), nT |
---|---|---|
20,000 | 0.86 | 0.02 |
30,000 | 0.19 | 0.02 |
40,000 | −0.19 | 0.02 |
50,000 | −0.60 | 0.02 |
60,000 | −1.28 | 0.01 |
70,000 | −2.07 | 0.01 |
80,000 | −3.05 | 0.03 |
90,000 | −4.51 | 0.04 |
1000 000 | −6.31 | 0.03 |
RVM systematic errors ∆se(B) and standard deviation S(B) depending on the magnetic induction (B).
All the experiments demonstrate conformity of all RVM characteristics with requests of high precision aeromagnetic survey.
A number of magnetic surveys measuring total magnetic intensity (TMI) have been carried out using UAMS during the fall of 2016 and 2017 in different regions of Russia and Kazakhstan (Table 4). In all cases, the preprogrammed flights were executed along the parallel lines. Example of a flight layout is demonstrated in Figure 8.
Location | Size of area | Height of the survey (position of the sensor) | Distance between the flight lines | Type of the survey |
---|---|---|---|---|
Leningrad region, Agalatovo village | 0.8 × 1 km | 150 m from the highest point | 50 m | Test survey |
Republic Sakha-Yakutia | 1 × 1 km | 100 m from the highest point | 100 m | Demonstration survey |
Republic Kazakhstan, Eastern Kazakhstan, southwestern part of Kazakhstan Altay | 7.5 × 4 km | 50 m from the surface | 50 m | Commercial survey |
1 × 1 km detalization | 30 m from the surface | 50 m | Commercial survey | |
70 m from the surface | 100 m | Commercial survey | ||
Republic Kazakhstan, Central Kazakhstan | 3.5 × 12 km | 30 m from the surface | 100 m | Commercial survey |
Magnetic surveys executed by Geoscan, Ltd. between September 2016 and November 2017 using UAMS on the basis of “Geoscan-401” quadcopter with RVM.
TMI map of the first test survey in Leningrad region.
The first survey has been carried out in Leningrad region just as a test of UAMS in the area with relatively quiet natural magnetic field with a local TMI anomaly of over 60 nT amplitude measured during regional aeromagnetic survey. The test survey has revealed an anomaly of concordant shape with higher (above 300 nT) intensity, which is due to lower height of the flight.
The results of the survey confirm workability of UAMS. Also, the comparison of task lines and real survey lines shows the difference of about 10 m for all flights of southward direction and approximately 1 m when the UAS moved northward (Figure 8). The latest demonstrates an influence of west wind (10 m/s) on a ring-shaped gondola. After this survey, the new gondola design (crossbar) has been implemented and used in all the subsequent surveys. The rope length has been cut from 50 to 20 m.
The second test was conducted in Republic Sakha-Yakutia in the area determined by potential UAMS buyer (Figure 9). The area is located at the flank of iron ore deposit and is characterized by more intensive TMI anomalies.
TMI map of the demonstration survey in Republic Sakha-Yakutia.
The survey has demonstrated stable measurements under conditions of high-gradient (up to 30 nT/m) magnetic field and, by conclusion of the buyer, good compliance with results of ground survey. Two UAMSs have been acquired, and, by now, about 100 km2 of 1:10,000 magnetic survey has been carried out.
In 2017, 465 line km of 1:10,000 UAMS magnetic survey has been carried out in Central Kazakhstan [7]. The task of the survey is geological mapping, in particular—tracing of zones prospective for lead-zinc and iron-manganese ores of stratiform type in carbonyte rocks buried under sand and clay deposits. What is important, a comparison was made between UAMS and ground survey (Figure 10) as well as between UAMS and traditional aeromagnetic survey (Figure 11).
Comparison of ground (blue) and UAMS (red) measurements along the same line. X-axis—distance, m; Y-axis—TMI, nT.
TMI map of the commercial survey in Central Kazakhstan: (a) UAMS 1:10,000 survey, 2017 and (b) 1:25,000 aeromagnetic survey, 1988.
The survey was carried out at as low as 30 m height (sensor position). Control measurements demonstrate TMI standard deviation at ±0.35 nT, which is a very good characteristic in comparison with both traditional aeromagnetic and ground surveys.
The more detailed (1:5000) UAMS survey was executed in the Eastern Kazakhstan over an area of 30 sq. km in the frames of gold ore deposits prospecting.
At the moment, the use of UAV in geology, including UAMS magnetic survey, experiences a fast grow. In 2016, special session named “Unmanned aerial vehicles (UAV)-based technologies for geology and Earth sciences” had been organized in the frames of 35th International Geological Congress. In 2018, similar session is supposed to take place at 15th Quadrennial Symposium of International Association for Genesis of Ore Deposits (IAGOD). These events indicate an interest of geological community to the new opportunities and, vice versa, growing readiness of the technologies for implementation.
In the frames of this study, few technical conclusions can be made, including the following:
fixed-wing and multirotor UAVs can be used as a transport platform for UAMS;
for UAMS based on the fixed-wing UAVs, optimal location of magnetic sensor(s) is at the ends of wings, and for the multirotor UAVs—at a gondola, it is attached to UAV by a rope or cable;
design of UAMS includes deep adaptation of both UAV and magnetometer, targeting minimization of magnetic influence of UAV and its components on the magnetic measurements;
UAMS based on “Geoscan-401” quadcopter is efficient for high-precision magnetic survey in the areas from first to n × 100 km2. One UAMS facilitates from 120 to 160 line km of magnetic survey per day;
UAMS magnetic survey is more informative in comparison with traditional aerial survey at the count of lower flight and technical ability to circumvent the terrain;
use of fixed-wing UAV can be more effective than of multirotor one, especially for large (over 100 km2) areas, but fixed-wing UAMS still has issues to be resolved before entering the market.
One of the promising directions of the further development of UAMS magnetic survey is multilevel magnetic survey. Theoretical basis for such survey has been developed in the middle of twentieth century, but it would be extremely expensive to fly few times the same area by piloted aircraft. UAMS survey makes it effective when 3D magnetic field measurements are useful for geological purposes.
In comparison with traditional magnetic survey, advantages of UAMS are:
the possibility of conducting a night flight;
the simplified obtaining of resolving documentation for the flight;
simultaneous survey by several UAMSs;
independence from the location of the airports;
reducing the cost of flight hours;
the increase profitability of detailed survey compared to aeromagnetic and ground surveys.
Altogether, UAMS magnetic survey represents the future of magnetic prospecting, especially—in the ore geology, and provides geologists with new effective tool for field work.
Sufficient part of this research was funded by the Ministry of Education and Science of Russian Federation, under Agreement no. 14.607.21.0081 (ID no. RFMEFI60714X0081). The authors would like to thank FGUNPP “Geologorazvedka” and, personally, Vadim Tsirel for assistance in the testing of RVM. TOO “NPTs Geoken” and TOO “Kazzinc” have kindly allowed authors to demonstrate results of the first commercial survey executed with UAMS.
Systemic sclerosis is a chronic rheumatic autoimmune disease characterized by abnormal fibrotic processes, microvascular damage, and excessive deposition of collagen into connective tissues. The vascular alterations and immunological activation lead to progressive fibrosis of multiple organ systems including the skin, the gastrointestinal tract, kidneys, and the lungs. Disease-associated changes can have a negative impact on sexual functioning [1, 2]. Generally, sexuality in systemic sclerosis has been a neglected area so far, especially female sexual dysfunction. Impaired sexual functioning in women was probably less studied due to the complexity and multifactorial nature of female sexual response. A little bit more attention was paid to erectile dysfunction, where etiology is more pronounced even though women are affected by this disease more often [3, 4, 5]. The etiology of sexual dysfunctions in systemic sclerosis is not well known; the causes are multifactorial and are related to both the disease symptoms and the therapy. The most common physical problems associated with female sexual dysfunction include vaginal dryness, dyspareunia, vaginal tightness, Raynaud’s phenomenon, fatigue, generalized pain, muscle weakness, joint contractures, heartburn, and dyspnea. Presence of depression, fear, changes in face and body appearance, and lack of self-esteem are the psychological aspects, which can play a key role in the pathogenesis of sexual dysfunction in systemic sclerosis patients [6]. The etiology of erectile dysfunction is a little bit more understood. It is considered to be a result of microangiopathic changes. Due to corporal fibrosis and myointimal proliferation, the blood flow in the penile arteries is reduced.
\nSeveral studies have suggested that sexual dysfunction is a widespread problem in both men and women with SSc. It is more prevalent than in general population and other chronic diseases [7]. The most common symptoms of female sexual dysfunction are vaginal tightness, dryness, and dyspareunia [7, 8]. More severe sexual dysfunction is usually associated with depression symptoms, aging, and functional impairment [2, 9, 10]. The prevalence of erectile dysfunction is about 80% [11, 12, 13]. In women, more than half of the SSc patients experience some sexual problems [7, 8]. The management of erectile dysfunction has been more studied compared to female sexual dysfunction treatment. However, the number of publications regarding the efficacy of erectile dysfunction treatment in SSc patients is still very limited and further research is needed. The treatment of female sexual dysfunction in SSc women has not been paid much attention so far. There are only general recommendations available.
\nIn order to better understand why and how systemic sclerosis may affect sexual functioning, there is an overview of sexual response models, developed over the past few years, which led to the current diagnostic and classification criteria for sexual dysfunction. The first model of female sexual response was described by Masters and Johnson in 1966. They published that a normal female sexual response consists of four consecutive phases including desire, plateau phase, orgasm, and resolution. It was supposed that in both women and men, the sexual response is commenced by desire which is influenced by the activity of two brain centers—dopamine sensitive excitatory center and serotonin sensitive inhibitory center. These centers send a signal going through the descendent nervous system into the spinal cord from where the genital sexual reaction is triggered. The arousal phase is mediated by the parasympathetic nervous system, which leads to vascular and genital changes such as enlargement of the clitoris, dilatation of perivaginal arterioles, and lubrication and expansion of two-thirds of the vagina. The following level of excitement is referred to the plateau phase that lasts until the orgasm. The orgasm phase is accompanied by contractions of pelvic floor muscles, increased heart rate, respiratory rate, and blood pressure. After reaching orgasm, the body usually calms down and this phase is called the refractory or resolution phase (Figure 1) [14].
\nThe four-phase model of female sexual response cycle; BP = blood pressure, HR = heart rate, and RR = respiratory rate. Modified according to [14].
In 1979, this model was modified by Kaplan into a three-phase model, which consists of desire, arousal, and orgasm [15]. Based on this linear model, the diagnostic and classification system was developed. The World Health Organization International Classifications of Diseases-10 (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) by the American Psychiatric Association were established. The ICD-10 focused on how physical factors influenced sexual response, whereas DSM-IV classification emphasized more emotional and psychological aspects of female sexual dysfunction. Because both approaches followed the linear model of sexual response, which was later criticized for not taking into consideration the complexity of female sexual response, the new classification was needed [16].
\nIn 1998, the Sexual Function Health Council of the American Foundation for Urologic Disease (AFUD) convened an interdisciplinary congress, which was attended by 19 experts on female sexual dysfunction selected from five countries. The aim was to develop a consensual definition and classification based on the ICD-10 and DSM-IV. The new developed classification has been extended to include psychogenic and organic causes of desire, arousal, orgasm, and sexual pain disorders. An essential point of this classification is the personal distress criterion considering sexual complaint as a disorder only if it causes a subjective feeling of distress [17].
\nFurther research has shown that the model of female sexual response is still incomplete and that many aspects affecting women’s sexual function have been omitted. Studies reported that women often describe overlapping phases of sexual response in variable sequences. For instance, the unfounded assumption that desire always precedes arousal has been mistaken, and based on the women self-report and research data, it was proven that arousal and desire co-occur and reinforce each other. It was also found that motivation for sexual activity is much more complex than the mere presence of sexual desire defined as thinking or fantasizing about sex. Women in different surveys cited that increased desire for sexual activity may be caused by the emotional closeness of a partner or intimacy that increases female well-being and self-image, which may include the sense of feeling attractive, appreciated, loved, or desired. If enough appropriate sexual stimulation is provided, enough time and intimacy are available, the woman’s enjoyment and excitement can be intensified. The type of stimulation, time needed, and interpersonal context are highly individual. Moreover, spontaneous desire can be affected by the menstrual cycle, which usually decreases with age and grows with a new relationship. These new findings have surpassed the original hypothesis that women’s sexual response must always begin with sexual desire (thoughts and fantasies) and its absence is the result of a disorder. In addition, it was confirmed that, unlike men, there is no correlation between female subjective excitement and genital congestion. Subjective excitement could be influenced by interpersonal relationships, contextual factors, privacy, appropriateness, general emotional status, emotional relationships, biological factors, presence of depression, the influence of hormones (dopamine, testosterone), and others. In 2003, therefore, a revision of the current definition was done. The International Definitions Committee consisting of 13 experts from seven countries convened and proposed new definitions, which take into account new findings in the field of female sexual response [18, 19, 20].
\nCurrent definition was again revised in 2010 by the International Consensus of Sexual Medicine, where the movement away from the nonoverlapping linear model toward a more circular model depicting the variety of triggers of women’s desire was accepted. It was emphasized that innate sexual fantasies and thoughts are not necessary for healthy sexual functioning and that desire is the result of sexual incentive that may be physically or subjectively perceived. Based on the previous findings, the arousal disorder was reclassified into subjective arousal disorder, genital arousal disorder, combined genital and subjective arousal disorder, and persistent genital arousal disorder. In May 2013, DSM-V was released, which also takes the focus away from the four-phase model, removed the sexual aversion disorder and merged vaginismus and dyspareunia into a new genito-pelvic pain/penetration disorder. It was finally noted that sexual dysfunction is a result of both psychological and biological and many other contributing factors [15, 21]. In 2015, the Fourth International Consultation on Sexual Medicine presented the new set of definitions of all forms of sexual dysfunction in women and men, which was based on ICD-10 and DSM-V (Figure 2) [22].
\nNonlinear model of female sexual response cycle. The initial stage of female sexual response is sexual neutrality, but with positive motivation (left). The reasons why a woman is willing to initiate or agree to sexual activity can be that she wants to feel loved, share physical pleasure or be emotionally closer to her partner, please her partner, or she wants to increase her own satisfaction. Stimuli for sexual activity are being processed in the woman’s mind, influenced by biological and psychological factors, and result in subjective sexual arousal. If sexual stimuli last sufficiently long, sexual arousal and enjoyment will intensify, and it can trigger a desire for further sexual activity. It is important to note that desire appears at this point, not in the initial phase. When the stimulation continues and no negatives outcomes are involved, the process results in sexual satisfaction (with or without orgasm). Modified according to [23].
The newest changes in nomenclature of female sexual dysfunction came in May 2018, when the World Health Organization developed the eleventh revision of the International Classification of Diseases and Related Health Problems (ICD-11). The ICD-10 classification of sexual dysfunctions was separated to two main groups: “organic” and “nonorganic” conditions. The nonorganic sexual diseases were classified as mental and behavioral disorders and organic belonged to diseases of the genitourinary system chapter. However, since ICD-10 definition, lots of evidences have been accumulated regarding the causes of sexual dysfunction, which often involve a combination of physical and psychological factors. The ICD-10 classification was therefore not consistent with clinical approaches in sexual health. ICD-11 diagnostic guidelines organize sexual dysfunctions into four main groups:
sexual desire and arousal dysfunctions;
orgasmic dysfunctions;
ejaculatory dysfunctions; and
other specified sexual dysfunctions.
Moreover, a separate grouping of sexual pain disorders has been established. Where possible, categories in this new classification of sexual dysfunctions apply to both men and women even though the differences in sexual response are known. On the other hand, the neural pathways and neurotransmitters mediating sexual response are the same for both men and women. Separate sexual dysfunction categories are provided where clinical manifestations differ [24].
\nThe overview of current diagnostic criteria of sexual dysfunctions is presented below in Table 1. The present definition according the WHO ICD-11 is: “Sexual Dysfunctions are syndromes that comprise the various ways in which adult people may have difficulty experiencing personally satisfying, noncoercive sexual activities. Sexual response is a complex interaction of psychological, interpersonal, social, cultural and physiological processes and one or more of these factors may affect any stage of the sexual response. In order to be considered a sexual dysfunction, the dysfunction must: (1) occur frequently, although it may be absent on some occasions; (2) have been present for at least several months; and (3) be associated with clinically significant distress” [25].
\nICD-11 (2018) | \nDSM-5 (2013) | \n
---|---|
Chapter: conditions related to sexual health | \n|
Grouping: sexual dysfunctions | \nGrouping: sexual dysfunctions | \n
Category: hypoactive sexual desire dysfunction | \nCategory: female sexual interest/arousal disorder; male hypoactive sexual desire disorder | \n
Category: sexual arousal dysfunction | \nCategory: female sexual interest/arousal disorder | \n
Category: orgasmic dysfunction | \nCategory: female orgasmic disorder | \n
Category: ejaculatory dysfunction | \nCategory: erectile disorder | \n
Subcategory: male early ejaculation | \nCategory: premature (early) ejaculation | \n
Subcategory: male delayed ejaculation | \nCategory: delayed ejaculation | \n
Category: other specified sexual dysfunction | \nCategory: other specified sexual dysfunction | \n
Category: unspecified sexual dysfunction | \nCategory: unspecified sexual dysfunction | \n
Grouping: sexual pain disorders | \n\n |
Category: sexual pain-penetration disorder | \nCategory: genito-pelvic pain/ penetration disorder | \n
Persons with systemic sclerosis can experience a variety of symptoms that may affect all aspects of life, including sexual functions. The exact etiopathogenesis of sexual dysfunctions in systemic sclerosis is not well known; the causes are multifactorial and are related to both the disease symptoms and the therapy. Medical, pathophysiological, psychological, and social components may be involved in sexual dysfunction. Both physical and psychological problems arising from disease-related condition contribute to partnership difficulties, less active and less enjoyable sexual life [3, 27, 28].
\nThe most common physical symptom is skin tightness. Due to skin tightness, the fingers becomes fixed in bent position, which could interfere with sexual foreplay, touch, and masturbation. If skin tightening causes the mouth to shrink, kissing or oral sex could become difficult. Sometimes the skin become stiffer around the vaginal introitus, which often leads to painful penetration, and changes in the vaginal mucosae causing lubrication disorder contribute to this [27, 29, 30]. Specifically, 56% of SSc female patients reported painful penetration during the intercourse [31]. The sexual difficulties such as vaginal tightness, dryness, and dyspareunia were reported by more than half of systemic sclerosis female patients [7, 8]. It was also published that vaginal tightness (71%), dyspareunia (56%), and ulceration (23%) were the most common symptoms of sexual dysfunction observed in 60 women with systemic sclerosis [31]. These genital tract abnormalities could be associated with a decrease in number and intensity of orgasm, which are also often observed in SSc individuals [32].
\nA majority of the systemic sclerosis patients experience Raynaud’s phenomenon, which can affect not only fingers and toes but also tongue and nipples. This is another reason, why the cuddling, foreplay, and oral sex could become uncomfortable and unpleasant [27]. In addition, a lot of patients suffer from secondary Sjögren’s syndrome characterized by drying of oral, nasal, ocular, and vaginal mucosae. The prevalence of Sjögren’s syndrome in systemic sclerosis ranged in different studies from 20 to 69% depending on the criteria used and sample size. In Saad’s study, 37% from 83 systemic sclerosis female patients reported Sjögren’s syndrome, 56% of them had impaired sexual function, and vaginal dryness was the most presented symptom [29].
\nAnother disease-related problem that impedes sexual activity is the affection of musculoskeletal system. The presence of joint contractures, stiffness, or pain leads to limited range of motion and it could restrict the ability to engage in sexual activities. Other aspects that reduced exercise capacity are muscle weakness and fatigue. It can be difficult to become sexually aroused when extremely tired. The consequence of skin thickening and other physical changes is the impaired body image, self-esteem, and sexuality. However, it has been also reported that body image dissatisfaction does not correlate with reduced sexual function [30]. In a different study, the major reasons for decreased sexual activity in married women with SSc were fatigue, altered body image, and pain [2]. Regarding psychological factors, depression is another often presented symptom that has been significantly associated with a sexual function disorder [8].
\nThere are a few more causes that could lead to less active sexual life in SSc patients. For instance, in rare cases, the fibrotic process of visceral vessels leads to renal impairment that may have an impact on sexual desire and orgasm. It is usually the medication used to treat kidney problems rather than the problems themselves. Also, gastrointestinal problems such as heartburn or chronic diarrhea may disrupt sexual activities [7].
\nTo sum up, existing studies of sexual function among women with SSc have concluded that sexual dysfunction is common in comparison to the general population. It was even showed a significantly greater decrease in orgasm and its intensity in SSc female patients compared to other systemic rheumatic diseases—rheumatoid arthritis and systemic lupus erythematosus [31]. What is more, Knafo et al. [4] published that the prevalence of sexual dysfunction is higher in SSc than in other chronic diseases such as breast cancer, gynecological cancer, or HIV positivity. On the other hand, Impens et al. [33] maintain that SSc women remain sexually active despite the psychological and physical difficulties caused by the disease. In this study, only 17% of women suffered from female sexual dysfunction primarily caused by systemic scleroderma. Other reasons for sexual inactivity were the absence of a partner (37%), personal choice (32%), and the health status of respondents’ partners (20%).
\nThe first step in the diagnosis of female sexual dysfunction is a detailed personal, sexual, pharmacological, and psychosocial history. Where necessary, further examination by a psychiatrist, gynecologist, or physiotherapist is indicated. There are several objective methods assessing female sexual function, such as laboratory tests including hormonal profile or Doppler ultrasonography. However, laboratory tests in clinical practice are used only as auxiliary diagnostic methods. With duplex Doppler ultrasonography, it is possible to display a blood flow in cavernous tissue vessels, which is performed either under basal conditions or during sexual stimulations (vibrational or audiovisual) and objectified sexual arousal reactions. The most commonly used physiological method for evaluating sexual response is vaginal photoplethysmography, which investigates vascular reactivity during sexual arousal. It is based on the assessment of congestion of the vaginal mucosae. Other methods include electromyography, measurement of changes in vaginal pressure, and measurement of pH [34, 35].
\nAnother widespread screening method is the questionnaire survey. Self-report questionnaires have a long history of use in psychological and sociological studies of sexual behavior. For example, Derogatis Sexual Function Inventory is a 245-item, multidimensional scale that evaluates a wide range of sexual behavior in 10 separate domains. Despite the very strong psychometric properties, this scale is not widely used in clinical trials due to its excessive length and complexity. Instead, several short evaluation scales have been developed [36, 37]. Currently, the female sexual function index (FSFI) is the “gold standard” in assessment of female sexual functioning [38]. FSFI is a widely used tool that has been validated for use across multiple populations including women of various age groups, in various health problems and sexual dysfunctions. It has been developed as a simple multidimensional self-assessment tool for assessing the key domains of female sexual function. The questionnaire consists of 19 items that evaluate sexual function over the last 4 weeks in six domains: sexual desire, sexual arousal, lubrication, orgasm, satisfaction, and pain [39]. Since the first validation study, it has been translated into more than 20 languages and validated in over 30 countries [40, 41].
\nIt has to be noted that both objective methods and questionnaire screenings have their limitations. The main disadvantage of objective methods is the absence of an intimate condition that can play a key role in the female subjective arousal. Basson et al. published that intimacy and desire are essential to women’s sexual activity. Raina et al. reported that intimacy leads to emotional arousal of a woman, followed by sexual desire and physical arousal that result in sexual satisfaction. These findings suggest that the presence of intimacy can be crucial in examining sexual arousal, and its absence can lead to a lack of emotional excitement and consequently to incomplete sexual responses [35, 42, 43]. On the contrary, the questionnaires are filled in private and evaluate women’s real sexual experiences. Moreover, this method is not time-consuming and costly. However, as with any brief self-report scale of a complex psychophysiological construct, the questionnaire assessment has notable practical and theoretical limitations. Self-reported screening does not provide objective information but only patient’s subjective perception.
\nIn terms of FSFI, its drawback is the assessment of sexual activity in the past 4 weeks. Of course, there are number of reasons why women may be sexually inactive during a 4-week period and it does not necessarily imply significant sexual dysfunction. For example, the absence of sexual partner is a very common reason, why patients are not sexually active. Specifically, the FSFI questionnaire contains 15 questions, which could be answered “No sexual activity” or “Did not attempt intercourse.” Both possible responses are scored as zero that could become problematic when lower scores indicate severer sexual dysfunction. In that case, the FSFI could produce biased results. Other inaccurate data may be the result of relatively vague terminology. A problematic issue seems to be to define and measure sexual desire and subjective sexual arousal. Studies suggest that women often have difficulty distinguishing desire and arousal in their sexual experience. Another drawback of the FSFI questionnaire is that questions in orgasm subscale are basically focused on the orgasmic function associated with penile-vaginal contact. In fact, the vagina is primarily a reproductive organ with little sensitivity, and clitoral stimulation is more important for female orgasm. Therefore, achieving orgasm should be judged more in conjunction with masturbation or oral sex than sexual intercourse [38, 44].
\nThe FSFI is also the most common questionnaire evaluating sexual function in women with systemic sclerosis. It has been used by an Italian team to evaluate the prevalence of sexual dysfunction in 46 women with SSc. The second purpose of this trial was to investigate the association with sociodemographic, physical, psychological, and disease-related variables. Compared to healthy controls, only the FSFI desire subscale score was significantly lower. The overall score did not substantially differ from healthy controls. The association with health status, functional ability, mouth affection, hand disability, and presence of depression was reported [10]. A very similar study has been conducted in the Netherlands. The FSFI was used to assess the sexual function of 69 SSc women aged 18–60 years. It was that the FSFI total score and the subscale scores for lubrication, orgasm, arousal, and pain were significantly lower in comparison with healthy population in the same age. Impaired sexual functioning and sexual distress were associated with marital distress and depressive symptoms [9]. Levis et al. first detected women with SSc who had engaged in sexual activities with their partner in the past 4 weeks, and then only sexually active patients completed a 9-item version of the FSFI. The aim of this Canadian cross-sectional multicenter study was to evaluate sociodemographic and clinical variables that distinguish sexually active from inactive patients and identify the source of pain during and after sexual activity in sexually active patients. The results showed that in total only 17% of 547 women were sexually active without sexual disorder [45]. The same group of scientists in different project used a shortened version of FSFI to compare sexual activity and impairment rates of women with systemic sclerosis to general population data. Among women with SSc, 296 of 730 (41%) were sexually active and 181 (61%) of sexually active patients reported sexual dysfunction. It means that only 115 of 730 (16%) patients engaged in sexual activities without impairment. It was also confirmed that SSc patients are significantly less likely to be sexually active and more likely to be sexually impaired than the general population of women [46]. Severe sexual dysfunction was also observed in married women with systemic sclerosis. About 8 out of 10 women achieved low scores in the FSFI questionnaire assessed, and all the subscales were affected in this study. The reasons why patients reported decrease in the frequency of intercourse since the onset of their disease and a diminished desire for a sexual relationship were fatigue, altered body image, and pain [2].
\nThe management of female sexual dysfunction in the general population is based on the understanding of the basic physiology of female sexual response. Currently, several approaches of female sexual function treatment are available. It is known that some antidepressants can cause sexual dysfunction as a side effect. Antidepressants, such as SSRIs, are commonly associated with hypoactive sexual desire disorder (HSDD) and they have to be eliminated or dosed at lower levels. In women with major and disabling mood disorders, the adjustment of antidepressants requires a continuous collaboration with the prescribing psychiatrist, because dosage adjustments of antidepressants must be done very gradually [47]. Bupropion, buspirone, mirtazapine, vortioxetine, and vilazodone have been found to have lower rates of antidepressant-induced sexual dysfunction than other antidepressants, and they can be a suitable medication options for the treatment of depression [48, 49, 50].
\nAnother option, primarily used in menopausal women, is hormonal therapy. Estrogen therapy may be used to increase clitoral sensitivity and libido and to reduce pain during and after sexual intercourse. In women with menopause-related sexual dysfunction that have estrogen treatment experience improved sexual desire, vaginal atrophy and vaginal dryness [49]. Transdermal estradiol has been found to be a preferred therapy for depleted estrogen. It is considered as the most effective therapy available for reducing vasomotor symptoms and associated menopausal symptoms with minimal adverse effects. Intravaginal estrogens combined with mechanical dilatations are also highly effective for treatment of vaginal atrophy [47]. Testosterone replacement therapy may also be considered to increase sexual desire and libido. Several high-quality sources documenting that transdermal testosterone is effective in restoring sexual desire are available [47]. Intramuscular testosterone combined with estradiol in postmenopausal women had a positive impact on sexual desire, arousal, and frequency of sexual fantasies compared with women without testosterone treatment [51].
\nFlibanserin is the first nonhormonal treatment for female sexual dysfunction to be approved by the Food and Drug Administration (FDA). The approval, in August 2015, occurred fully 18 years after the approval of sildenafil, the first treatment for erectile dysfunction. Flibanserin is a 5-HT 1A agonist and 5-HT 2A antagonist and is indicated for acquired hypo-active sexual desire disorder in premenopausal women. It is strongly recommended to avoid consumption of alcohol while using flibanserin treatment, because several serious adverse events were found: dizziness, loss of consciousness, hypotension, and circulatory collapse [49]. Another drug approved by the FDA is ospemifene, which is indicated in treatment of dyspareunia in postmenopausal women. It is a selective estrogen receptor modulator that can be prescribed when hormone replacement therapies fail. The daily dose of 60 mg of ospemifene has been found to be effective and tolerable for postmenopausal women with vaginal dryness and atrophy [52, 53]. To improve sexual functioning in domains of arousal, orgasm, and satisfaction, bupropion can be used, whose efficacy is based on the influence of dopamine and norepinephrine reuptake [54]. Although phosphodiesterase type 5 (PDE-5) inhibitors are mostly used in erectile dysfunction treatment, they can be used in women as well. Sildenafil has been found to significantly improve arousal, orgasm, and enjoyment in women without sexual dysfunction. In women with antidepressant-associated sexual dysfunction, sildenafil (in dose ranges of 50–100 mg) has also shown good efficacy [49].
\nRehabilitation treatment can be useful in patients suffering from vaginism, dyspareunia, and anorgasmia due to pelvic muscle spasms. Adequate exercises can lead to normalization of muscle tension and relaxation [55]. Psychotherapy is recommended where the pathogenesis of sexual dysfunction has a psychological nature. Because recent studies have suggested that more severe sexual dysfunctions in patients with SSc are significantly associated with the presence of depression [2, 9, 10], the psychotherapy should be an integral part of the treatment of sexual dysfunction in SSc patients. In terms of sexual pain disorder, psychotherapy seems to be immediately helpful although objective research on the long-term efficacy of psychotherapy for sexual pain disorder is limited and difficult to evaluate [47].
\nThere are some general recommendations for women with systemic sclerosis that may help to continue enjoying an active, fulfilling sexual life. If sexual activity is reduced due to pain, it can be alleviated by use of pain medication. The sexual activity can be scheduled for a time the pain will be at a minimum. A warm bath or shower before sexual activity often eases arthritic stiffness. The range of motion exercises before sex may help to reduce the stiffness. If the range of motion is limited and do not allow comfortable position, then it seems to be a good solution to experiment with sexual positions and try to find those that are the most suitable [3, 56]. If sclerosis has caused the mouth to shrink, physical therapist or occupational therapist can teach patients how to do the exercises to stretch the mouth. The regular stretching can improve the range of motion of the mouth and make kissing and oral sex more enjoyable. When fingers become fixed in a bent position, its possible to integrate stretching exercises as well and use the other part of hands (thumbs, wrists, or backs of the hands) to touch yourself or partner. An auxiliary material such as vibrators, creams, and lotions can also be used to enhance sexual activity. In order to avoid fatigue, patients with SSc may schedule their sexual activity for that part of the day when they still have enough energy, because becoming sexually aroused, when tired, is difficult. To prevent a Raynaud episode, it is necessary to keep entire body warm. It is possible to turn up the thermostat, leave some clothes on, or use extra blankets. When vaginal dryness and dyspareunia occur, the use of vaginal moisturizers on a regular basis along with lubricants as needed for sexual activity is the initial step in managing these symptoms. Women can choose from a number of commercially available lubricants that are either water based, mineral or plant oil based, or silicone based [47, 55]. Dilator therapy is an another option that can be useful in treatment of vaginal tightness. This method offers a nonsurgical approach to restore vaginal capacity and elasticity and alleviate sexual discomfort. If the penetration is still painful, there are alternative sexual activities like clitoral stimulation that can be sometimes more enjoyable than intercourse. If there is no interest in sex, still it is possible to stay physically close by holding or caressing one another [3, 56].
\nSeveral options for the treatment of female sexual dysfunction in normal population are available. The management of impaired sexuality in women with systemic sclerosis was less studied and the further research is strongly needed. What is essential and beneficial for the patients is the team-based model of care for management of sexual dysfunction including a medical provider, physical therapist, occupational therapist, psychotherapist, and sex therapist [57].
\nSystemic sclerosis is an autoimmune connective tissue disorder characterized by following typical findings: endothelial changes, microangiopathic damages, and progressive fibrosis. These pathological processes may affect various organs including penile arteries leading to erectile dysfunction (ED). Male erectile dysfunction is defined as the consistent inability to reach and maintain an erection sufficient to permit satisfactory sexual performance. It is a widespread issue in men with systemic sclerosis. Sexual dysfunction in men has been given more attention than female sexual dysfunction, and the etiology is more obvious compared to women. Erectile dysfunction is a result of microangiopathic changes, when the blood flow is reduced in the small penile arteries due to corporal fibrosis and myointimal proliferation [5]. It was proven that damage of the penile cavernous arteries occurs in almost all SSc patients regardless of clinical symptoms. They are characterized by the presence of hyperechoic spots, suggesting fibrotic changes and low peak systolic velocities that are signs for vascular alterations [58].
\nThe prevalence of erectile dysfunction in SSc patients ranged from 12 to 81% in different studies [28]. However, most studies agree that about 80% of SSc men are affected [11, 12, 13]. It was also found that ED is more prevalent in systemic sclerosis than other inflammatory rheumatic diseases. In a majority of men with systemic sclerosis, ED started to manifest after the onset of the disease. The mean duration from the onset of the first SSc symptom to erectile dysfunction was around 3 years [12]. Risk factors of erectile dysfunction such as smoking, hypertension, diabetes, and steroid use have been investigated. It was found that only self-reported history of nerve damage and diabetes are significant for predicting the likelihood of ED in systemic sclerosis. There are also risk factors that are presented in non-SSc men as well, like older age or alcohol consumption. The ED association with more severe diseases in terms of worse skin involvement, elevated pulmonary arterial pressures, presence of restrictive lung disease, and muscular and renal involvement in SSc patients was also confirmed [5, 12, 13, 59].
\nThe most likely hypothesis of ED in SSc is a combination of vascular and fibrotic abnormalities. In men with SSc, decreased penile blood pressure, impaired peak systolic and diastolic blood flow in the penile arteries, and the presence of veno-occlusive dysfunction were found. Also, a decreased penile temperature and a slow recovery after cold exposure were reported. A duplex sonography was conducted to reveal the thickening of tunica albuginea and diffuse hyperechogenic spots within the corpora cavernosa. All these findings point to the microangiopathic cause of ED in male SSc patients. This is confirmed by the fact that no carotid artery thickening has been found in SSc, which would predict atherosclerotic macroangiopathy. From a histological point of view, the ED cause in SSc men is the presence of severe corporal fibrosis, increased collagen production by penile smooth muscle cells, and increased accumulation of extracellular matrix. Due to these changes, penile hypoxia arises, which can lead to overexpression of platelet-derived growth factor (PDGF), transforming growth factor (TGF)-β1 and TGF-β1 receptors in the corpora cavernosa, which are important profibrotic regulators of collagen synthesis and production of extracellular matrix. In addition, endothelin (ET-1) is also released by penile smooth muscle cells. Thus, penile hypoxia stimulates penile fibrosis. Therefore, it can be assumed that once ED in patients with SSc is manifested (due to disease), its next mechanisms are similar to those of non-SSc population. Other causes such as hormonal abnormalities or neurological causes have not been confirmed. No disturbances have been found in follicle-stimulating hormone, luteinizing hormone, serum testosterone, prolactin, estradiol, and thyroid hormones in SSc patients [5, 11, 59, 60].
\nThe diagnosis of erectile dysfunction in SSc patients is not always easy. We are following the common steps starting with taking a detailed history. Then assessment with appropriate questionnaires and dynamic penile Duplex ultrasound is required. The ambiguity lies in the fact that penile vascular damage occurs in almost all SSc patients, regardless of clinical symptoms and the questionnaire results that often do not match with vascular findings. Thus, it is always better to carry out both investigations: the duplex ultrasound to document the degree of vascular involvement and self-administered questionnaire. The International Index of Erectile Function is the standardized and most widely used tool for evaluating erectile dysfunction. As mentioned above, penile temperature in SSc patients is lower than in healthy individuals. Since cutaneous temperature depends on cutaneous blood flow and thermal exchanges with deeper tissues, these findings could suggest the presence of functional alterations of both tissue properties and blood flow. Therefore, assessing changes in thermal properties and temperature control processes of the penis in SSc patients could provide a potential clue in diagnosis of erectile dysfunction. It has to be noted that with the progression of micro/macrovascular damage in the natural course of the disease, a concomitant penile fibrosis and veno-occlusive dysfunction occur and usually lead to difficult-to-treat ED. We should pay attention in cases where the reduced blood flow is observed, for example, on the hands (Raynaud’s phenomenon), because it can suggest that the penile arterial flow will be also altered, and it may be a sign of initial stage of ED in SSc patients [61, 62].
\nIt is not a mistake to initiate ED treatment by eliminating general cardiovascular risk factors including lifestyle, psychological, or drug-related factors, but such treatment is often unsatisfactory. This step usually has beneficial effect on erectile function in the general population [63]. Phosphodiesterase-5 (PDE-5) inhibitors are recommended as a first-line option for pharmacotherapy. In non-SSc men, this group of drugs causes the relaxation of smooth muscle cells and temporarily increases arterial blood flow in the penis. However, to achieve an erection, sexual stimulation is required, because this class of drugs is not considered as an initiator of erection. Several types of PDE-5 inhibitors are currently available. The most commonly used are sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). Except these, newer molecules of PDE-5 inhibitors can be used, for example, mirodenafil, udenafil, and avanafil. All types of PDE-5 inhibitors are effective and safe regarding the treatment of ED in the normal population. The differences are only in their half-lives, when, for instance, tadalafil is effective for up to 36 hours whereas the effectiveness of sildenafil is only 12 hours. The choice of a PDE5-I depends on the frequency of intercourse and the patient’s personal experience [64, 65]. However, research on the efficacy of PDE-5 inhibitors is very limited in SSc patients [5]. Proietti et al. reported that once-daily tadalafil improved both erectile function and vascular measures of cavernous arteries in men with SSc-related erectile dysfunction. Also, an increase in frequency of morning erections and decrease in plasma ET1 levels were found. They suggest that daily tadalafil dose could play a potential role in preventing progression of penile fibrosis and erectile dysfunction in male SSc patients [58]. Furthermore, long-acting PDE-5 may lead to a decrease in the frequency and severity of Raynaud’s phenomenon and the promotion of digital ulceration [66].
\nPatients who do not respond to PDE-5 inhibitors may be offered to try vacuum constriction devices. It was reported that patients who used the vacuum therapy system for a month to increase blood oxygenation in the corpora cavernosa and then employed the vacuum constriction device to maintain penile erection for sexual intercourse significantly improved their erectile function and sexual satisfaction [67]. However, there are no reports about the use of this system in patients with SSc.
\nAnother option for the treatment of erectile dysfunction is prostaglandin analogues, which can be administered via intracavernous injections or intraurethral application. Alprostadil is a stable form of prostaglandin E1 that increases the concentration of cyclic adenosine monophosphate and decreases the intracellular calcium concentration, resulting in the relaxation of smooth muscle cells. Several studies reported the efficiency of alprostadil in the general population, but in terms of SSc patients, it was reported that a substantial percentage of SSc patients did not respond adequately to intracavernous prostaglandin E1 injections [68].
\nWhen pharmacotherapy fails and the patient wants a permanent solution, the surgical implantation of a penile prosthesis may be considered as the third-line option. Penile prosthesis improved erectile dysfunction in over 70% of men in the general population. Available prostheses are either malleable (semirigid) or inflatable (two or three pieces), but it should be considered that there are two main complications of penile prosthesis implantation—the mechanical failure and infection [5, 64, 65].
\nMost of the treatment options described above have not been verified in patients with systemic sclerosis yet. In spite of the fact that erectile dysfunction is common in men with systemic sclerosis, demographics, risk factors, and ED treatments have not been sufficiently investigated. Only a small case series has described unsatisfactory results with on-demand sildenafil (25–50 mg). The higher dose of sildenafil has not been investigated. Tadalafil has been slightly better evaluated in the treatment of SSc-related erectile dysfunction. The efficiency of 20 mg tadalafil on demand and 20 mg tadalafil in a fixed alternate day regimen has been compared. The results showed that flow-mediated dilatation and peak systolic velocities of cavernous arteries at penile duplex ultrasound improved significantly with the alternate day treatment; but no significant changes were observed after the on-demand tadalafil dosing. In addition, the alternate day regimen also reduced the plasma levels of ET-1 and vascular cell adhesion molecule as markers of endothelial function [68]. Therefore, long-term administration of tadalafil and its constant plasma level seems to have a positive effect on the treatment of ED in male SSc patients.
\nSexual dysfunction is a common problem in both men and women with systemic sclerosis. Erectile dysfunction is the dominant issue in males, which seems to be tightly linked to vascular dysfunction. Sexual dysfunction in the female patient is not less prevalent, but it is considerably more complex and it has been less studied. Several diagnostic approaches have been established to assess sexual dysfunction. Also, there are some treatment options available, but most of them have not been sufficiently verified in patients with systemic sclerosis. Further research regarding sexual dysfunction in patients with systemic sclerosis is strongly needed.
\nThis work was supported by grants AZV NV18-01-00161A, 16-33542A, 16-33574A, and institutional support of the Ministry of Health of the Czech Republic for the Institute of Rheumatology number: 023728 and GA UK 1578119.
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