ABSTRACT BOOK 1 CONTENTS

WELCOME...... 3

COMMITTEES...... 4

SCIENTIFIC PROGRAM...... 5-13

SUMMARY OF PRESENTATIONS...... 14-37

ORAL PRESENTATIONS...... 38-63

2 Dear Distinguished Colleagues,

We will launch the 2nd International Congress of Reconstructive- Aesthetic Genital & Sexology (RAGSS) between the dates 12- 15th of December 2019 led by our Society, ISAGSS (International Society of Aesthetic Genital Surgery and Sexology). We will host again numerous national and international specialists in Istanbul who work in sexology and reconstructive-aesthetic genital surgery fields and contributing medical, psychological, sexual and social benefits for women.

As it is known, especially from the beginning of 2000s, reconstructive and aesthetic for genital area are in fast demand among patients in the world. In recent years, non-surgical physicians have also been involved in the field as well together with the introduction of non-invasive genital laser, radiofrequency, genital fillers, PRP and stem cell practices into the market. No matter how many colleagues are interested in the field, they have limited knowledge and experience. Throughout our lives as physicians, our first duty must be to meet the needs of our patients with the right, evidence-based technique and practices, in line with the features of patients taking the “do not harm first, contribute in the best way possible afterwards” logic as basis.

Participant colleagues will be able to observe the multidisciplinary approaches in treatments and will have the chance to experience many novel technologies in this meeting.

In the congress program, ‘sexual dysfunctions of women and men’ sessions will take part which are not narrated in detail during our medical educations. In this context, vaginismus, dyspareunia, sexual desire and orgasm problems will be handled in the aspects of organic and psychological basis, also the current treatment methods will be discussed.

In pre-congress day (December 12th), there will be two different courses: Aesthetic Genital Surgery course with practical applications and video presentations, and Sexology course with full of lectures over vaginismus, dyspareunia, sexual desire and orgasmic dysfunctions in women.

I hope that this unique meeting will be quite fruitful and nice for everyone together with different social programs and special activities to be organized.

Hope to see you at the congress,

Dr. Süleyman Eserdağ Congress and ISAGSS President

3 COMMITTEES

HONORARY PRESIDENT

Akın Sivaslıoğlu MD

CONGRESS PRESIDENT

Süleyman Eserdağ MD

CONGRESS SECRETARY

Burcu Akdağ Özkök MD

SCIENTIFIC COMMITTEE

Cebrail Kısa MD Maria Riedhart-Huter MD Cem Turan MD Mete Güngör MD Cesar Arroyo Romo MD Oya Gökmen MD Cihat Ünlü MD Orhan Ünal MD Eray Çalışkan MD Özgür Leylek MD Eren Akbaba MD Prabhu Mishra PhD Ernesto Miguel Delgado Cidranes MD Suat Dede MD Faruk Köse MD Süleyman Engin Akhan MD Fransiska Mochtar MD Tahir Özakkaş MD Jack Pardo Schanz MD Yaprak Üstün MD Malgorzata Uchman-Musielak MD

ORGANIZING COMMITTEE

Aşkı Ellibeş Kaya MD Murat Emanetoğlu MD Cem Keçe MD Orhan Orhan MD Didem Kurban MD Ozan Doğan MD Doğukan Anğın MD Sevtap Handemir Kılıç MD Evrim Erdem MD Selçuk Sarıkaya MD Gökçe Devrim Ader Psychologist Selcen Bahadır MD Gülin Yeğin MD Ulaş Güvenç MD Mehmet Sakıncı MD Yasemin İrkilata MD Mine Kiseli MD

4 SCIENTIFIC PROGRAM

5 12 December 2019, Thursday SEXOLOGY COURSE 09:00-10:00 REGISTRATION 10:00-11:30 SESSION 1 Moderators: Şule Kıray, Selcen Bahadır 10:00-10:20 Sexual response theories since Master & Johnson until Burcu Akdağ Özkök today 10:20-10:40 Hypnotherapy for vaginismus treatment Mehmet Karav 10:40-11:00 Two complementary methods in vaginismus treatments: Mazhar Eserdağ HRT (Hypnotic Rework Therapy) and Acupuncture 11:00-11:20 Who are the resistant patients in vaginismus and what Şenay Eserdağ should be the management in treatment? 11:20-11:30 Discussion

11:30-11:50 COFFEE BREAK 11:50-13:00 SESSION 2 Moderators: Cem Keçe, Akın Sivaslıoğlu 11:50-12:10 What is gynesexology? Cem Keçe 12:10-12:30 Managements of orgasm dysfunctions in women Şule Kıray 12:30-12:50 Therapy techniques in women with sexual desire Gökçe Devrim Ader problems 12:50-13:00 Discussion

13:00-14:00 LUNCH 14:00-15:30 SESSION 3 Moderators: Süleyman Engin Akhan, Ege Can Şerefoğlu 14:00-14:20 Gynecologic management of female genitopelvic pain Selcen Bahadır and penetration disorders 14:20-14:40 Vulvar operation in dyspareunia Süleyman Engin Akhan patients 14:40-15:00 Mesotherapy for dyspareunia Gülcan Albayrak 15:00-15:20 Paramount cornerstones in treatment of men’s sexual Ege Can Şerefoğlu dysfunctions 15:20-15:30 Discussion

6 12 December 2019, Thursday AESTHETIC GENITAL SURGERY COURSE 09:00-10:00 REGISTRATION 10:00-11:30 SESSION 1 Moderators: Süleyman Eserdağ, Jack Pardo 10:00-10:20 Labia minoraplasty and clitoral hoodoplasty: Malgorzata Uchman- My technique Musielak 10:20-10:40 Labia minoraplasty and clitoral hoodoplasty: Jack Pardo My technique 10:40-11:00 Surgical vaginal tightening and perineoplasty Leila Khalili 11:00-11:20 Labia majora augmentation by autologous fat transfer Süleyman Eserdağ 11:20-11:30 Discussion

11:30-11:50 COFFEE BREAK 11:50-13:00 SESSION 2 Moderators: Ahmed Al Qahtani, Malgorzata Uchman-Musielak 11:50-12:10 Growth factors action in wound healing Ahmed Al Qahtani 12:10-12:30 Stemcell treatments for cosmetic gynecology and Prabhu Mishra gynecelogical diseases 12:30-12:50 PRP and HA applications in functional and cosmetic Malgorzata Uchman- gynecology Musielak 12:50-13:00 Discussion

13:00-14:00 LUNCH 14:00-16:10 SESSION 3 Moderators: Özgür Leylek, Cesar Arroyo Romo 14:00-14:20 Long and short term hymenoplasty Akın Sivaslıoğlu 14:20-14:40 Fat grafting to as a regenerative method Mitra Bahmanpour 14:40-15:00 Using hyaluronic acid in vaginal mucosa as a Özgür Leylek regenerative agent for treatment of genitourinary syndrome of menopause 15:00-15:20 Genital laser and RF technologies in functional and Didem Kurban cosmetic gynecology 15:20-16:05 Erb:Yag managements for aesthetic and functional Ebru Alper purposes 16:05-16:25 Genital bleaching and antiaging therapies Yasemin Savaş 16:25-16:35 Discussion

7 Thursday,13 December 27 September 2019, Friday 2018

Süleyman Eserdağ 09:00-09:05 OPENING SPEECH Akın Sivaslıoğlu 09:05-10:15 SESSION 1: ENTRY TO COSMETIC GYNECOLOGY Moderators: Cihat Ünlü, Leila Khalili 09:05-09:20 Patient selection and important motivators for surgical Ozan Doğan decision in aesthetic genital surgery 09:20-09:35 Pelvic floor anatomy Mehmet Sakıncı 09:35-09:50 Indications and contraindications of aesthetic genital Murat Emanetoğlu surgeries 09:50-10:05 Declarations form different societies against cosmetic Orhan Orhan gynecology 10:05-10:15 Discussion

10:15-10:30 COFFEE BREAK 10:30-12:10 SESSION 2: Moderators : Ateş Karateke, Jack Pardo 10:30-10:45 Overview on cosmetic plastic genital surgery Süleyman Eserdağ 10:45-11:00 Tips and tricks in labiaplasty operations Akın Sivaslıoğlu 11:00-11:15 Clitoral hoodoplasty ve frenuloplasty techniques Didem Kurban 11:15-11:30 Revision of botched labiaplasty Jack Pardo 11:30-11:45 Labiaminoraplasty complications and managements Malgorzata Uchman-Musielak 11:45-12:00 Techniques in labio majoraplasty operations Leila Khalili 12:00-12:10 Discussion

12:10-13:30 LUNCH

8 13 December 2019, Friday

13:30-14:40 SESSION 3: OPERATIONS IN COSMETIC GENITAL SURGERY Moderators : Oya Gökmen, Eray Çalışkan 13:30-13:45 Body shaping by liposculpturing methods in women Naci Çelik 13.45-14:00 Genital lipofilling Eray Çalışkan 14:00-14:15 Are G spot injections effective? Doğukan Anğın 14:15-14:30 Sociocultural, religious and medicolegal aspects of Gülin Yeğin hymenoplasty 14:30-14:40 Discussion

14:40-15:00 COFFEE BREAK 15:00-16:10 SESSION 4: COSMETOLOGY, ANTIAGING and VULVAR PATHOLOGIES Moderators : Suat Dede, Murat Emanetoğlu 15:00-15:15 HPV and HSV Infections: What’s new? Gaye Sarıkan 15:15-15:30 Preop preparation and postop care in cosmetic Mine Kiseli gynecologic procedures 15:30-15:45 Mesotherapy treatments for genital rejuvenation, Ahmet Atalık bleaching and antiaging 15:45-16:00 PRP applications for genital rejuvenation and sexual Aşkı Ellibeş pleasure 16:00-16:10 Discussion

16:10-16:20 COFFEE BREAK 16:20-18:20 SESSION 5: Oral Presentations Moderators : Didem Kurban, Doğukan Anğın

9 Thursday,14 December 27 September 2019, Saturday 2018

09:00-10:40 SESSION 6: RECONSTRUCTIVE SURGERY Moderators : Cem Turan, Gazi Yıldırım 09:00-09:15 Evaluation and staging of POP patients Önder Sakin 09:15-09:30 Managements of POP patients Gazi Yıldırım 09:30-09:45 Repair of anal sphincter and perineum tears Murat Naki 09:45-10:00 Surgical vaginal tightening and perineoplasty operations Murat Emanetoğlu 10:00-10:15 Neovagen surgery Evrim Erdemoğlu 10:15-10:30 Combination of cosmetic gynecology and classical Jack Pardo gynecological surgeries 10:30-10:40 Discussion

10:40-11:00 COFFEE BREAK 11:00-12:40 SESSION 7: REGENERATIVE TREATMENTS (1) Moderators : Süleyman Eserdağ, Prabhu Mishra 11:00-11:15 Regenerative medicine’s past, present and future Prabhu Mishra 11:15-11:30 Fat grafting for sexual enhancement and genital Mitra Bahmanpour rejuvenation 11:30-11:45 The truth about regenerative medicine, facts and fictions Ahmed Al-Qahtani 11:45-12:00 Domains of adipose stem cells in aesthetic medicine and Prabhu Mishra infertility 12:00-12:15 Myths and truths of stem cell treatments Gürsel Turgut 12:15-12:25 Discussion

12:40-14:00 LUNCH

10 14 December 2019, Saturday

14:00-15:10 SESSION 8: REGENERATIVE TREATMENTS (2) Moderators : Ahmed Al Qahtani, Ulaş Güvenç 14:00-14:15 Can COG threads be used for vaginal tightening and Özgür Leylek treatment of mild SUI patients? 14:15-14:30 Principles of hyaluronic acid applications Ulaş Güvenç 14:30-14:45 Labia majora augmentation by hyaluronic acid Malgorzata Uchman-Musielak 14:45-15:00 Growth factors in the field of regenerative medicine Ahmed Al-Qahtani 15:00-15:10 Discussion

15:10-15:25 COFFEE BREAK 15:25-16:25 SESSION 9: ENERGY BASED TECHNOLOGIES (1) Moderators : Cesar Arroyo Romo, Cemal Tamer Erel 15:25-15:40 Vaginal rejuvenation, do we have data? Jack Pardo 15:40-15:55 Monopolar and Bipolar RF in treatment of Genitourinary Cesar Arroyo Romo Syndrome of Menopause (GSM) 15:55-16:10 Erb: YAG iaser for menopausal genitourinary syndrome Cemal Tamer Erel 16:10-16:25 One year of personal experience with hybrid vaginal laser Jack Pardo

16:25-16:40 COFFEE BREAK 16:40-17:50 SESSION 10: ENERGY BASED TECHNOLOGIES (2) Moderators: Faruk Köse, Yaprak Üstün 16:40-16:55 High intensity focus electromagnetism as a treatment of Cesar Arroyo Romo pelvic floor disorders 16:55-17:10 In which indications of SUI and vaginal relaxation, can Sevtap Handemir lasers be preferred more than surgery? Kılıç 17:10-17:25 Sexual functioning and sexual dysfunctions in infertile Yaprak Üstün women 17:25-17:35 Discussion

11 Thursday,15 December 27 September 2019, Sunday 2018

09:00-10:10 SESSION 11: MALE GENITAL AESTHETICS AND SEXUAL DYSFUNCTIONS / ISEMA Moderators : Cebrail Kısa, Orhan Ünal 09:00-09:15 What are the markers for differential diagnosis in male Cebrail Kısa sexual dysfunctions? 09:15-09:30 Prophylaxis and treatment of surgical scars Ümit Tursen 09:30-09:45 Contemporary diagnostic tools and treatment options of Selçuk Sarıkaya erectile dysfunction - ISEMA 09:45-10:00 Surgeries for penile enlargement Ege Can Şerefoğlu 10:00-10:15 The latest updates for male genital aesthetic surgery Selçuk Sarıkaya outcomes 10:15-10:30 Causes and treatments of premature ejaculation Ege Can Şerefoğlu 10:30-10:45 Penile prostheses Ömer Faruk Karataş 10:45-11:00 Discussion

11:00-11:20 COFFEE BREAK 11:20-13:15 SESSION 12: LET’S TALK ABOUT SEX Moderators : Erkut Attar, Tahir Özakkaş 11:20-11:35 Evaluation of sexual dysfunctions in the context of holistic Tahir Özakkaş psychotherapy 11:35-11:50 Physical and molecular changes during orgasm in women Suat Süphan Erşahin 11:50-12:05 Female ejeculation and squirting dilemma Şule Kıray 12:05-12:20 Female sexual desire and arousal disorders by Selcen Bahadır gynecologist’s point of view 12:20-12:35 in pregnancy and postpartum periods Aşkı Ellibeş 12:35-12:50 Sexual life in postmenopausal period Eren Akbaba 13:05-13:15 Discussion

13:15-14:15 LUNCH

12 15 December 2019, Sunday

14:15-16:55 SESSION 13: WHEN SEX HURTS Moderators : Akın Sivaslıoğlu, Süleyman Engin Akhan 14:15-14:30 The role of gynecologist in treatment of genitopelvic pain Burcu Akdağ Özkök and penetration disorders 14:30-14:45 Psychological and sexual health in pelvic pain Erkut Attar 14:45-15:00 Complementary medicine for vaginismus treatments Şenay Eserdağ 15:00-15:15 Botox injections for vaginismus and dyspareunia Leila Khalili treatments 15:15-15:30 The pathophysiology of localized provoked vulvodynia Süleyman Engin (VVS) and reflections to the treatment Akhan 15:30-15:45 Pelvic floor rehabilitation for sexual dysfunctions in Yasemin İrkilata women 15:45-15:55 Rational drug use presantation Burcu Akdağ Özkök 15:55-16:00 Discussion

13 SUMMARY OF PRESENTATIONS

14 SP-01 DİSPARONİ OLGULARINA MEZOTERAPİ YAKLAŞIMI Gülcan Albayrak

Dyspareunia

Multidisciplinary treatment

Diagnosis  History   Ultrasound  Different branch physicians may need to see

Where is the pain located? When is the onset of the pain? (before, entry, vaginal, deep or after) Is it pruritic, burning or aching in quality? What is the chronologic history? If multiple pain sites, which came first? Is it situational or positional? Has it been lifelong or acquired? Are there other sexual dysfunctions such as arousal, lubrication or orgasmic difficulties? What treatments have been attempted?

15 Painful intercourse  Superficial  Deep  Vestibulitis  Vaginismus  Vaginitis  Vulvodynia  Swollen feeling

Explore potential gynecologic causes.  Are there vaginal symptoms, including discharge, burning or itching?  Does patient have a history of STDs, especially HSV or HPV?  Is there an obstetric delivery history of lacerations, or other trauma?  Is there an abdominal or genitourinary surgical or radiation history?  Has the patient had prior gynecologic diagnoses, including endometriosis, fibroids or chronic pelvic pain?  What is the patient’s current contraception method and is there any history of intrauterine device use?

Diagnosis

 Vaginismus  Vulvodynia,Vulvar vestibulitis  Infections (HPV;HSV;PID;Endometritis,Vajinitis,Servisitis)  Endometriosis, uterine fibroids, pelvic adhesions  Adnexal pathology  Retroverted , pelvic relaxation DIFFERENTIAL DIAGNOSİS FOR DYSPAREUNIA  Pelvic congestion  Urethral enf,interstitial cystitis  Atrophic Vaginitis

Cascading treatment protocol  Medical (medikal)  Surgery (cerrahi)  Complementary Medicine (uzun dönem yönetim)

Mesotherapy  Mezoterapi ilk kez 1952 yılında, Fransa’da Dr. M.PİSTOR tarafından geliştirilmiş, sonraki yıllarda başta Fransa olmak üzere tüm Avrupa’da yaygın olarak kullanılmaya başlanmıştır.  Tedavi edilecek bölgede, mid-dermise az miktarda ilacın tek veya karışım olarak, ince uçlu iğnelerle verilmesi olarak özetlenebilir.  Tedavide kullanılacak farmakolojik maddeler antiinflamatuar ilaçlar, vitaminler, mineraller, aminoasitler veya enzimler olabilir.

16 Mezoterapinin Gelişimi  Mezoterapiyi 1996 yılında ‘Fransa Ulusal Sağlık Akreditasyon ve Değerlendirme Ajansı ‘ resmi olarak tanımış ve sağlık alanındaki güvenilirliği tescil edilmiştir.  1998 yılında Brezilya’da VIII.Mezoterapi Kongresi düzenlenmiştir.  2000 yılında ise IX.Mezoterapi Kongresi Paris’te düzenlenmiştir.  Ülkemizde de geçen yıl Mezoterapi Derneği resmi olarak kuruldu. Mezoterapi Kullanım Alanları  Başlangıçta ağırlıklı olarak kas-iskelet sistemi ile vasküler sistem hastalıklarında ağrı kontrolü ve yönetimi için kullanılıyorken, günümüzde birçok sistem hastalıklarında, spor yaralanmalarında ve iyi yaşlanma yönetiminde dermatolojide yaygınlıkla kullanılmaktadır.

Mezoterapinin etki mekanizması 1.Refleks Teorisi---Dr.Pistor 2.Mikrodolaşım Hipotezi---Dr.Bicheron 3.Üç ünite ya da Mezoderm teorisi---Dr.Balloz-Bourguignon 4.Enerjik Mezoterapi Teorisi---Dr.Ballesteros 5.Sistematize edilmiş Mezoterapi Teorisi---Dr.Mrejen 6.Üçüncü Dolaşım Teorisi---Dr. Multedo 7.Bütünleştirici Teori---Dr. Kaplan

17 Mezoterapide olası etki mekanizmaları  Dolaşım birlikteliği  Nöro-vejetatif birliktelik  İmmunolojik yanıt birlikteliği

Özetle Mezoterapi kökenini tıpkı mid-dermis gibi mezodermden alan (yağ dokusu, kas-iskelet sistemi gibi) ortak embriyolojik kökenli doku ve organ patolojilerinin, mid-dermis injeksiyonları yoluyla tedavi edilmesidir.

Dermatomlar

Dermatom  Herbir spinal sinir tarafından innerve edilen deri alanına verilen isimdir.  Derinin yüzeyel alanı, spinal sinirler tarafından uyarılan belirli bir bölge olarak 30 ‘a bölünmüştür.  Jinekolojik bölge ağrılarında potansiyel olarak uyarılan bölgeler çoğunlukla L2-S3 dermatomlarını içerir.

18 Working group  32 patients  VAS: 7.2  Life Quality Score (SF-36): 51

Sessions  1% procaine 1 cc + 1 cc pentoxifylline + 1cc diluted meloxicam  4 mm 30 gauge needle tip  Symphisis pubis, pelvic and inguinal region  2.5-3 cc content

Segmental Therapy  Sympathetic: Th12 - L2 (3)  Parasympathetic: S2-S4  Gyn W, Trigger Point  Napage to the uterovaginal ganglion projection area

Inter-session evaluation  Trigger points decreased significantly after the 3rd session  Nappage technique was applied in single sessions  Pain history ⇩ Response time to treatment⇧  The most effective recovery period in patients with surgical history

19 To The Patients who complain about vaginal dryness  Intravaginal hyaluronic acid treatment was applied to patients with dryness.  (2 sessions).

Oral analgesic agents were discontinued 3 sessions Evaluation  VAS (Visual Analogue Scale) 7 ⇨ 2  Life Quality Index 51 ⇨ 83 Conclusion  Mesotherapy is a fine way of pain treatment  Can be added to all other medical treatment  Increases overall life quality

20 SP-02 ERB: YAG MANAGEMENTS FOR AESTHETIC AND FUNCTIONAL PURPOSES Ebru Alper Obstetrician and Gynecologist, American Hospital, Istanbul Turkey

“Innovation” is the key word in the 21st century and it’s the future of the medicine. One of the new trends gaining interest is the vaginal laser for vaginal rejuvenation, stimulating collagen regeneration, contracture of elastin fibers, neovascularization, and improved vaginal lubrication. The research field is very active with large multicenter studies currently being conducted to facilitate the acquisition of knowledge and best practices. Although the studies are showing excellent results in terms of patient satisfaction, and functional restoration, most of the studies published until today are prospective case series with limited follow up pe- riod and lack of placebo controls. There is still no concensus on ideal treatment interval and the need for retreatment. Vaginal relaxation syndrome and pelvic organ prolapse VRS is a new terminology, which leads to problems mainly related to decreasing sexual satisfaction for both the woman and her partner. The efficacy of VEL treatment for POP of grade II or higher has been assessed by Ogrinc et al., using the Baden-Walker scale. At the final follow-up, the large majority of patients had their prolapse reduced by at least one grade, 30–45% by two grades and approximately10% by three grades. The follow up period after the last VEL therapy is 12 months. No adverse events were reported and majority of the patients reported improvement. A significant partner reported improvement in vaginal laxity (76.6%) as well as in sexual satisfaction (70.0%). Stress urinary incontinence (SUI) In their study, Ogrinc et al enrolled 175 women with urinary incontinence. Scores on the Incontinence Severity Index (ISI) were significantly reduced after two sessions of VEL, and there was an improvement of SUI symptoms in all age groups. After one year follow up, the majority of the SUI patients (77%) were improved while in the MUI group the improvement was only 34%; the difference between these two groups was statistically significant. After one year, 62% of all patients remained dry. This study clearly shows that patient selection is vital in order to predict the effectiveness of VEL in treating urinary incontinence. Genitourinary syndrome of menopause (GSM) Laser therapies for the treatment of GSM are showing excellent results. A recent randomized, double blind placebo controlled clinical trial by Cruz et al compares therapeutic response to vaginal laser with sham estrogen cream versus vaginal estrogen cream with sham laser versus laser with vaginal estrogen cream. Fortytwo patients were followed for 20 weeks and patients with laser and vaginal estrogen cream had the most improved GSM scores followed by vaginal estrogen alone. Cohort prospective studies show that laser treatment for the restoration of vaginal function might improve the quality of life and that the procedure is effective and safe. Optimal patient selection criteria remains to be determined. Laser treatment in the field of gynecology is an emerging and promising concept and despite the lack of robust evi- dence it’ s an encouraging method in the hand of well-trained physicians.

21 SP-03 NONINVASIVE GENITAL REJUVENATION Didem Kurban

Genital Rejuvenation is an umbrella term to describe the aesthetic and functional correction and restoring vagina and the surrounding tissues

There is an increasing demand in genital aesthetic operations in women’s modern life. Reasons are; --Epilation -Increase in life span and expectations -Web sites -Porn sites -Awareness of another antiaging

Functional Reasons for nonivasive genital rejuvenations are; Vaginal laxity and atrophy Menopausal GUS ( Genitourinary syndrome) Urinary incontinence Orgasmic dysfunction

How the CO2 and ER-YAG lasers functions ? Laser Energy is being converted to infrared light. Infrared light which is imposible to see with the naked eye,causes an artificial wound by making thermal necrosis. And healing begins around the surrounding area. New collagen and elastin are produced by fibroblast activation.

How the RF functions? RF working princible based on focused electromagnetic waves.Electrical field changes the tissue polarity. It causes heat increase until 4 mm.New collagen and elastin are produced by fibroblast activation,neo- vascularisation and the result is: Tightened vagina and Despite the fact of this technical presentation, ACOG 2007 and FDA declares that: Laser and Radiofrequency appli- cations have not been proven to be effective and secure solution.But it’s an alternative solution for the patients who don’t want to have an operation.As many other new innovations more studies and researches are needed to be done.

22 SP-04 OVERVİEW ON COSMETIC PLASTIC GENITAL SURGERY Süleyman Eserdağ

Female cosmetic plastic genital operations encompass surgical and non-surgical parts.

Surgical Parts:

• Labiaplasty

Labia minora reduction, Labia majora reduction / augmentation

• (Clitoral hoodoplasty) and Frenuloplasty

• Surgical

Posterior colporraphy, Anterior / Lateral colporraphy

• Perineoplasty (Perineorrhaphy, perineal repair)

• Hymenoplasty (Hymenorrhaphy, revirgination, hymenal repair)

Non-surgical Parts:

• Laser Therapies

Vaginal rejuvenation (NS vaginal tightening) Stress Urinary Incontinence (SUI) treatment Non Surgical Vulva Bleaching and Tightening

• RF Therapies

Vaginal Rejuvenation Stress Urinary Incontinence (SUI) treatment Vulvar resurfacing

• G-spot bulking (G Spotplasty)

• Genital PRP and O-spotplasty

• Regenerative medicine: Stem cell managements

• Others: Vaginal HIFU, Threads, Mesotherapy, Carboxytherapy

The women mostly seek these operations for aesthetic, cultural, functional, hygienic and sexual reasons.

23 Figure 1- Perfect Vulva Concept by Western Society

The operations can be done by local, sedation, regional and general anesthesia.

Marking before the cutting is very important.

The surgeon should be careful and plan which method to be used previously.

Classical metzembaum scissor, scalpel, laser or RF can be used for cutting.

Training before practicing is cruel!

Labiaminoraplasty is the most demanding operation by the patients. It should be done mostly with clitoral hood reduction. Otherwise ‘penis-like’ shape can be formed in clitoral hood area.

24 Figure 2- Curvilinear labiaplasty with clitoral hoodoplasty

Figure 3- Labia majoraplasty and minoraplasty combined surgery

25 Figure 4- Labia minora reconstruction and reduction (Depending on a partial tear of the labium)

TAKE HOME MESSAGES 1) Genital aesthetic operations increase body image and self-confidence.

2) These operations are demanded for not only aesthetic, but also functional, social, hygienic, medical and sexual reasons.

3) Before the surgery, patients should be illuminated about advantages, disadvantages, and all the possible complications. 4) Training before the practicing is very important to minimize complications and ensure patient satisfaction

26 SP-05 CLITORAL HOOD REDUCTION Didem Kurban

Clitoris is the main pleasure center in female sexuality and has thousands of nerve endings. Clitoral hood is the fold of skin that surrounds the head of the clitoris. It protects the sensitive clitoris from friction or rubbing. The innervation of clitoral hood is generally attributed to the dorsal nerve of the clitoris, The reductive hoodoplasty is a surgical intervention to decrease the excessive length or to reduce the thickness of the clitoral hood. GHR is rarely performed as an isolated procedure. Mostly is performed in combination with labia minora reduction. Women don’t want protruding visible clitoral hood between anterior commissure Techniques for hoodoplasty -Reverse V Plasty -Reverse Y Plasty -Bilateral parallel vertical incisions -Extended wedge resection with horseshoe modification

Cutting with scissor is suitable.Excess skin on the clitoral hood is resected through an incision parallel on both sides of the clitoral body. Contraindications are; Patients with unrealistic expectations Untreated psychosexual conditions Patients confusion with hoodectomy procedures Active vulvovaginal infections Inflammatory diseases Coagulopathy Smoking After Labiaplasty and Clitoral Hoodoplasty operations!!! -High operation satisfaction rates (>90%) -Improved sexual quality (>85 ) -Increased self confidence(>82%) -Low complication - revision (3%) rates (2-10%)

27 SP-06 ARE G-SPOT INJECTIONS EFFECTIVE? Ali Doğukan Anğın

The G-spot has really been discussed for years. Although De Graaf defines the first erogenous region, the first that comes to mind when we call G spot is Ernest Gräfenberg and this erogenous grafenberg spot goes into the literature in 1982 as g-spot. There are many publications in the literature such as cadaver studies, alive tissue studies, neurological and imaging methods. A study from Egypt showed that G spot is functionally exist in 82% of the patients, anatomically in 54%, and histologically in 47%. In one of the MRI studies, it is stated that there is a g spot complex. Puppo states that there is no clitorouretrovaginal complex, that the vagina is unrelated to the clitoris and that the g-spot does not exist. In a recent review published by Adam Ostrezenski in November 2019, it’s stated that the g-spot exist, but it is not an erectile tissue, it’s a neural and vascular structure, and unrelated to female ejaculation. The g-spot as described by Marartos is 4-5 cm from the urethral meatus and an area of approximately 1 cm2 on the anterior wall, and existing generally on the right or left side, not in the middle. In one study, women were asked about their beliefs about g-spot and it was found that sexual dysfunction was less common in women who knew and believed g-spot. Orgasm is of two kinds; the first occurs with direct clitoral stimulation and called clitoral orgasm, the other is the vaginal orgasm during penetration, which is also called indirect clitoral orgasm. The clitoris extends into the vagina and surrounds the 1/3 of the entrance of the vagina, and we know that only this part of the vagina is sensitive to the stimulations. However, the orgasm is very variable, multifactorial, also the orgasmic disorders are so. So it may not be possible to achieve success with just one injection. The clitoris varies from woman to woman, like young people have a denser clitoral neural network. Someone can only reach orgasm by stimulating the external genitalia. Although only vagina and clitoris are considered, there may be a feeling of orgasm from different regions, orgasm in the dream is the best example of this. Even the G-point can be personalized. There is no study that measures the clitoris size and orgasm connection, but a smaller clitoral-urethral meatus distance has been found to be significant in those with optimal sexual experience.

For g-spot injections we use autologous fat tissue, hyaluronic acid or PRP. The aim is to create a raised area to increase the contact and satisfaction of the anterior vaginal wall during penis penetration, that is to say, stimulating the clitoris indirectly. We already know that the G spot is not an extension of the clitoris. In the ultrasound, when the finger or penis is in the vagina, they appear in direct contact with the vaginal anterior wall, the clitoris. So it seems that the anterior wall of the vagina, the g-spot, the clitoris, they form the parts that in relation with the orgasm. The G-spot is like a pacemaker, the pressure increase in this region increases the electrical activity, ie the g-point activity. Thus, a fluffy g-spot, ie inflating with filler material, can be effective. The problem is that there is no clear study of g-spot injections. There is evidence that injections may increase sexual functions but there is no clear information about the g-spot. Recommendations in most studies suggest that g-spot injections may not be effective and should not apply until the effects are proven with scientific basic. In conclusion, considering that the vaginal upper wall is in close contact with the clitoris extensions and therefore the vaginal orgasm is indirect clitoral orgasm, injections or augmentations to this region may be beneficial but there is a need for scientific quantification. It is difficult for this kind of applications to be effective in a woman who has no orgasm experience, but it may be considered to be effective in women who have experienced orgasm before but then having a decreased or none orgasm. In additon, the sexual cycle and orgasm are so complex that planned procedures for regulating sexual life, such as g-spot injections, should be combined with sexual therapy.

28 SP-07 SOCIOCULTURAL, RELIGIOUS AND MEDICOLEGAL ASPECTS OF HYMENOPLASTY Gülin Yeğin

The translation of the word ‘virgin’ is parthenos in Greek, betulah in Hebrew or bakire in Turkish. Unless otherwise stated, the word generally refers to a female. Virginity is defining in our language as ‘ the situation of the woman who did not have sexual intercourse, related to the life before together, specific to that period ‘. The concept of virginity dates back to the Greek Soranus and was shown anatomically by Vesalius of Rome in 16th century(1). Social psychologists classify cultures in 3 different types. The first one is face cultures (ex. Japan), second is dignity (ex. South America) and the third one is honour cultures (ex. Spain, Turkey)(2). In a society dominated by honor culture, one’s family or groom to-be, insist on the bleeding and certificating of virginity before marriage. The same conservative will is determined to ignore all medical realities; such as elastic , non-bleeding sexual intercourse, and rejects the possibility of being born without embryonal residual tissue. In a study conducted by Trakya University, including two- hundred-fifty-two nursery students was an observation of nursery students perpectives regarding hymen examination and hymenoplasty(3). Eighty one point five percent of males and eighty-eight point nine percent of females does not approve sexual relationships before marriage(3). The majority of participants think ‘virginity is important’ and approximately half of the participants of both genders agree with the statement ‘broken hymen requires marriage afterwards’(3). Virginity is a controversial issue and aspects in terms of religion differs between authorities. For example, Jewish couples sign a written contract before marriage named ‘’ketubah’’. In this contract, the woman called as ‘the maiden‘ in every statement referring bride. Virginity is a very important concept in the Bible. The Bible defines sex outside of marriage as a sin because it is a form of sexual immorality(4). In Islamic religion, premarital sexual intercourse is prohibited. Hymenoplasty falls under the juristic category of modern-day issues and thus has no direct textual reference in the Qurʾan(5). According to the majority of reverends, hymen can only be lost after a legitimate wedding. In the former Turkish Penal Code (TPC) (article 418/2),‘’ the loss of virginity is a factor that aggravates the sexual offensive crime’’. While the new TPC (article 102) regulates the deterioration of physical and mental health as an aggravating factor. In this case, the determination of whether it is aggravating - the article titled Genital examination (Article 287). When the subject is examined within the Turkish Civil Code; three different views emerge. According to the first opinion, the woman who had a hymenoplasty should discuss the issue with her husband without waiting for her husband to question him. If she had deceived his husband by staying silent, this was the reason for the annulment of the marriage because of the deception. According to another opinion, “Being silent may constitute an obstacle to the cancellation of marriage, but if the woman mispresented herself as a virgin, her husband is deemed to be deceived and because of infidelity causes the cancellation of marriage “. Another opinion; ‘Virginity is not a qualification, legally this concept is no longer recognized. Rational cannot be derived from the unrecognized concept. In conclusion, when it comes to stigmatization (labeling) and security threats for women, doctors need to take the risks of not having hymenoplasty if we reject to perform. The responsibility of not subcontracting the secondary gain providers from unjust norms also belongs to the physician who will perform this operation. Other public health providers should also be invited to take active steps to tackle problematic social norms that push women to demand hymenoplasty.

REFERENCES 1.Alain Corbin, Jean-Jacques Courtine, Georges Vigarello (dir.), A History of Virility, New York, Columbia University Press, 2016, 744 p., Traduit du français par Keith Cohen, ISBN : 978-0-231-16878-6. 2. Kim YH1, Cohen D, Au WT. The jury and abjury of my peers: the self in face and dignity cultures. J Pers Soc Psychol. 2010 Jun;98(6):904-16. 3. Süt KH, Küçükkaya B. Investigationof Perspectives of Nursing Students About Hymenoplasty and Hymen Examination. DEUHFED 2016, 9(2), 52-60 4. Kellogg Spadt S, Rosenbaum TY, Dweck A, Millheiser L, Pillai-Friedman S, Krychman M. Sexual health and religion: a primer for the sexual health clinician. J Sex Med. 2014 Jul;11(7):1607-18; quiz 1619. doi: 10.1111/jsm.12593. Review. 5. Bawany, Mohammad H. et al. Hymenoplasty and Muslim Patients: Islamic Ethico-Legal Perspectives. J Sex Med 2017;14:1003 29 SP-08 WHAT’S NEW IN HPV Gaye Sarıkan

Anogenital warts are a significant public health problem with global estimates of incidence of 160-289 cases per 100,000 person years. Although Europe-wide data are lacking, estimates of annual incidence in several European countries range from 0.13 to 0.16% of the general population. Transmission rates of HPV between sexual partners are high and transmission may occur in the absence of visible warts. Anogenital infection with HPV is common, with a global prevalence of any HPV genotype of 11.7% estimated from cervical cytology samples. In most cases the infection is asymptomatic and visible genital lesions develop only in a minority of those infected. Longitudinal studies have recorded warts developing in 14.6-64.2% of those infected with HPV 6 or 11. The incubation period between incident genital HPV infection and the appearance of warts is highly variable but has been found to be shorter in women (median 2.9 months) than men (median 11.0months)Most patients notice only the presence of warts, which are otherwise asymptomatic. However, symptoms can include itching, bleeding, or dyspareunia. Biopsy is not necessary for typical anogenital warts but is recommended. Biopsy : if there is diagnostic uncertainty or suspicion of pre-cancer or cancer Of the options available currently, only surgical treatment has a primary clearance rate approaching 100%. Recurrences occur after all therapies. Recurrence rates, including new lesions at previously treated or new sites, are often 20–30%, and increase with longer duration of follow-up.All topical treatments are associated with local skin reactions including itching, burning, erosions and pain. Podophyllotoxin 0.5% solution (1A) and 0.15% cream. Podophyllotoxin is self-applied to lesions twice daily for 3 days, followed by 4 rest days, for up to 4 or 5 weeks (according to the product licence). Common reactions include transient tenderness, erythema and erosions. Podophyllotoxin is contraindicated during pregnancy, and women of childbearing age must be advised to use an effective method of contraception or abstain from vaginal intercourse during therapy. The use of podophyllotoxin to treat peri-anal warts is outside the product licence for either preparation, but is well-established in clinical practice. Clinical experience suggests that for ease of application the cream formulation is preferable for vulval and peri-anal wartstherefore we suggest the use of podophyllotoxin cream for warts at these sites. A mirror and digital palpation can facilitate the application procedure. Clearance rates of 36-83% for podophyllotoxin solution (26-34) and 43-70% for podophyllotoxin cream have been reported. A recent systematic review and meta- analysis confirmed the effectiveness of podophyllotoxin 0.5% solution relative to placebo (RR 19.86, 95% CI 3.88- 101.65). They found the 0.5% solution to be superior to the 0.15% cream (RR 1.26, 95% CI 1.07-1.48).However neither the meta-analysis nor the included studies were stratified by the site of the warts. Imiquimod cream is supplied as single use sachets. It is applied directly to the warts three times weekly prior to normal sleeping hours and washed off with soap and water between six and ten hours later. In clinical studies, wart clearance has been reported in 35 -75% of patients with treatment courses up to sixteen weeks. Two RCTs have evaluated lower concentrations of imiquimod cream (2.5% and 3.75%) applied daily for up to 8 weeks. Clearance rates were low for men (14.3 and 18.6%) and women (28.3% and 36.6%) for the 2.5% and 3.75% strength respectively. No RCT has directly compared either lower strength preparation with imiquimod 5%. Imiquimod 3.75% is available in Europe for the treatment of actinic keratoses but it is not licensed for the treatment of warts. Sinecatechins are derived from green tea leaves of the Camellia sinensis species containing the active ingredient epigallocatechingallate (EGCG; Polyphenon E®). The mechanism of action is uncertain but various immunomodulatory and antiproliferative properties have been proposed. EGCG is formulated as a 10% ointment which is marketed in most European countries as Veregen® and in the UK as Catephen®.

30 Recommended clinic-based treatments • Cryotherapy • TCA • SURGERY Excision Electrocautery Laser Tx Clearance rates of 94-100% and recurrence rates of 22% have been reported. Surgery may be used as a primary therapy, and the majority of patients can be treated under local rather than general anaesthesia (e.g. 1-2% lidocaine for sub-cutaneous infiltration). The addition of adrenaline reduces bleeding but its use in the penis and in the clitoris region is controversial owing to the potential risk of necrosis. Its safety has not been established and clinics therefore may choose not to stock the combined preparations to prevent inadvertent use. When performed carefully, simple surgical approaches give highly satisfactory cosmetic results.Electrosurgery, electrocautery and laser surgery should be performed with the use of surgical masks by the treatment team, and the use of an extractor fan due to the potential presence of infectious HPV particles in the smoke plume generated by these techniques. Combination therapies have often been used as the last step.Treatments have often been used in combination. There is some theoretical rationale, for example initial use of an ablative therapy may enhance local penetration of subsequent topical treatment, particularly for keratinized warts. In one placebo-controlled study, adjuvant podophyllotoxin cream following cryotherapy did not improve wart clearance at 4, 12 or 24 weeks post treatment initiation. Photodynamic Therapies :Photodynamic therapy (PDT) employs topical 5-aminolevulinic acid (ALA) as photosensitiser, followed by irradiation with red light to induce cell death or immunomodulation through generation of reactive oxygen species. stratified by the site of the warts. Imiquimod cream is supplied as single use sachets. It is applied directly to the warts three times weekly prior to normal sleeping hours and washed off with soap and water between six and ten hours later. In clinical studies, wart clearance has been reported in 35 -75% of patients with treatment courses up to sixteen weeks. Two RCTs have evaluated lower concentrations of imiquimod cream (2.5% and 3.75%) applied daily for up to 8 weeks. Clearance rates were low for men (14.3 and 18.6%) and women (28.3% and 36.6%) for the 2.5% and 3.75% strength respectively. No RCT has directly compared either lower strength preparation with imiquimod 5%. Imiquimod 3.75% is available in Europe for the treatment of actinic keratoses but it is not licensed for the treatment of warts. Sinecatechins are derived from green tea leaves of the Camellia sinensis species containing the active ingredient epigallocatechingallate (EGCG; Polyphenon E®). The mechanism of action is uncertain but various immunomodulatory and antiproliferative properties have been proposed. EGCG is formulated as a 10% ointment which is marketed in most European countries as Veregen® and in the UK as Catephen®. Recommended clinic-based treatments • Cryotherapy • TCA • SURGERY Excision Electrocautery Laser Tx Clearance rates of 94-100% and recurrence rates of 22% have been reported. Surgery may be used as a primary therapy, and the majority of patients can be treated under local rather than general anaesthesia (e.g. 1-2% lidocaine for sub-cutaneous infiltration). The addition of adrenaline reduces bleeding but its use in the penis and in the clitoris region is controversial owing to the potential risk of necrosis. Its safety has not been established and clinics therefore may choose not to stock the combined preparations to prevent inadvertent use. When performed carefully, simple surgical approaches give highly satisfactory cosmetic results.Electrosurgery,

31 electrocautery and laser surgery should be performed with the use of surgical masks by the treatment team, and the use of an extractor fan due to the potential presence of infectious HPV particles in the smoke plume generated by these techniques. Combination therapies have often been used as the last step.Treatments have often been used in combination. There is some theoretical rationale, for example initial use of an ablative therapy may enhance local penetration of subsequent topical treatment, particularly for keratinized warts. In one placebo-controlled study, adjuvant podophyllotoxin cream following cryotherapy did not improve wart clearance at 4, 12 or 24 weeks post treatment initiation. Photodynamic Therapies Photodynamic therapy (PDT) employs topical 5-aminolevulinic acid (ALA) as photosensitiser, followed by irradiation with red light to induce cell death or immunomodulation through generation of reactive oxygen species. Its uses include the treatment of actinic keratoses, basal cell carcinomas, and Bowen’s disease. Studies of its use as adjuvant and stand-alone treatment in genital warts show some efficacy but there is not yet sufficient data There is no single optimum treatment for anogenital warts. All modalities of treatment have advantages and limitations, and all are associated with a substantial risk of wart recurrence. Evaluation of the evidence is limited by the heterogeneity of study designs and reporting outcomes and a lack of head to head comparisons between treatments. Patient-centred outcomes, in particular satisfaction with treatment, have been largely overlooked. Future studies should address these limitations. Local management protocols incorporate medical review of cases at regular intervals, for example every 4 weeks, until warts have resolved, with switching of treatments if an inadequate response is observed. • - Patients with first episode genital warts should be offered sexually transmitted infection screening as per local guidelines. • - Female patients should be informed about cervical cytology screening as per local or national guidelines. • - Condoms have been shown to at least partially protect against the acquisition of anogenital warts. Whether condoms protect against • HPV transmission is less clear but some data suggest that male condom use may protect female partners against HPV acquisition • Vaccination with Gardasil® and Gardasil9® both provide durable protection against HPV genotypes 6 and 11, which cause the majority of anogenital warts. • A recent trial suggested that there may be a benefit in using vaccine in conjunction with topical imiquimod or podophyllotoxin for the treatment, or prevention of recurrence, of genital warts but this has not been established. Vaccination prior to sexual debut will maximise the protective benefits. Countries differ in their HPV vaccination strategies. However substantial reductions in genital wart incidence in young women and heterosexual men have been observed in Australia following the introduction of Gardasil® vaccine for schoolgirls. Unexpectedly, a reduction in genital wart episodes was also seen in women and heterosexual men aged 15-19 in the UK following introduction of the bivalent vaccine Cervarix®.

32 SP-09 SURGICAL SCAR PROPHYLAXIS AND TREATMENT Ümit Türsen

Estimates indicate that each year around 100 million people in the developed world acquire scars following surgery. Of these, approximately 15% have excessive or unaesthetic scars. Incision design, atraumatic handling of soft tissue, hemostasis, aseptic techniques, tension reducing approaches, the care of an incisional wound should be considered as a continual process, and minimizing scar formation should be a long-term goal. First-line therapy of these scars include hypoallergenic microporous tape, massage, silicone gel sheeting and silicon gel creams, pressure garments, pulse dye lasers, antihistamines /gabapentin; Second-line therapies include corticoids, surgical interventions such as Z-plasty, excision plus grafting and flaps. Lasers and light-based therapies are becoming more and more used nowadays and appear promising in the management of scars. Patients should be encouraged to take active participation in wound care, even long after the skin appears to have healed. Postoperative visits should focus on prevention, screening, and treatment of hypertrophic scars.

33 SP-10 PENILE ENLARGEMENT SURGERIES Ege Can Şerefoğlu

EThroughout history, the penis has defined masculinity. Discussion of the penis has been deemed taboo, socially unacceptable; and at other times, it is the topic of lighthearted conversation and jokes. Length, girth and function, however, have been an issue for men throughout history1. Penile shortening is a phenomenon that is associated with certain medical and surgical conditions. When speaking of penile enhancement surgery, one must distinguish between those procedures that increase penile circumference, penile length and plastics procedures to change skin surrounding the penis. Fat injection into the penis is the mainstay of girth enhancement procedures. The goal of fat injection into the Dartos layer of the penis is uniform enhancement of penile circumference2. The mainstay of penile lengthening procedures are a combination of release of the suspensory ligament of the penis with an inverted V–Y penopubic skin advancement3. Regardless of which type of procedure is being sought, the patient should be aware that there is no universally accepted protocol for either type of surgery. Most of the reported case studies have been in a small experimental population with short follow-ups. They should also be informed of the numerous complications that can result from such procedures, which included but are not limited to poor cosmetics, further shortening and sexual dysfunction4. Plastic surgical procedures on the skin of the penis hold more optimism. It appears that the overall risks of these procedures are minimal. Quality of life data collection will be necessary to determine if the value of these procedures approach that of breast augmentation for women.5

References: [1] Vardi Y, Lowenstein L. Penile enlargement surgery--fact or illusion? Nature clinical practice Urology. 2005;2: 114-5. [2] Panfilov DE. Augmentative phalloplasty. Aesthetic plastic surgery. 2006;30: 183-97. [3] Van Driel MF, Schultz WC, Van de Wiel HB, Mensink HJ. Surgical lengthening of the penis. British journal of urology. 1998;82: 81-5. [4] Dillon BE, Chama NB, Honig SC. Penile size and penile enlargement surgery: a review. International journal of impotence research. 2008;20: 519-29. [5] Zilg B, Rasten-Almqvist P. Fatal Fat Embolism After Penis Enlargement by Autologous Fat Transfer: A Case Report and Review of the Literature. J Forensic Sci. 2017;62: 1383-85.

34 SP-11 PREMATURE EJACULATION-CAUSES AND TREATMENTS Ege Can Şerefoğlu

Over the past several years, many advances have been made in our understanding of the epidemiology, pathophysiology, and management of premature ejaculation. Newly developed definitions of premature ejaculation are now available, and our perception of the classification, prevalence, aetiological factors, and treatment options for premature ejaculation has evolved. Premature ejaculation is extremely prevalent and can have substantial effects on quality1 oflife . In 2014, the International Society for Sexual Medicine (ISSM) provided standard evidence-based definitions of lifelong and acquired premature ejaculation2. The aetiologies of lifelong and acquired premature ejaculation are different; the former suggests an underlying neurobiological functional disturbance, while the latter is more likely related to underlying medical, psychological, or interpersonal causes. The pathophysiological mechanisms of premature ejaculation have not yet been entirely elucidated, but 5-hydroxytryptamine, dopamine, and various hormonal factors have been suggested to have a role3. Prolactin might also have a hormonal role in the ejaculatory mechanism: low prolactin levels have been associated with an increased risk of premature ejaculation, even after adjusting for confounding variables4. The prevalence of premature ejaculation has been reported to be increased in men with hyperthyroidism compared with those who were hypothyroid or euthyroid5. In addition to hormonal disruptions, some urological conditions might contribute to premature ejaculation. For example, symptoms of prostatitis have been found to be associated with acquired premature ejaculation6. A number of treatment options for premature ejaculation are available selective 5-hydroxytryptamine-reuptake inhibitors (SSRIs), topical anaesthetic creams, and phosphodiesterase type 5 (PDE¬5) inhibitors are widely used, and psychological therapies and behavioural techniques have not been completely abandoned7. The new ISSM unified evidence-based definition of premature ejaculation produced in 2014 could be a critical step in improving our understanding of the scope and process of this disorder, as it provides concrete operational criteria to include as limitations in future studies. Much remains to be learned with regards to the mechanisms of pathophysiology and management options for premature ejaculation; however, credible progress has been made and the future seems bright. Current medical therapy offers several effective options, with many more in development and trial. As our understanding of the pathophysiology continues to evolve and new therapies are developed, the options available for men with premature ejaculation can only increase.

References: [1] Laumann EO, Nicolosi A, Glasser DB, et al. Sexual problems among women and men aged 40-80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. International journal of impotence research. 2005;17: 39-57. [2] Serefoglu EC, McMahon CG, Waldinger MD, et al. An evidence-based unified definition of lifelong and acquired premature ejaculation: report of the second international society for sexual medicine ad hoc committee for the definition of premature ejaculation. Sexual medicine. 2014;2: 41-59. [3] Waldinger MD, Berendsen HH, Blok BF, Olivier B, Holstege G. Premature ejaculation and serotonergic antidepressants-induced delayed ejaculation: the involvement of the serotonergic system. Behavioural brain research. 1998;92: 111-8. [4] Corona G, Mannucci E, Jannini EA, et al. Hypoprolactinemia: a new clinical syndrome in patients with sexual dysfunction. The journal of sexual medicine. 2009;6: 1457-66. [5] Carani C, Isidori AM, Granata A, et al. Multicenter study on the prevalence of sexual symptoms in male hypo- and hyperthyroid patients. The Journal of clinical endocrinology and metabolism. 2005;90: 6472-9. [6] Lee JH, Lee SW. Relationship between premature ejaculation and chronic prostatitis/chronic pelvic pain syndrome. The journal of sexual medicine. 2015;12: 697-704. [7] Castiglione F, Albersen M, Hedlund P, Gratzke C, Salonia A, Giuliano F. Current Pharmacological Management of Premature Ejaculation: A Systematic Review and Meta-analysis. European urology. 2016;69: 904-16.

35 SP-12 BÜTÜNCÜL PSİKOTERAPİ BAĞLAMINDA CİNSEL DİSFONKSİYONLARIN DEĞERLENDİRİLMESİ Tahir Özakkaş

Bu sunumda, cinsel bozuklukların bütüncül psikoterapi bağlamında nasıl değerlendirildiği, vakaların nasıl ele alındığıyla ilgili bilgiler verilmektedir. Bütüncül psikoterapi yaklaşımıyla ilgili kısaca bilgi verildikten sonra cinsel bozuklukların bu bağlamda nasıl ele alındığına değinilecektir. Cinsel işlev bozuklukları, estetik kaygılar, cinsel kimlik bozuklukları ve/veya benzer kaygılarla terapiye başvuran kişilerin bütüncül bir yaklaşımla ele alınıp psikodinamik yapılarının incelenmesi çok büyük bir önem arz etmektedir. Semptomla sebep arasındaki ilişki, kişilik dinamikleri, ilişki dinamikleri, zihinsel mekanizma, davranışsal öğrenmeler gibi faktörlerin ayrı ayrı veya birlikte cinsel semptomlar üzerindeki etkisine ve bu faktörlerin tedavi sürecinde değerlendirmeye alınmasının önemine değinilmiştir. Çeşitli vaka örnekleriyle cinsel bozuk- luk ve psikodinamik nedensellik arasındaki ilişki değerlendirilmiştir. Anahtar Kelimeler: Cinsel disfonksiyon, bütüncül psikoterapi, narsisistik kişilik bozukluğu. Bütüncül psikoterapi ne demektir? Bütüncül psikoterapiler son yıllarda muhtelif terapi tekniklerinin bir araya getiril- erek gerçekten geçerliliği, güvenilirliği olan terapi ekollerinin birleştirilmesine yönelik olarak yapılan çalışmaları içerir. Bütüncül psikoterapiler, dört temel grup altında incelenir: Eklektik terapiler, entegratif terapiler, ortak faktörlere dayalı terapiler ve asimilatif terapiler. Türkiye’de bütüncül terapi olarak kendi kültürel değer yargılarımıza uygun ve muhtelif terapi ekollerinin birlikte dizayn edildiği bir terapi anlayışı gelişmektedir ve bunun organik yapılarla psikolojik yapılar arasındaki ilişkisine bakılmaktadır. Bütüncül psikoterapi, organik ve psişik elementlere birlikte bakar; bedensel somatik belirtiler, beyin işlev bozuklukları, beyin tümörlerinden metabolik hastalıklara kadar psişik yapımızı etkileyecek her türlü fenomene bakılır; diğer taraftan da psişik yapımızın oluşturduğu, psişik yetilerimizin oluşturduğu beyin fonksiyon- ları değerlendirilir. Psişik elementleri, davranışçı öğrenme ilkelerine bağlı patolojiler, bilişsel öğrenme ilkelerine bağlı patolojiler, dinamik öğrenme ilkelerine bağlı patolojiler ve varoluşsal öğrenme ilkelerine bağlı patolojiler olarak grup- landırabiliriz. Dünyadaki bütün psikoterapiler incelediğinde bu dört alt kümeye indirgenebilir. Ama her birinin altında onlarca terapi ekolü, yaklaşım tarzı ve tekniği mevcuttur. Bütüncül psikoterapi bireyi, bütüncül olarak değerlendirir; davranışsal, bilişsel, dinamik ve varoluşsal yapılardan oluşan bir bütün olarak görür. Semptom ve sebep arasındaki ilişki nedir? Bu noktada jinekologlarla, ürologlarla veyahut da estetik cerrahlarla psiki- yatristler arasında fikir ayrılıkları olabilir. “Fikirlerin farklılığından hakikat çıkar.” demiştir Namık Kemal. Biz de böyle bir fikirler tartışmasından hakikate ulaşmaya çalışalım. Psişik semptom, altta yatan patolojiyi aşikar kılan şeydir. Doktora başvurulan her türlü fiziksel ve ruhsal hastalığın, semptomun arkasında psişik bir nedensellik vardır. Eğer sadece semp- tom tedavi edilmeye çalışılırsa sadece bir sivrisinek öldürülmüş olur. Sivrisineğin arkasındaki bataklık asla kurutulamaz. Bu nedenle hekimlerin, bataklık ve sivrisinek arasındaki ilişkiyi çok iyi bilmesi gerekir. Her türlü organik ve psişik tablo bir semptom olabilir. Basit bir ağrıdan söz edecek olursak bu ağrının gerçek nedeni vardır. 100 üzerinden ağrıyı şidde- tlendirecek ve değerlendirecek olursak ağrının yüzde 20’si gerçekten organik nedenselliğe bağlı bir ağrıyken; yüzde 80’i psişik bir faktörün üzerine ilave edilmesiyle ortaya çıkan bir ağrı olabilir. Bunun haricinde cinsel organlarla ilgili estetik kaygılar, vücutla, göğüsle veya elmacık kemikleriyle ilgili estetik kaygıların hepsi psişik birer nedensellik taşıyan bir hikây- eye bağlı olabilir. Cinsellikle ilgili tüm semptomlar psişik patolojilerin yüzeysel görünümleri olabilir. Dolayısıyla yüzeysel görünümlerde erken boşalma, sertleşme bozukluğu, disparonaya veyahut da cinsel yönelimle ilgili çeşitli sıkıntıları olan bireylerin arka planlarında ruhsal yapılarıyla ilgili ciddi problemler olabileceği, psikolojik rahatsızlıklar olabileceği, psi- kiyatrik rahatsızlıkların ötesinde psişik gelişimimizle ilintili birtakım içsel çatışmaların görünür hale geldiği tablo olarak değerlendirilebilir. Bu sebeple her semptomun arkasında davranışsal öğrenmelerin, bilişsel çarpıtmaların, dinamik ned- enselliğe bağlı ki bunlara preödipal ve ödipal dönemle ilgili patolojiler denir ve/veya varoluşsal kaygılarla ilgili birtakım ögelerin olup olmadığının derinliğine anlaşılması ve kavranması gerekir. Psikiyatri ve psikoterapide cinsellikle ilgili semptomlar üç temel kategoride sınıflandırılmıştır. Bunları, cinsel işlev bo- zuklukları, parafililer ve cinsel kimlik bozuklukları olarak üç grup altında değerlendirebiliriz. Hastada görülen her bir semptomun arkasında psişik nedenselliğin anlaşılması ve kavranması gerekir. Sunacağım vaka örneğinde kadın bir hasta

36 labia majörlerindeki irilik nedeniyle kendisini kötü ve değersiz hissettiğini, bununla ilgili estetik bir cerraha gidip labia majörlerini küçülteceğine dair bir talebi olduğunu ifade etmişti. Psikodinamik nedeneselliği incelendiğinde aslında ko- casının ona olan sevgisinin azalma ihtimali karşısında bir estetik cerraha giderek labia majörlerini küçültmekle ilgili bir operasyon geçirmek istediği ortaya çıkmıştı. Eşiyle yapılan görüşmede ise hikâyenin bir başka görünümü olduğu an- laşılmıştı. 35 – 40 yaşlarında olan eşinin karısına bir kusur arayarak eşini artık istemediğini belirtmesi sonucu hastanın estetik kaygılarının arttığı, bu kaygıların aslında eşinin ona olan sevgisinin azalması şeklinde arka plandaki bir dinamiğe bağlı olabileceği görülmüştü. Dolayısıyla bir hastanın estetik kaygılarla ilgili getirdiği semptomların arkasında birden fazla dinamik faktör olabileceği göz önünde bulundurulmalı ve cerrahi bir müdahale uygulanmadan önce mutlaka psikoterapötik ve psikiyatrik bir gö- zlemin dikkate alınması gerekir. Penis boyu, göğüs büyüklüğü, vajinal yapı gibi çoğu estetik kaygıların her birinde kişinin kendilik algısının ve zihinsel yapısının çok iyi değerlendirilmesi gerekemektedir. İnsanların estetik kaygıları nedeniyle birtakım operasyonlara hakları olmasına rağmen herhangi bir estetik operasyon yapılmadan önce dinamik nedenselliğe bağlı bir rahatsızlık olup olmadığı değerlendirilmelidir. Defalarca estetik operasyon geçirip en nihayetinde psikiyatriste gelen veya psikoterapi sürecine gelen çok fazla vaka görülmektedir. Bireyin zihin yapısı düzenlenmediği sürece estetik cerrahi operasyonların yapılması estetik kaygılarını gidermekte çözüm olmamaktadır. Dolayısıyla semptomların her birinin arkasında davranışsal öğrenme ilkeleri, bilişsel çarpıtmalar, dinamik nedensellik ve varoluşsal etmenler olabilir ve/veya bu ögeler belirli oranlarda birlikte etki gösteriyor olabilir. Bu nedenle tüm ögelerin değerlendirmeye alınması gerekir. Bir başka vaka örneğinde, cinsel uyarılma eksikliği olan bir erkek hasta, eşiyle cinsel uyarılma olmadığını fakat üç dört yaşlarındaki üvey kızını yatağa aldığında ve o çocuğu bir eliyle okşadığında sertleşme, sertleşmeyi muhafaza etme ve tatmin edici bir cinsel uyarılma yaşayabildiğini ifade etmiştir. Durumsal pozisyonlarda bazı psikodinamik nedenselliklere bağlı olarak uyarılmalarda azlık veya fazlalık olabilir ya da tiksinti meydana gelebilir. Bunun nedenselliğinin detaylı bir şekilde incelenmesi ve ayrı bir psikoterapötik konu olarak değerlendirilmesi gerekebilir. Otto Kernberg, çağımızda yaşayan efsane olarak adlandırılan bir psikanalitik psikoterapisttir. Aktarım odaklı terapinin kurucusudur. Narsisistik kişilik bozukluğunun ilk belirtisi erken boşalmadır. Dolayısıyla cinsel işlev bozukluğu açısından hastalara sorduğunuzda narsisistik kişilik bozukluğuna tanı koyabilmek için cinsel işlev bozukluğunun olup olmadığını derinliğine araştırmanız ve değerlendirmeniz gerekir. Ancak günlük uygulamalarda penis başına uyuşturucu ilaçların verildiğini veya birtakım yatıştırıcı müdahalelerin uygulandığını görüyoruz ya da davranışçı öğrenme ilkeleriyle “dur – çek” tekniği uyguluyoruz. Oysa ki denetimsiz boşalmanın arka planında, narsisistik kabarmanın, bunun ani bir şekilde kişiyi olumsuz etkilemesiyle ilgili birçok psikolojik nedensellik bulunmaktadır. Bu nedenselliklerin her birinin ayrı ayrı incelenmesi gerekir. Bir metaforla açıklamak gerekirse bir telefon santralinin kablolarında bir arıza olmasına bakmadan telefonun hattını tamir etmeye çalışmaya benzetebiliriz. Kaynaktaki problem çözüldüğünde yani zihinsel mekanizma- larda düzelme sağlandığında kişi kendi kontrolü dahilinde istediği zaman, istediği gibi düzenleyebildiği bir ilişki yaşaya- bilecektir. Bunun adı psikoterapidir. Cinsel ağrı bozukluğu, parafililerin her biri çok ciddi manada üzerinde durulması gereken bozukluklardır. Bir başka vaka örneğinde genç bir erkek hasta aşağılandığını veya tehdit edildiğini hissettiğinde akşam vakitleri ara sokaklara gittiğini ve yalnız olan hanımlara yaklaşarak onlara sürtündüğünü ve göğüslerini ellediğini söylemişti. Kadınlar korku ve panik hissiyle çığlık attığında sertleşme oluyordu ve hasta, kendisini ancak bu şekilde güçlü hissediyordu. Bu vakaları, küfürler ederek bir ilişki içerisine giren kişinin kendi aşağılanmışlık duygusu üzerinden ifade edip kontrol etmeye çalışan psişik bir yapıda olduğunu değerlendirebilmeliyiz. Sonuç olarak tüm cinsel bozuklukların, davranışsal, bilişsel, dinamik ve varoluşsal yaklaşımlar açısından değerlendi- rilerek bütüncül bir bağlamda ele alınması, herhangi bir cerrahi veya davranışsal bir müdahaleden önce psişik ned- enselliğin derinliğine araştırılması ve tedavi planının bu değerlendirmeye göre yapılandırılmasının önemli olduğu düşünülmektedir. Kaynaklar American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Pub. Kernberg, O. F. (1992). Aggression in personality disorders and perversions. Yale University Press. Kernberg, O. F. (1993). Severe personality disorders: Psychotherapeutic strategies. Yale University Press.

37 ORAL PRESENTATIONS

38 OP-01 The effect of pregnancy on urinary incontinence: A prospective study

Ahmet Beyazıt1, Ali Ulvi Hakverdi2, Kerem Han Gözükara3 1Obstetric and Gynecology Department, Hatay State Hospital, Hatay, Turkey 2Obstetric and Gynecology Department, Mustafa Kemal University Hospital, Hatay, Turkey 3Urology Department, Mustafa Kemal University Hospital, Hatay, Turkey

BACKGROUND and AIM: Urinary incontinence is a condition that causes social, medical or hygienic problems. The increase in the incidence of stress incontinence, particularly with increasing parity; shows that pregnancy plays a role in the etiology of incontinence and other urinary symptoms. The aim of this study is to investigate the effect of pregnancy on urinary incontinence and other urinary symptoms with the guidance of patient history and urodynamic data.

MATERIALS-METHODS: The study was conducted at Mustafa Kemal University, Medical Faculty, Obstetrics, and Gynecology Department. Primigravid 72 pregnant women without any urinary problems were included in the study. Patients with severe chronic disease, neurological disorders, antepartum hemorrhage, multiple pregnancies, age under 18, and also patients with physical and mental disability were excluded. All patients were initially evaluated at the 1th trimester, and finally at the 6th week of the postpartum period. Demographical and obstetric data, including urological complaints and urodynamic findings, were recorded.

RESULTS: There was a significant increase in nocturia, frequency, dysuria, urgency, and stress urinary incontinence complaints in pregnant women. The urge incontinence was not significantly different after pregnancy. In the postpartum urodynamic studies, 9 (%12.5) stress urinary incontinence and 6 (%8.3) detrusor instability was detected. There was no significant difference between cesarean section and vaginal delivery in terms of incontinence.

CONCLUSION: In our study, it was shown that pregnant women who were continent before pregnancy could become incontinent after birth according to urodynamic data. However, long-term studies are needed to determine whether this incontinence is temporary or not. Additionally, according to our results, the cesarean section should notbe recommended so as to prevent incontinence.

Keywords: pregnancy, urinary incontinence, urodynamic study, pelvic anatomy

39 OP-02 Vaginismus Treatment Experiences

Süleyman Eserdağ Hera Vaginismus Treatment, Training and Research Association

PURPOSE: Vaginismus is defined as a recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse. In this study, we aimed to present the demographic information, treatment protocol and results of 482 female patients who were admitted to our clinic which is specializing in sexual dysfunction with the diagnosis of primary vaginismus between 2016 and 2018.

Material-METHOD: Female patients were interviewed alone; 8 questions including demographic information such as age, occupation, education level; 13 questions including questions about marriage; 7 questions about family structure and upbringing; 3 questions about the patient’s previous psychiatric diseases and general phobias; 17 questions about sexual history and previous treatments.Male spouses were asked 7 questions including age, occupation, educational status, number of , personality structure, sexual experience and sexual dysfunction. Vaginismus grade was determined according to Lamont clacification on the gynecological examination table of female patients and it was decided whether there was any anatomic or hymenal problem.

RESULTS: The median age of the female patients was 28, and the median age of their spouses was 29. The mean duration of marriage was 18.2 months and ranged from 4 days to 15 years.65.4% of the patients felt that they would feel pain during sexual intercourse and 23.6% stated that they really felt pain. 74.1% of the patients stated that they were told horror stories about their first night in their close environment in the pre-marital period. 85.7% ofthe patients received only Cognitive Behavioral Therapy (CBT), 5% received CBT after under local anesthesia, 9.3% received CBT after hymenectomy under general anesthesia.

CONCLUSION: According to the results of our study, the fact that false and exaggerated information about sexuality is located in the subconscious of the woman is quite effective in the development of vaginismus. On the other hand, traditional family structure, adolescent traumas, first night stories, superstition about sexuality which we call ‘sexual myths’ are among the important causes of vaginismus.

Keywords: Vaginismus, sexual dysfunction, cognitive behavioral therapy

40 OP-03 The Effects of Vaginal Symptoms and Pelvic Floor Symptoms on Sexual Function

Burcu Sert1, Serap Özgül2 1Hacettepe University, Institute of Health Sciences, Department of Physiotherapy and Rehabilitation, Ankara, Turkey 2Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Physiotherapy and Rehabilitation Unitfor Women&Men Health, Ankara, Turkey

PURPOSE: The aim of this study was to investigate the effects of vaginal and pelvic floor symptoms on sexual frequency and behavioural/emotive, physical and partner-related domains of sexual function in postmenopausal women.

METHODS: Sexually active postmenopausal women were included in this study. Demographic and physical characteristics, vaginal and pelvic floor symptoms and sexual function of subjects were evaluated. As vaginal symptoms, vaginal dryness, soreness, irritation and itching symptoms were questioned. As pelvic floor symptoms, urinary incontinence, fecal incontinence, voiding difficulty, pelvic organ prolapse, chronic constipation and chronic pelvic pain were questioned. Symptoms were recorded as “present / absent”. The subjects were then grouped as “women with at least one of the vaginal symptoms” and “women with no vaginal symptoms”, “women with at least one of the pelvic floor symptoms” and “women with no pelvic floor symptoms”. Sexual function was assessed by “The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12)”. In addition, the frequency of sexual intercourse within one month was asked. In the analysis of the comparison of sexual function scores of groups (with and without vaginal symptoms or with and without pelvic floor symptoms) “Independent Samples T Test” was used when parametric assumptions were provided; and “Mann-Whitney U Test” was used when parametric assumptions were not provided. Statistical significance was set at p <0.05.

RESULTS: A total of 103 women with a mean age of 56.9 ± 6.97 years (min-max: 40-79 years) were included in the study. The mean body mass index was calculated as 27.78 ± 4.56 kg/m². A statistically significant difference was found in sexual frequency (p=0.024), total sexual function score and emotional and physical domains of sexual function (p<0.001) between women with (n=67) and without vaginal symptoms (n=36). However, there was no statistically significant difference in the partner-related domain(p>0.05). On the other hand, a statistically significant difference was found in sexual frequency (p=0.01) and all domains of sexual function between women with (n=51) and without pelvic floor symptoms (n=52) (total score, behavioural/emotive and physical domains p<0.001, partner-related domain p=0.032). It was found that both sexual frequency and sexual function scores were lower in groups with vaginal or pelvic floor symptoms.

CONCLUSION: The results of this study show that both vaginal and pelvic floor symptoms negatively affect sexual function. In this respect, prevention and treatment of vaginal symptoms and pelvic floor symptoms are important in the management of sexual dysfunction. Further studies are needed to examine the effectiveness of different approaches, including conservative approaches such as physiotherapy, in the first step.

Keywords: vaginal symptoms, pelvic floor, pelvic floor symptoms, sexual function, sexual dysfunction

41 OP-04 She was diagnosed as vaginismus in a family with one child. A case report

Duygu Ayhan Üsküdar University, İstanbul, Turkey

Women sexuality is a multi factored situation with anatomy, physiology, medical and social factors being it’s components. Vaginismus is a sexuality disorder where the muscles of vagina contracts and hinders the sexual intercourse disregarding the desire of the couple for the act. Women with vaginismus sometimes express this situation as a repulsion from intercourse, fear and pain dysfunction. Some writers define it as an “incomplete marriage”. Many factors come together to bring out vaginismus as a problem. It is known that negative parent acts and bad parenting are few of the factors of the reasons. T.A. who is brought up as the only child has been diagnosed with vaginismus and requested consultancy from our centre and the sexual therapy case was approached with a cognitive behaviorist treatment.

Keywords: Keywords: vaginismus, sexual dysfunction, sexual therapy

42 OP-05 The effect of TVT (Tension-free vaginal tape) operation on female sexual function in surgical treatment of stress urinary incontinence

Burak Elmas Etlik Zubeyde Hanım Women’s Health Education and Research Hospital, Ankara, Turkey

BACKGROUND: Urinary incontinence may be associated with sexual dysfunction. Operation can also change sexual functions in patients treated for stress urinary incontinence. The aim of this study was to evaluate the effect of TVT operation on female sexual function in the treatment of stress urinary incontinence.

METHODS: A total of 96 sexually active women who underwent TVT for stress urinary incontinence were included in the study. Demographic characteristics, preoperative, intraoperative and postoperative characteristics of the patients were also recorded. Pelvic organ prolapse / urinary incontinence sexual function questionnaire form-12 (PISQ-12) was administered to patients in order to evaluate sexual function preoperatively and at 6 months postoperatively and the results were recorded.

RESULTS: Total Urogenital distress inventory-6 scores (UDI-6), which were used to evaluate the quality of life at preoperative and postoperative 6th month, showed significant improvements (p <0.05). PISQ-12, which evaluated preoperative and postoperative sexual functions, also showed significant improvements (p <0.05).

CONCLUSIONS: Although there are controversial results in the studies, TVT operation applied to stress urinary incontinence patients has positive effects on quality of life and sexual function in general.

Keywords: urinary incontinence, sexual function, TVT

43 OP-06 Vaginal Rejuvenation and PRP

Tijen Ataçağ Department of Obstetrics and Gynecology, Dr Suat Gunsel Kyrenia University, Kyrenia, Cyprus

Physiological changes in a woman’s life, such as childbirth, weight fluctuations and hormonal changes due to aging and menopause, can lead to various conditions that may have a negative effect on a woman’s quality of life, self-confidence and sexuality. As happens everywhere else in the human body, tissues ageing occurs in the female intimate area including the entire vaginal canal.

Vaginal rejuvenation was introduced into the medical literature in 2007. Vaginal rejuvenation are the procedures performed to alter, enhance the intimate area appearance and to repair the relaxed vulvar-vaginal wall and to rejuvenate the vaginal tissues. The patients need to improve their quality of life.

1 out 3 women over the age of 45, 1out 2 women over the age of 65 will have a pelvic health concern within their lifetime.

There are certain treatment options for vaginal rejuvenation.

PRP has been used clinically for tissue regeneration, reconstructive and plastic operations, and surgery, including wound hemostasis, wound sealing, augmentation of bone grafts periodontics and treatment of tendonitis. PRP can be considered as an effective therapy in vaginal rejuvenation.

Keywords: PRP, vaginal rejuvenation, self-confidence

44 OP-07 Male Factor in Vaginismus

Didem Kurban Hera Vaginismus Treatment, Training and Research Association

Vaginismus is defined as a recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse. Normally the vaginal muscles are under the woman’s control but during sexual intercourse before the penis enter the vagina, these muscles are strongly contracted, this situation makes intercourse almost impossible. Often these symptoms are accompanied by avoidance of sexual intercourse Erectile dysfunction is a challenge to provide adequate erection to initiate or maintain any sexual activity. Itisin the first place among men who have sexual problems. The causes of erectile dysfunction are classified as organic and psychogenic, and psychogenic causes are classified as developmental, interactive, non-psychiatric and psychiatric reasons. Among the developmental causes, we can say that the most frequent lack of sexual information, the marriage problems among the interactional causes, and the most frequent performance anxiety among psychiatric reasons. When diagnosing erectile dysfunction, it is necessary to differentiate organic psychogenic. It is known that it is more common in couples with vaginismus than in normal couples.

Although premature ejaculation is a common sexual dysfunction in men, it is often unreported and untreated. Two- thirds of men may experience premature ejaculation at any time in their lives. PE was considered a psychogenic disease in the early twentieth century. Although nowadays the primary PE is mostly thought neuro-biological origin and the subsequent PE is thought to be caused by both medical and psychological reasons, the etiology of both types of PE has not been fully elucidated. Experimental studies and especially in the 1990s, serotonin reuptake inhibitors and clomipramine-administered drug therapy studies have enabled the better understanding of the neuro-biological basis of PE. Also in couples with vaginismus premature ejaculation is more common like erectile dysfunction.

In our study, we aimed to investigate male factor in 482 couples who came to 3 clinics in Istanbul, Ankara and İzmir who were specialized in the treatment of sexual dysfunction between 2015-2018.

While 88.3% of the female patients participated in the treatment with their spouse, 11.7% were individual. 2.5% of women, described the personality of their spouses’ oppressive-conservative ‘, 10.6% ‘ nervous’, 74.7% ‘extreme gentle- patient’, 1.9% as ‘violent’. 82.4% said there was no other problem in their marriage. When asked about 425 male sexual experiences which are the spouses of the female patients; 45,8% stated that they had sexual experience, 38,5% had no sexual experience, 15,7% had very little sexual experience. Of the 111 men (26.1%) who had sexual problems, 4 (0.9%) had primary erectile dysfunction, 22 (5.1%) had secondary erectile dysfunction, and 21 (4.9%) had primary premature ejaculation, 41 (9.6%) secondary premature ejaculation, 2 (0.47%) primary sexual reluctance, 22 (5.1%) secondary sexual reluctance.

In conclusion, it should be noted that the male factor should be examined decently in the spouses of vaginismus patients. It should be known that male sexual dysfunctions are seen more frequently in vaginismic couples than the normal population and the necessary cognitive and medical treatments should be applied.

Keywords: Vaginismus, erectile dysfunction, premature ejaculation

45 OP-08 Adult Buried Penis

Emrah Yakut Departmen of Urology, Memorial Ankara Hospital, Ankara, Turkey

A buried penis is called a penis with a normal corporal structure and normal length to remain hidden in suprapubic fat. Although it is frequently seen in the pediatric age group, it can also be seen in adulthood, especially in relation to obesity. Although the majority of adult patients are obese, the problem remains with weight loss, especially because of the suprapubic pannus. Post-circumcision scar contraction, massive scrotal lymphedema, balanitis xerotic obliterans and lichen sclerosis are other causes of adult acquired burial penis. Both physical (sexual dysfunction, voiding difficulty, skin irritation, urinary tract infection, etc.) and psychological problems were detected in adult buried penis cases. Although a large number of surgical techniques have been described in the treatment of adult buried penis for different etiologic conditions, there is no generally accepted standard approach for buried penis treatment. In this study, we have reviewed adult burial penis in a 31 years old male patient.

CASE: A 31-year-old male patient was admitted to our hospital with complaints of voiding, pain during erection, and inability to have sexual intercourse. The patient had undergone obesity surgery 6 months ago. Physical examination revealed a 0.5 cm opening which was thought to be due to scar contraction after circumcision, but the penis could not be reached. The patient was explored. The case was entered as a plastic surgery and urology team. The scar was opened and the penis was released and removed. However, because there was not enough skin, it was repaired with full-thickness skin graft. The patient was discharged without any problem. The adult buried penis is caused by two main problems; suprapubic lubrication and scar formation. In men who gain weight, the suprapubic region is one of the priority areas for fat accumulation. Moreover, with fat loss, the fat usually persists. Therefore, obesity is one of the most common causes of adult buried penis and aggravates the existing pathology. Diabetes mellitus also increases infections in the deformed hygienic genital area and scar formation. Past operative or idiopathic genital lymphedema, trauma, genital elephantiasis and lichen sclerosis due to filariasis are other etiologic factors in adult pathophysiology of the embedded penis. Westerman et al. Performed a ventral incision (VSSF) operation with a scrotal skin flap of their own defined lichen sclerosis with 87% (13/15) of biopsy-proven lichen sclerosis and achieved approximately 75% success. Although they included obese patients, they excluded those with suprapubic adiposity that contributed to the buried penis. Ghanem et al., 60% (6/10) obese patients, because of the embedded penis only applied their own liposuction techniques and suggested that they provide penis enlargement similar to falloplasty. Adham et al. Recommended the fixation of the herniated skin and penopubic junction to the rectus sheath after liposuction and abdominoplasty. As a result; Adult buried penis is a rare but sociocultural pathology with very severe consequences. Although treatment options are variable, success rates are high and complication rates are relatively low.

Keywords: Buried penis, sexual dysfunction, reconstructive surgery

46 Adult buried penis After Surgery

Adult buried penis SURGERY

47 OP-09 A new practical surgical technique for Hymenoplasty. Primary repair of hymen with vestibulo-introital tightening

Suleyman Eserdag1, Didem Kurban1, Mine Kiseli2 1Department of Gynecology, Hera Klinik, İstanbul, Turkey 2Department of Obstetrics and Gynecology, Ufuk University, Ankara, Turkey

PURPOSE: Hymenoplasty in genital cosmetic surgery has a distinct location in clinical practice, with its ethical and psychological issues. It is performed in order to narrow the vaginal opening to ensure vaginal bleeding with a penetration. There are various kinds of techniques with different success rates.

MATERIALS-METHODS: We report a new hymenal reconstruction technique with vestibulo-introital tightening with the results of 145 procedures. The new technique includes diamond shaped incision to the vestibulum with the base in the posterior midline and superior corner 2-3 cm higher above the hymen. The angles are accommodated according to the degree of tightening and the submucosal layer is closed from the apex downwards involving the vaginal mucosa.

RESULTS: The procedure has satisfaction rate of 99.3 % in 143 patients in whom we could get feedback. There were no intraopertaive complications related to the surgical procedure nor any infection postoperatively.

CONCLUSION: Compared with previous techniques described, this hymenal reconstruction technique is an alternative with the advantage of low risk of loosening because the tension on hymen alone is decreased. Additional tightening of the introitus increase the satisfaction rates in some of the patients.

Keywords: Hymenoplasty; revirgination; vestibular tightening.

Figure 1

Hymenoplasty technique: Dissection pf posterior vaginal wall; approximation of hymenal caruncles; vestibular tightening sutures; final vision of the hymen

48 OP-10 Assessing the patients with premature ejaculation in terms of etiology, laboratory results and treatment options: Single center experience

Selçuk Sarıkaya Gulhane Research and Training Hospital, Department of Urology, Ankara, Turkey

INTRODUCTION: Although premature ejaculation is a common sexual dysfunction in men due to shortness of time for intravaginal ejaculation, it is often not expressed and remains untreated.

MATERIALS AND METHODS: The data of the patients admitted to the Urology Outpatient Clinic of Gulhane Training and Research Hospital between January 2019 and November 2019 and diagnosed as premature ejaculation were evaluated. Age, premature ejaculation type, hormonal parameters, fasting blood glucose, cholesterol levels, hemogram parameters, urea and creatinine levels were analyzed. Also comorbidities and treatment options were examined.

RESULTS: 116 patients diagnosed as premature ejaculation were included in the study. The mean age of the patients was 36.7 years. While 41 patients had lifelong premature ejaculation, 75 patients had acquired type of premature ejaculation. Mean FSH levels of patients were 6.34 mIU / mL, mean LH level was 3.29 mIU / mL, mean total testosterone level was 3.79 ng / mL, mean free testosterone level was 12.38 pg / mL, and mean estradiol level was 30.42 pg. / mL, average prolactin level was 8.81 ng / mL, average total testosterone level was 3.79 ng / mL, average fasting blood glucose level was 90 mg / dL, average total cholesterol level was 187.6 mg / dL, triglyceride level was 146.2 mg / dL, LDL cholesterol level was 97 mg / dL, HDL cholesterol level was 45.4 mg / dL, WBC level was 7.42, Plt level was 245.5, Hgb level was 15.3 g / dL, neutrophil level was 4.29, lymphocyte level was 2.25, monocyte level was 0.66, eosinophil level was 0.16, mean urea level was 30.8 mg / dL and mean creatinine level was 0.96 mg / dL(Table), 9 patients had concomitant erectile dysfunction, 1 patient had leukemia, 2 patients had depression and anxiety, there was reflex neuropathic bladder in 1 patient and 4 patients had benign prostatic hyperplasia. Infertility was present in 2 patients. Urinary incontinence and pituitary disorder was present in 1 patient. Sertraline was prescribed in 9 patients, paroxetine for 5 patients and dapoxetine and local anesthetic agents were preferred in 102 patients.

RESULT: Premature ejaculation is a common sexual problem in the male population and needs to be treated. If left untreated, it affects sexual health negatively. In the treatment, especially accompanying diseases and background biochemical abnormalities should be taken into consideration.

Keywords: premature, ejaculation, male, sexual, dysfunction

49 Table: Outcomes of patients with premature ejaculation

Number of patients(n) Mean values

Lifelong PE 41 35,30% Acquired PE 75 64,70% Age 116 36,7 years FSH 72 6,34 mIU/mL LH 67 3,29 mIU/mL Total testosterone 72 3,79 ng/mL Free testosterone 44 12,38 pg/mL Estradiol 52 30,42 pg/mL Prolactin 64 8,81 ng/mL Glucose 45 90mg/dL Total cholesterol 39 187,6 mg/dL Triglyceride 41 146,2 mg/dL LDL cholesterol 40 97 mg/dL HDL cholesterol 40 45,4 mg/dL WBC 44 7,42 PLT 44 245,5 HGB 44 15,3 g/dL Neutrophyl 44 4,29 Lymphocyte 44 2,25 Monocyte 44 0,66 Eosinophyl 44 0,16 Urea 35 30,8 mg/dL Creatinine 35 0,96 mg/dL

Neutrophyl/Lymphocyte 44 1,9

Neutrophyl/Monocyte 44 6,5 Neutrophyl/Eosinophyl 44 26,8

50 OP-11 menopause and sexual life

Yasemin Alan Menopause and Sexual Life

World Health Organization defines menopause as the end of menstruation due to loss of ovarian activity. Although the age of menopause varies according to societies and individuals, it is generally seen between the ages of 45 and 55. Menopause, the permanent termination of menstruation by loss of ovarian activity, is an important point in the climacterium period. Menopause is a period in which changes in sexuality have psychological and physical effects as well as physical and anatomical effects. It is a fact that an individual in menopause experiences shame, distress, frustration, stress, or anger. Since all of these symptoms directly or indirectly affect sexual intercourse, menopause needs to be examined extensively for the well-being of couples. Happy life and happy relationship; psychological, physical, emotional satisfaction and sexual desire. Due to the changes in hormone levels that occur during menopause, sexual dysfunction causes many problems that may lead to drug treatments such as antidepressants. In menopausal period, there is an increase in some diseases that may affect female sexual function and prepare the ground for dysfunction (chronic diseases, endocrine, diabetes, renal, hepatic, malignancies and the problems that may develop after the drugs used). In the menopausal period, some sexual identity changes may occur in women. Sensitivity in the breast and genital area decreases due to changes in the breast and genital system due to the increase in some hormones and decreases in some hormones. Vaginal dryness occurs as a result of atrophy of the vaginal mucosa due to the decrease in estrogen level. Sensory loss can occur in sensory organs such as smell, taste and touch. During the transition to the menopausal period and aging process, physical and psychological changes may cause sexual dysfunction. Increased pituitary FSH and therefore atrophy in the vaginal epithelium due to estrogen deficiency and dryness directly affect sexual intercourse. Both individuals may experience discomfort from sexual intercourse due to these problems. With sexual aging, blood flow and secretion decrease in the vagina and and sexual arousal and intercourse frequency decrease. Couples with regular sex life before and after menopause are less likely to suffer from menopause and decrease in relationship quality.

Keywords: Estrogen, menopause, sexuel life, vagina

51 OP-12 Presentation of 2 cases with a rare disease; Penile Mondor’s Disease, thrombophlebitis of penile superficial dorsal vein

Can Sicimli, Senan Asgerli, Selçuk Sarıkaya Health Science University Gülhane Training and Researh Hospital

INTRODUCTION: Penile Mondor’s disease is the condition of the thrombophlebitis of superficial dorsal vein of penis. The disease is commonly seen in chest wall and brest superficial veins. It is rarely seen in other parts of body. In this case report, a rare case of penile mondor’s disease was mentioned.

CASES: The first case is a 26-year-old male patient who admitted to our clinic with pain on the dorsal part of the penis. It was learned that his complains started 1 week before and after sexual intercourse. There was no any illness or operation in the history of the patient. There was no pathology except his father’s hodgkin lenfoma in his family history. Physical examination revealed superficial vascular structures in the dorsal surface of the penis (Figure a) No pathology was found in the skin. No pathology was found caused by penile traumatization. Abdominal ultrasonography showed no specific pathology other than gr 1 hepatosteatosis in liver. Doopler ultrasonography examination showed trombosis in dorsal vein of penis. Penile mondor’s disease was considered and acetylsalicylic acid 300 miligrams and chondroitin polysulfate-containing pomade were prescribed as superficial thrombophlebitis treatment.And patient was included follow-up program. The Second case is a 54 -year-old male patient that admitted to our outpatient clinic with the complaints of stiffness in coronal sulcus of glans penis and difficulty during the sexual intercourse. The physical examination verified the stiffness (Figure b-c-d)and afterwards the color doppler ultrasonography revealed findings compatible with Penile Mondor’s Disease. We prescribed the same medications with the firs case and the patient was included in the follow-up program.

CONCLUSION: As with this presentation, Mondor’s disease can rarely be seen in the penile dorsal superficial vein. It can be detected idiopathically and caused by;enteroviral infections, contact with menstrual blood (because of irritant effect), tuberculosis, scar tissue formed due to circumcision, excessive sexual activity (sexual intercourse or masturbation), traumas during sexual intercourse, surgical applications of pelvic or external genital system, and intra- pelvic tumors. Conservative treatment can be selected and medical treatment can be applied. Surgical treatment should be selected in case of medical treatment resistant cases. We have tried to summarize the penile mondor’s disease which responds to medical

Keywords: mondor, penis, pain,thrombophlebitis

Physical examinations of patients

52 OP-13 Evaluation of the most common reasons for women having vaginal tightening and perinoplasty operations

Cansu Kanlıoğlu Bulancak State Hospital, Giresun, Turkey

INTRODUCTION: Vagina tightening and perinoplasty operations are considered within genital aesthetics and cosmetic gynecology. Vaginal tightening operations are generally performed to restore enlarged and sagged vagina. These surgical procedures are commonly performed today for many reasons. We aimed to determine the various reasons of surgery for patients who wanted to have vaginal tightening and perinoplasty surgery and the demographic features of these patients.

MATERIALS-METHODS: Sixty patients who applied to Bulancak State Hospital gynecology polyclinics between 1 May- 2018 and 1 November 2019 were evaluated in the study.The common reasons of vaginal tightening and perinoplasty surgery were about cosmetic factors and functional reasons (Table). Patients were allowed to choose multiple reasons if they want.

RESULTS: A total of 60 patients were included in the study. The avarage age of total patients was 34.5 years. All patients were selected from at least one delivery. Seven of them were graduates of primary education, 14 of them secondary, 27 of them high school graduates and 12 of them university graduates. When we evaluate the table results, we saw the most common reason was the unpleasure and feeling anything during the sexual intercourse with the rate of %70. The rarest reason was the thought that her partner would humiliate her during sexual intercorse. All the patients were given survey to evaluate their life quality after surgery and all results were positive. After these operations, positive results were obtained in terms of sexual functions and cosmetic results in women

CONCLUSION: In our study we obtain that vaginal tightening and perinoplasty surgery were both preferred by educated and uneducated women. According to our study the most common reason of these operations were being unsatisfied during sexual intercourse and the second common reason was the bad appearance of external genitalia. Vaginal tightening and perinoplasty provide positive results and can be applied to appropriate patients for functional and cosmetic reasons.

Keywords: cosmetic factors, functional reasons, perinoplasty, vaginal tightening

53 Table

Number and Number Reasons for surgery rates 1. I get infections frequently 18 (%30) 2. I feel uncomfortable with my stitch marks which occured after my birth. 21 (%35) I dont like the appearance of my vagina since ı can see the inner part of it from the 3. 36 (%60) outside 4. I dont feel anything during sexual intercourse 42 (%70) 5. I cant have an orgasm during sexual intercourse and ı want to have 27 (%45) 6. I hear sound like gas out of the vagina during sexual intercourse 18 (%30) 7. I have urinary incontinence during sex, laughing, coughing and when ı carry heavily 25 (%41,6) 8. My partner isnt satisfied during sex and he says he doesnt feel anything 16 (%26,6) 9. My partner wants me to have surgery 12 (%20) 10. I am ashamed of my partner 30 (%50) My partner wants to divorce me or thinking of cheating so ı want to have surgery to 11. 7 (%11,6) save my marriage 12. My partner humiliates me during sexual intercourse 5 (%8,3)

Reasons for surgery

54 OP-14 Evaluation of the most common reasons for women having vaginal tightening and perinoplasty operations

Cansu Kanlıoğlu Bulancak State Hospital, Giresun, Turkey

INTRODUCTION: Vagina tightening and perinoplasty operations are considered within genital aesthetics and cosmetic gynecology. Vaginal tightening operations are generally performed to restore enlarged and sagged vagina. These surgical procedures are commonly performed today for many reasons. We aimed to determine the various reasons of surgery for patients who wanted to have vaginal tightening and perinoplasty surgery and the demographic features of these patients.

MATERIALS-METHODS: Sixty patients who applied to Bulancak State Hospital gynecology polyclinics between 1 May- 2018 and 1 November 2019 were evaluated in the study.The common reasons of vaginal tightening and perinoplasty surgery were about cosmetic factors and functional reasons (Table). Patients were allowed to choose multiple reasons if they want.

RESULTS: A total of 60 patients were included in the study. The avarage age of total patients was 34.5 years. All patients were selected from at least one delivery. Seven of them were graduates of primary education, 14 of them secondary, 27 of them high school graduates and 12 of them university graduates. When we evaluate the table results, we saw the most common reason was the unpleasure and feeling anything during the sexual intercourse with the rate of %42. The rarest reason was the thought that her partner would humiliate her during sexual intercorse. All the patients were given survey to evaluate their life quality after surgery and all results were positive. After these operations, positive results were obtained in terms of sexual functions and cosmetic results in women

CONCLUSION: In our study we obtain that vaginal tightening and perinoplasty surgery were both preferred by educated and uneducated women. According to our study the most common reason of these operations were being unsatisfied during sexual intercourse and the second common reason was the bad appearance of external genitalia. Vaginal tightening and perinoplasty provide positive results and can be applied to appropriate patients for functional and cosmetic reasons.

Keywords: cosmetic factors, functional reasons, perinoplasty, vaginal tightening

Table Number Reasons for surgery Number and rates 1. I get infections frequently 18 (%7,00) 2. I feel uncomfortable with my stitch marks which occured after my birth. 21 (%8.17) I dont like the appearance of my vagina since ı can see the inner part of it from 3. 36 (%14,00) the outside 4. I dont feel anything during sexual intercourse 42 (%16,34) 5. I cant have an orgasm during sexual intercourse and ı want to have 27 (%25,70) 6. I hear sound like gas out of the vagina during sexual intercourse 18 (%7,00) I have urinary incontinence during sex, laughing, coughing and when ı carry he- 7. 25 (%9,72) avily 8. My partner isnt satisfied during sex and he says he doesnt feel anything 16 (%6,22) 9. My partner wants me to have surgery 12 (%4,66) 10. I am ashamed of my partner 30 (%11,67) My partner wants to divorce me or thinking of cheating so ı want to have sur- 11. 7 (%2,72) gery to save my marriage 12. My partner humiliates me during sexual intercourse 5 (%2,72)

55 OP-15 Repair of rectovaginal fistulas due to obstetric traumas with modified Martius flap technique

Sultan Seren Karakus University of Health Sciences, Zeynep Kamil Maternity and Childrens Hospital

OBJECTIVE: Rectovaginal fistulas (RVF) are rare. The most common cause is obstetric trauma. Treatment is based on fistula classification and localization of the fistula. The modified Martius flap technique is a surgical procedure that allows the successfully repair of lower and middle rectovaginal fistulas by interposition of the bulbocavernosus fat tissue flap. We aimed to evaluate the postoperative outcomes of patients who underwent rectovaginal fistula repair with modified Martius flap technique in our clinic.

METHOD: Five patients who were operated for rectovaginal fistula between January 2018 and March 2019 using the modified Martius flap technique were discussed. In all patients, defect were due to obstetric injury and fistula was localized in the lower 1/3 vagina. The degree of rectovaginal fistula was determined according to Fry classification. Three patients were of the second type (perineal defect with fistula in the lower 1/3 of the vagina), two of them were of type 3 (isolated fistula in the lower 1/3 of the vagina). In the surgical procedure, posterior vaginal wall was separated from the rectum. Rectal and vaginal mucosa was repaired separately. In patients with anorectal sphincter involvement, sphincteroplasty was performed. Skin incision lines marked bilaterally (vertical curves of 8 cm with an angle of about 30 degrees in accordance with the natural lateral sulcus of the labium mayors starting from a ventrolateral distance of about 5-6 cm from the perineum). After skin incision, adipose tissue flap created by preserving the vascular pedicle; posterolateral to anteromedial. Bilateral subcutaneous tunnel was prepared under the bulbospongiosus muscle. The flap was transposed to rectovaginal area. Bilateral flap ends were fixed to each other and the upper of the anal sphincter with tension-free sutures and perinoplasty was performed. Postoperative recovery was evaluated at the 1st, 3rd, 6th month visits.

RESULTS: Anal incontinence and genital aesthetic discomfort are the main complaints in fistula cases with perineal defect. In isolated fistula cases the presenting complaint was recurrent vaginitis and malodorous vaginal discharge. The mean operation time was 115 minutes in cases with perineal defect, 75 minutes in isolated cases. In cases with perineal defect, anal incontinence was improved in all 3 patients at the postoperative 1st month control. Genital aesthetic improvement was achieved in 2 patients in the postoperative 3rd month, while one patient developed hard edema in the left removed adipose tissue area. This was completely improved at 6 months. In the postoperative 6th month control, quality of life was expressed as excellent in all 3 patients. Vaginal discharge regressed in the postop 1st month control in the isolated fistula group; the quality of sexual life was reported to have improved at 3th month postoperatively.

CONCLUSION: Martius procedure for RVF repair is a safe method with good cosmetic and functional results. Separation of vaginal and rectal layers provides additional benefits such as creating a distance as perineal body and neovascularization in the rectovaginal area. The results show that patients benefit from a dramatically improved quality of life after repair using the Modified Martius approach.

Keywords: Martius flap, obstetric trauma, rectovaginal fistulas,

56 After surgery

Repair of rectovaginal fistules with modified Martius flap technique

Type 2 rectovaginal fistula (Fry classification)

perineal defect with fistula in the lower 1/3 of the vagina

57 OP-16 The effect of local vaginal estrogen treatment on sexual life in menopause

Murat Alan Department of Obstetrics and Gynecology, Universty of Health Sciences Tepecik Education and Research Hospital, İzmir, Turkey.

The effect of local vaginal estrogen treatment on sexual life in menopauseMenopause is a condition in which the menstrual period ends permanently as a result of loss of activity of . Menopause, which occurs naturally or surgically with the removal of ovaries, is an anatomical, physiological and psychological process with frequent negative effects on female sexuality. During menopause, sexuality is affected by a number of factors ranging from significant reduction in estrogen and androgen secretion to internal and interpersonal factors. After menopause, low estrogen causes anatomical and physiological changes in low urogenital tissues. Anatomical changes; collagen content, decrease in hyalinization and elastin, thinning of epithelium, alteration of function and appearance of smooth muscle cells, increase in density of connective tissue, decrease of blood vessels. Thinning of the labia minor, hymen residues and loss of elasticity often cause dyspareunia. The urethral canal becomes vulnerable to physical irritation and trauma. Physiological changes in the vagina; decrease in blood circulation, adipose tissue, elasticity and elasticity and increase in vaginal pH. Epithelial thinning; lactobacillus loss, increase in pH, vaginal flora and changes in microbiome. In addition, a decrease in vaginal tissue resistance may increase the susceptibility to epithelial damage resulting in post-intercourse vaginal pain, burning, cracking, irritation and bleeding. Decrease in estrogen production leads to vaginal dryness and directly affects sexual function, while flushing and night sweats cause loss of energy in women and thus decrease in libido. Quality of life in menopause is affected by sexual dysfunction rather than the presence of vasomotor symptoms. Sexuality is an essential component of the health status of women of any age. Today, the treatment of vaginal atrophy has become important today. Estrogen has many important effects on vulvovaginal tissue, including blood flow, secretion, increased vaginal epithelial thickness and decreased pH. Estrogen therapy is the gold standard for vulvovaginal atrophy. In the presence of estrogen, vaginal epithelium thickens, elasticity of the artery, blood flow increases and vaginal pH decreases. Apart from the effect on estrogen receptors, estrogen therapy also reduces nociceptive neurons in the vagina, reducing pain and discomfort associated with vulvovaginal atrophy. The use of low-dose vaginal estrogen is effective in relieving the symptoms of vulvovaginal atrophy, while its systemic effects are minimal. Local estrogen therapy is recommended only in postmenopausal women with symptoms of vulvovaginal atrophy. Treatment may require at least 3 months to completely eliminate symptoms. Progestin therapy is not recommended to protect the in women with local estrogen therapy and uterus. However, long-term use is not recommended in women with uterus since there is no data on the use of local estrogen therapy for more than 1 year. Local estrogen therapy leads to improvement in urinary symptoms as well as vaginal atrophy.

Keywords: Menopause,local vaginal estrogen,vulvovaginal atrophy,sexual life

58 OP-17 Determination of Aesthetic Genital Operations According to the Problems Women Encountered

Süleyman Eserdağ, Zeynep Dilşah Karaçam, Burcu Akdağ Özkok, Gökçe Devrim Ader Hera Clinic, İstanbul

AIM: In recent years, the demand for aesthetic genital operations has been increasing. This study was carried out to determine aesthetic genital operations due to the problems encountered by women.

METHOD: Women who underwent aesthetic genital operations (n = 100) between February 2019 and October 2019 in a private clinic are included in this study. The study was carried out retrospectively. Descriptive analysis was used in the evaluation of the data.

RESULTS: The operations in the study are classified as labiaplasty, vaginoplasty and other aesthetic genital operations. The average age of women who underwent operations was 29. The average age of women who underwent labiaplasty (n=38) was 29, their education level was minimum primary school maximum master’ s degree, 29 women were single and 9 women were married. When the problems encountered by women were examined; it was observed that women who did not like the aesthetic appearance of the labia (n=34), who had irritation problems due to rubbing on clothes (n=19) and who had asymmetric complaints (n=10) preferred labiaplasty operation more. The average age of women who underwent vaginoplasty (n=25) was 41, their education level was minimum secondary school maximum master’ s degree, 6 women were single and 19 women were married. It was observed that women who had excessive vaginal sensation (n = 19), noises during intercourse (n = 15), excessive lubrication of the vagina (n = 6) preferred vaginoplasty operation more. The average age of women who underwent other operations (Laser Vaginal Rejuvenation, O Shot, Bleaching of genital area with laser Genital Radiofrequency) (n=37) was 24, their education level was minimum high school maximum master’ s degree, 10 women were single and 27 women were married. It was observed that women who complained of numbness in sexual intercourse (n = 6), anorgasmia (n = 7), or darkening of the genital area (n = 12) preferred combined operation more. Significant relationship was not found between women’s marriage duration and operations. It was observed that women with vaginal deliveries had more vaginoplasty operations than women with C-sections. While there was no significant difference between the ages of women and having a labiaplasty operation, there was a significant difference in vaginoplasty operation (p <0.05).

CONCLUSION: As a result, when the problems encountered by the women included in the study were examined; the aesthetic appearance of the labia, irritation problems, women with asymmetric complaints operation concluded that they preferred labiaplasty operation, while the vagina excessive enlargement, the noises during the relationship, women with vaginal hyperlubrication operation concluded that they preferred vaginoplasty. It was also concluded that women who complained of desensitivity in sexual intercourse, anorgasmia and darkening of the genital area preferred other operations.

Key words: Aesthetic genital operations, labiaplasty, laser vaginal rejuvenation, vaginoplasty

59 OP-18 Genital Hyaluronic Acid Application to Overcome Dyspareunia Problem in Vulvar Vestibulitis Syndrome

Süleyman Eserdağ1, Burcu Akdağ Özkök1, Didem Kurban2, Zeynep Dilşah Karaçam1 1Hera Clinic, İstanbul 2Hera Clinic, Ankara

AIM: Vulvar Vestibulitis Syndrome (VVS) is one of the most common causes of superficial dyspareunia. Although many methods have been applied in treatment of VVS which is characterized by hyperesthesia in vestibular region, the ultimate treatment is surgery. The aim of this study is to determine whether the application of hyaluronic acid to vestibulitis area to reduce the complaints of dyspareunia.

METHOD: The study was performed on patients (n=8) who applied to a private clinic with dyspareunia complaint between January 2019 and May 2019, who were diagnosed with Vulvar Vestibulitis Syndrome by Q-type test and refused to have vulvar vestibulectomy operation and demanded a non-invasive method. FDA approved phosphate- buffered BDDE cross-linked hyaluronic acid 19mg (Desirial ©) filler was used in our study because of its effects on enhancement of collagen synthesis. In our prospective study, FSFI questionnaire and VAS scores were calculated. Patients were separated into two groups as localized and generalized vestibular hyperesthesia. The procedure was performed by applying of 1 ml (19 mg) BDDE cross-linked hyaluronic acid filler to the vestibular area with 0.5 mm and 2 mm intervals by 13 mm syringe tip under the local anesthesia. Local reactions were not observed in any patient. Patients were recommended to have 2 weeks of sexual intercourse avoidance and then behavioral sexual therapies were managed in 2 consecutive days. FSFI questionnaire and VAS scores were repeated 3 months after the procedure and verbal returns by phone were obtained after 6 months. RESULTS: This preliminary study included 8 patients, 7 of them were in the reproductive period and 1 of them was in the postmenopausal period. Involuntary contractions have been observed in 4 of 5 patients who had primary dyspareunia. After involuntary contractions disappeared by cognitive and behavioral sexual therapies, 4patients who had been diagnosed as VVS by Q-type test. Secondary dyspareunia has observed in 3 patients. Although the examination findings about one of these patients who is in postmenopausal period were consistent with vestibulitis, treatment was supported by vaginal PRP (Platelet Rich Plasma) and vaginal estrogen. 5 of patients were localized and 3 of them were compatible with generalized VVS. It was observed that the vestibular area was limited to hymen in 1 of 3 patients and continued to 0.5 cm lateral to hymen in 1 patient. One patient who had previously undergone hymenectomy in an external center had vestibulite findings in the area approximately 1 cm lateral to the hymen. The VAS scores of the patients ranged from 5 to 10 and the FSFI scores ranged from 3.6 to 26.6. The patient had a FSFI score of 3.6 and had the highest VAS score (10). All patients had decreased score in VAS at the end of 3 months and this score was at least 2 and at most 5 points. The FSFI questionnaire was repeated in 6 patients because 2 out of 8 patients had relational problems. The control FSFI score increased in 4 of 6 patients (maximum increase of 13 points), remained the same in 1 patient and decreased in 1 patient. Although the VAS score was decreased, the patients’ FSFI score was decreased, too. That means the patients’ pain was decreased but in contrast their sexual problems increased. At the end of the 6 months for the feedback, we received 5 patients. One patient reported that dyspareunia disappeared completely, two patients reported that the pain level decreased during the relationship but continued for a little while, and one patient experienced the same level of pain as before hyaluronic acid. One patient reported that dyspareunia completely disappeared for 5 months after the procedure, but she experienced dyspareunia in every relationship after 5 months. The patient was reevaluated and had superficial dyspareunia due to vestibulitis, and the VAS score was the same as before the hyaluronic acid application. This patient underwent vestibulectomy at the 6th month. CONCLUSION: In patients with vestibulitis, hyaluronic acid application can be considered as a local non-invasive option that can be preferred before surgical operation. It has been shown to be effective especially in cases of localized VVS and in the patient group who have high VAS scores. There are also questions about whether the hyaluronic acid may lose its effectiveness after a certain period of time. Controlled prospective studies by including more patients are needed to get more accurate results.

Key Words: Dyspareunia, Vulvar Vestibulitis Syndrome, Genital Fillers, Hyaluronic Acid, FSFI

60 Declaration: Hyaluronic acid fillers used in this study are provided by Vivacy Turkey (Tekamestetik).

N PAİN FİRST FİRST 3rd 3rd 6th MONTH ADDİTİONAL CONCLUSION FSFI VAS MONTH MONTH TREATMENT FSFI VAS 1 RIGHT SIDE 17,8 5 30,8 1 Dyspareunia - Vestibulectomy at 6 LOCALIZED in every months relationship for the last 1 month 2 GENERALIZED 22 7 31,2 2 Non - Dyspareunia Vaginal PRP + Satisfied Estrogen 3 LEFT SIDE 23 6 27,8 3 Mild Dyspareunia - Satisfied LOCALIZED 4 LEFT SIDE 3,6 10 0,8 8 - - Vestibulectomy at 3 LOCALIZED months 5 GENERALIZED 21,7 6 27,5 3 Mild Dyspareunia - Satisfied 6 RIGHT SIDE 8,9 8 - 4 - - Not relationship LOCALIZED 7 GENERALIZED 16 6 16 5 Same as before Surgery was Not satisfied dyspareunia recommended and the operation was planned. 8 LEFT SIDE 26,6 7 - 4 - - Not relationship LOCALIZED

61 OP-19 Physical and Molecular Changes during Orgasm in Women

Suat Süphan Erşahin Department of Obstetric and Gynecology, Altınbaş University, İstanbul, Turkey

Sexual response cycle, Series of emotional and physical changes that occur as a women becomes sexually aroused and participates in sexually stimulating activities including intercourse and masturbation. Masters and Johnson (1966) were the first to propose the four stages of the sexual response 1. Excitement, 2. Plateau, 3. Orgasm, 4. Resolution

The excitement phase (also known as the arousal phase or initial excitement phase) is the first stage of the human sexual response cycle. The body prepares for sexual intercourse, initially leading to the plateau phase. The plateau phase is the period of sexual excitement prior to orgasm. The phase is characterised by an increased circu- lation and heart rate in both sexes, increased sexual pleasure with increased stimulation, and further increased muscle tension. A stage in which the female body starts to prepare itself for imminent orgasm. The resolution phase occurs after orgasm and allows the muscles to relax, blood pressure to drop and the body to slow down from its excited state. The refractory period, which is part of the resolution phase, is the time frame in which men and women are unable to orgasm again. The limbic system, a region of the brain associated with emotion and motivation, is important in human sexual func- tion. Many hormones play a role in sexual behavior. Androgens (including testosterone), estrogens, neuropeptide hormones such as oxytocin,dopamine,norepinephrine play an important role in sexual desire and orgasm.

62 63 64