Stesura Seveso Archivio Italiano di Urologia e Andrologia 2022; 94, 2228 ORIGINAL PAPER No conflict of interest declared. really to be trumpeted and hardly shareable even with the closest ones (1). Up until 50 years ago, in Italy the influ- ence of the Church, its priests and the religious educa- tional and leisure facilities tended to instill the idea that Mst was a sin, as men should deliver their sperm only for reproductive purposes and therefore during a penetrative sexual intercourse (2). In the Sacro Cuore Catholic University of Rome (Medical Center of excellence in Rome and in Italy) it was not pos- sible to carry out a spermiogram to assess the fertility because this catholic facility would have had to accept a sperm sample not delivered in the vagina (hence for reproductive purposes), but collected in a container and for the only purpose to "assess" the quality of the ejaculate with no other ongoing disease. The sperm sample was accepted only for bacteriological examination in case of suspected infection (alleged or actual disease). Mst is one of the first sexual dexterities men begin to experience (at 11-13 years of age) in conjunction with the production of testicular androgens and the onset of ado- lescence (3). In the past, at this stage of life, adolescent males did not have the possibility or the opportunity to have a sexual partner, and therefore the resort to Mst was a need, a rule until they reached the age (20 and older) to start going out with women, marry and therefore have the possibility of enjoying regular penetrative intercourse (4). Up until 50-60 years ago, in the Italian social-economic- cultural reality the vast majority of women carried out mainly domestic activities and the work and life rhythms were influenced by the sunlight cycle; no home lighting, no TV and no nightlife implied that after dinner, and with the onset of darkness, couples went to bed and men had the possibility to have a sexual intercourse with orgasm and ejaculation, regardless of the desire and availability of the woman, who traditionally could not refuse the sexual requests of the man, also because women had to provide for the reproduction of the species through extremely fre- quent pregnancies, even one every year. Given such a context, men did not have specific physical reason to resort to Mst. It shall also be considered that, to masturbate men had to envisage sexual fantasies, visions, erotic behaviors linked also to environmental and cultural factors. All cultures Objective: We aimed to verify the rate of masturbation (Mst) in a group of 150 Italian patients complaining Erectile Dysfunction (ED). Materials and methods: Our diagnostic protocol for penile and sexual problems included the collection of the patient's history, general and local clinical examination, and metabolic and hor- monal analyses. Selected patients were also submitted to noctur- nal penile tumescence test (Rigiscan), Duplex ultrasound of the penis, Magnetic Resonance Imaging, neurological tests and car- diological examination. A group of 150 Italian males (aged between 20 and 86 years) who complained ED and who present- ed to our Andrological Center to research the possibility of cor- recting their ED and being able to recover adequate sexual erec- tile activity were included in this study. In this group of patients suffering from ED we decided to evaluate the practice of Mst by asking specific questions: 1. Do you sometimes practice Mst? 2. How often in a week? 3. Is Mst hidden or known by the part- ner? 4. What do you use as a masturbatory sexual stimulus? The frequency of Mst was assessed according to a Likert scale as follow: a: No Mst; b:1-2/week; c: 2-3/week; d: > 3/week; e: daily or more. We also asked if it was possible to have pene- trative marital intercourse on the same day as Mst (1-10 hours). We also asked what they used as a triggering sexual stimulus: press magazines, TV movies, the WEB. Results: Only 5/150 patients did not report Mst while 27/145 pts (aged 20-30 years) reported it more than 3 times a week; 44/145 (aged 31-50 years) 1-3 times a week and 27/145 (51-86 years) 1-2 times a week. Almost all patients used WebPorn as a stimulus for Mst. A group of patients over the age of 50 said they were quite satisfied with the physical results of Mst even though they would prefer to have sex as part of a couple rela- tionship. Conclusions: The outburst of Mst in this web-dominated era could affect the sexual activity of individual males and couples. KEY WORDS: Masturbation; Cyber pornography; WEB porn; Erectile dysfunction; ED therapy; Penile prosthesis. Submitted 8 May 2022; Accepted 29 May 2022 INTRODUCTION The practice of Mst in Western, Christian and even more Catholic realities has always been considered an improp- er sexual practice, not advisable, often deplorable, not Cyber pornography use and masturbation outburst. Considerations on 150 italian patients complaining erectile dysfunction and trying to solve it Diego Pozza 1, Mariangela Pozza 1, Augusto Mosca 2, Carlotta Pozza 3 1 Studio di Andrologia e di Chirurgia Andrologica, Roma, Italy; 2 UO Urologia e Andrologia, San Sebastiano Hospital, Frascati (RM), Italy; 3 Department Experimental Medicine, Sapienza University, Rome, Italy. DOI: 10.4081/aiua.2022.2.228 Summary 229Archivio Italiano di Urologia e Andrologia 2022; 94, 2 Masturbation in Italian patients with ED have produced images or figures of a sexual nature (stat- ues, frescoes, paintings, objects), which could stimulate the men’s fantasy, but that could, in the majority of cases, not be taken home (5). With the advent of writing, "licentious" texts started to appear, that could be enjoyed by the upper classes, since they were able to read, but not by the vast majority of the population. The introduction of the press allowed to produce in large number also “licentious” or “erotic” texts and more clearly “erotic” figures, drawings and representations, that could be enjoyed also by people unable to read and not having books to stimulate their sexual fantasies (6). In the late 1800s the first photographs (daguerreotypes) allowed to reproduce sexually stimulating female silhou- ettes and sex scenes easily enjoyable also by men unable to read but longing for an imaginative sexual stimulus for masturbatory or erotic-sexual purposes. However, the issues with those first photographs or books, not easy to be found, was keeping them at home without the wife, children or housekeeper being able to find them out. In 1941 the first periodical magazine with porn images, SWANK, was released in the USA, followed in 1953 by Playboy, which could be easily purchased at newsstands or by subscription in all countries of the world, and then by a variety of other periodicals (7). Also in that case, the problem was how to buy those mag- azines. Almost always they were bought at newsstands away from home, frequently at the station, and the pur- chase had to be concealed (i.e. “hiding” those magazine among other newspapers or magazines). Keeping them home could become a problem, as they had to be kept in places hardly visited by the other family members and yet easily accessible for masturbatory purposes. In some cases, such magazines were read together with the female partner as a “stimulus” to foster a freer sexuality. Nevertheless, keeping those magazines at home could imply serious problems, as well as discomfort in case they were discovered by the partner, who could have felt almost “betrayed” by such discovery. In the first postwar years, in 1950s, we saw the advent of television, which led to substantial changes in the life of the couple. Couples no longer went to bed after dinner, with the onset of darkness, but after spending a few hours watching TV and going to bed late, knowing that early in the morning, at dawn, they would have had to wake up to go to work. That resulted in less time and availability for sexual activity. In that same period many women took up a job, while continuing to take care of the house, the husband, and the children. Working outside their own home, spending time with other women, a certain eco- nomic and cultural independence, the first mechanical contraceptives and the pill changed the concept of preg- nancy, which was no longer perceived as an inevitable necessity or obligation, but as the result of a choice of the couple with the possibility for the woman to refuse sexu- al intercourse perhaps requested by the men but not solicited by the woman. In many couple realities, the man no longer had the pos- sibility to have an almost daily orgasm and ejaculation, and had to accept the decision of the woman, who might be little interested in the sexual activity (endocrine fac- tors) or who could fear a pregnancy with all the associat- ed negative aspects (8). In such cases, many men resort to masturbation to get that emotional and urological pleasure, regardless of the availability of the women (9). Internet opened up a whole new world to pornography (10). With the discovery of the WEB, the potential for the sup- ply and consumption of porn material rocketed to the extent of becoming a real global industry (11). Men longing to stimulate their more or less correct or dis- torted sexual fantasy no longer had to buy a magazine or a videotape, nor to find a “secret” place, but simply use a PC or smartphone without “concealing” any material. They could use it everywhere and anytime, paradoxically even in the presence of their partner without her know- ing about it (12). MATERIALS AND METHODS in our Andrology Center in Rome, since 2020, we examined 150 male patients (aged 20 to 86 years) with penile and/or sexual problems according a diagnostic protocol including the collection of the patient's history, the gen- eral and local clinical examination, metabolic analyses, and hormonal analyses (in all patients). In selected cases Nocturnal Penile Tumescence test (Rigiscan) (86 pts), dynamic penile Duplex sonography (138 pts), magnetic resonance imaging (36 pts), neurological tests (26 pts) and cardiological examination (100 pts) were performed (13-15). Since 2020, we administered a specific questionnaire to investigate masturbatory activity, including the following questions: 1. Do you sometimes practice Mst? Answers: No-Yes 2. With which frequency/week? Answers: 1-2-3-more, all days? 3. Is Mst concealed to the partner? Answers: No -Yes 4. What do you use as Mst sexual stimulus? Answer: fantasy - printed materials -WEB In our experience with the IIEF test utilized for other rea- sons, we had acknowledged that to some given questions many patients preferred to give false answers that put them in a "better light". On the other hand, all our patients, who came to under- go specific tests because their Erectile Function was not effective (being well aware of the need to solve their erec- tile problem) had no reason to withhold information on their masturbatory activity. RESULTS When asked by the Andrologist, during medical exami- nations, whether they practiced Mst, 145/150 (96,6%) patients answered positively. To the question about the Mst frequency (16): 27 pts (20-30 yrs; 18.0%) reported > 3 times/week, even every day; 44 pts (31-50 yrs; 29.3%)1-3 times/week; 56 Archivio Italiano di Urologia e Andrologia 2022; 94, 2 D. Pozza, M. Pozza, A. Mosca, C. Pozza 230 pts (51-70 yrs; 37.3%) 1-3 times/week, even every day;18 pts (71-86 yrs; 12%) 1-2 times/week; 5 pts (29, 36, 56, 75, and 80 yrs; 3.3%) no masturbation. Ten (6.8%) patients reported that their partner was aware of the Mst activity they practiced and did not show dis- appointment. When asked if it was possible to have a penetrative mari- tal intercourse on the same day of Mst (within 1-10 hours): 10 patients aged 20-30 years (37.0%) and 5 patients aged 31-90 (0.4%) answered affirmatively. When asked what did they use as triggering sexual stim- ulus 132 pts (20-86 years; 91%) reported using the web and 18 pts (> 60 years; 12%) reported to watch TV movies The sexual desire to have intercourse with their “stable partner” appeared rather reduced among the patients practicing Mst. In the following cases it is not simple to discriminate: 1. When the woman, perhaps no longer young and with children, showed no initiative to involve the man in a sexual activity. 2. When the woman was aware of the difficulty, often the impossibility of the man to have a satisfactory penetra- tive intercourse and therefore did not take any initia- tive. 3. When the woman, knowing that the man often was not capable to have an adequate erection (i.e. had an insufficient or short-lasting or totally unsatisfactory erection) preferred not to induce a depressive attitude of the partner. 4. When, due to erectile dysfunction a preliminary mas- turbatory activity tended to make the penetrative inter- course even more difficult resulting in disappointment, frustration, a sense of deficiency, and depression. DISCUSSION We are not aware of other cultural and religious realities, where the Mst practice can be easily accepted and revealed, but for sure in the Italian reality with a strict Christian-Catholic culture and education, it is quite uncommon that, among men talking about their sexual "performances" or "adventures", Mst is one of the issues discussed and revealed even if practiced frequently. Masturbation could and was practiced by men, who for different reasons could not have sexual intercourse with a woman (adolescence, celibacy, religious activity, illnesses, separation, widowhood, distance for work, emigration, wars, calamities). In principle, men could have a sexual activity leading to an orgasm and ejaculation on a regular basis because, until a few decades ago, most women had to accept a sex- ual intercourse for cultural, educational, economic, total dependence reasons, regardless of their will and the sex- ual prowess of the man (8). From the beginning of the twentieth century with women starting going to school, working and gaining economic independence, the awareness of the family context, the changes in the legislation, many women gained the power and started refusing the absolute duty of accepting a sex- ual intercourse with their partner. Mst requires a state of sexual excitement triggered by imagination, scents, visions, contiguity that needs a cer- tain psychological “commitment” as well as plenty of time. Even in ancient civilizations and societies it was possible to reproduce “sexually exciting" images which, however, were graphic, pictorial or statuary images affixed in spe- cific places, often public, and difficult to be used in pri- vate. With the advent of the press, books with erotic content began to be published, that, however, could be enjoyed only by people able not only to read but also to buy, pre- serve and consult a book. The possibility to paint and print images and pictures led to publications with sexually explicit images, which could be appreciated also by people, who were not able to read. The classic images in barber shops (men-only places) with more or less naked ladies became outmoded in the 40-50s due to the first publications (magazines, tabloids) with naked women which one could also purchase in more popular environment, such as newsstands, and eas- ily usable at home, although they had still to be hidden from mother, wife or partner. On the one hand, the erotic-porn publication boom could make Mst easier and more evocative but still with a set of practical problems, such as: – the purchase, (normally, never the usual newsstand near home, perhaps attended by some family member or acquaintance; men who bought a porn publication usually avoid doing it in a noticeable way, almost always buying other newspapers to hide it away from other customers of the newsstand, even if unknown), – the preservation at home of the magazines in an easily accessible place, but hidden from the women at home, – the possibility to read them in a place that had to be “secret” not to be seen by other family members and also lit enough to allow the reading. The development of the WEB in the 70s combined with the widest spreading of smartphones allowed to basically solve those problems. Men in need of a visual sexual stimulus no longer have to go to a newsstand to buy “in public” porn material, nor to worry about hiding the material at home. They can check it out anytime, everywhere, even in the dark. For the sake of argument, they can watch porn images or movies even when in close proximity to their partner, or use it just before having a sexual intercourse to strength- en the sexual performance with a woman who, perhaps, no longer excites him (17). However, porn web has specific consequences. Many functionally active and sexually capable young men report "web-masturbating" because they can do it at any time of the day even when their woman is not available or has to carry out other activities: web sex allows men to imagining to have sexual intercourse with extremely exciting, provocative women available in any situation, even extreme ones, without having to worry about a too quick ejaculation, an erection that is not sufficiently stiff and lasting to give enough pleasure to the partner (8). Moreover, they are not exposed to the “unpleasant and frustrating” judgement of the unsatisfied partner. Clearly teenagers, young men who had had a sexual inter- course with their partner could also be able to have 231Archivio Italiano di Urologia e Andrologia 2022; 94, 2 Masturbation in Italian patients with ED another sexual intercourse if explicitly requested (18), but with maturity and senescence it could be difficult to get a new conjugal erection after a masturbation (19). In other cases, after 50 years of age, or in case of meta- bolic, hormonal or vascular pathologies, men tend to masturbate to directly verify if their penis can deliver a good stiffness and maintain it, which triggers a compli- cated psychological mechanism. However, we have verified that in many patients over 50, who had had various sexual relationships in the past, the practice of masturbation was experienced and reported in a different way from those who had not had interperson- al relationships. A certain amount of patients reported obtaining with the Mst an acceptable erection, an orgasm (with or without ejaculation) quite satisfactory without having to worry about having induced a specific pleasure and having procured an orgasm in the woman and with- out having to expect a judgment of the woman on the ability to have procured a substantially pleasant inter- course and an orgasm. In the past, even recently, a male would never have bothered with the judgment of the woman. This aspect should be the subject of in-depth evaluations. Should sexual intercourse be considered only as a reproductive act, as a source of pleasure for the male or as a source of pleasure also for the woman and for the couple? AKNOWLEDGMENTS We thank the strict collaboration of Stefania Rosini for translation and revision of the article. REFERENCES 1. Fischer N, Graham CA, Traeen S, Hald GM. Prevalence of mas- turbation and associated factors among older adults in four European countries. 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Correspondence Diego Pozza, MD (Corresponding Author) diegpo@tin.it Mariangela Pozza, MD mariangela.pozza@gmail.com Studio di Andrologia e di Chirurgia Andrologica Via B. Gozzoli, 82 - 00142 Rome (Italy) Augusto Mosca, MD moscaaugusto@gmail.com UO Urologia Andrologia, San Sebastiano Hospital Via Tuscolana, 2, 00044 Frascati, Rome (Italy) Carlotta Pozza, MD carlotta.pozza@gmail.com Dept Experimental Medicine, Sapienza University Viale Policlinico, 00161, Rome (Italy)