Premature ejaculation: treatment update.

Premature ejaculation (PE) is the most common male sexual problem worldwide affecting 22-38% of men. It has a significant morbidity both on patients and their partners, causing distress, anxiety and relationship difficulties. The mainstay of treatment is a combined approach using behavioural therapies and non-licensed medication such as topical anaesthetic preparations, selective serotonin re-uptake inhibitors and phosphodiesterase-5 inhibitors. In recent years, there has been a greater emphasis placed on researching novel treatments and exploring the on-demand use of current preparations. This review provides an overview of current accepted treatments and emerging agents for the use in PE.

Hepatic encephalopathy as an unusual late complication of transjugular intrahepatic portosystemic shunt insertion for non-cirrhotic portal hypertension caused by nodular regenerative hyperplasia in an HIV-positive patient on highly active antiretroviral therapy.

Transjugular intrahepatic portosystemic shunt (TIPS) is an artificially created conduit between the portal and systemic vascular system in the liver performed percutaneously via radiological guidance. It is used mainly in conditions causing portal hypertension and its resulting complications. It reduces portal pressure by diverting portal blood flow into the systemic circulation. Hepatic encephalopathy is the most common complication following TIPS insertion and tends to present fairly early. We describe a case of hepatic encephalopathy as an unusual late complication of TIPS insertion (first presenting six years after) for non-cirrhotic portal hypertension caused by nodular regenerative hyperplasia in an HIV-positive patient on highly active antiretroviral therapy.

Chlamydia screening programme, HMP Hydebank Wood Young Offender Centre, Belfast, Northern Ireland, UK.

In a young offender's centre, 204 male prisoners were offered chlamydia screening, from January 2007 to April 2007. The aim of this screening programme was to identify and treat asymptomatic prisoners with chlamydia infection. Offering the screening within a prison was an opportunity to test a hard-to-reach population that is at high risk of chlamydia infection. The programme established a high level of testing acceptability with a 98% screening uptake rate. Using nucleic acid amplification testing, 21 (10.5%) tested prisoners were positive for Chlamydia trachomatis. Patients were treated under Patient Group Direction (PGD). Further screening for sexually transmitted diseases was offered to chlamydia-positive patients by the genitourinary (GU) medicine specialist.

How does HIV impact on non-AIDS events in the era of HAART?

Death rates from AIDS-related events in HIV-positive individuals have declined in the era of highly active antiretroviral therapy (HAART). It has also been shown that deaths from non-AIDS events have declined in this cohort since the advent of HAART. We review these data, as well as discussing some of the possible effects HAART might have on non-AIDS diagnoses and deaths in HIV-positive individuals with successfully treated HIV.

How to contain generalized HIV epidemics? A plea for better evidence to displace speculation.

In the worst generalized HIV epidemics in East and Southern Africa, from one-quarter to three-quarters of women aged 15 years can expect to be living with HIV or to have died with AIDS by age 40 years. This disaster continues in the face of massive HIV prevention programmes based on current inexact knowledge of HIV transmission pathways and risks. To stop this disaster, both the public and public health experts need better information about the specific factors that allow HIV to propagate so extensively in countries with generalized epidemics. This knowledge could be acquired by tracing HIV infections to their source - especially tracing HIV infections in women of all ages, and tracing unexplained HIV infections in children with HIV-negative mothers.

An eye on sexually transmitted diseases: sexually transmitted diseases and their ocular manifestations.

Ocular examination should be a part of the routine assessment of the patients seen at sexually transmitted diseases (STD) clinics due to the importance of these organs in the general wellbeing of patients. It is essential to keep an open eye on ocular signs and symptoms of patients with a history of exposure to common STD pathogens, to ensure prompt investigation and management of ocular complications of the STDs, which, if left unnoticed, otherwise could subject the patients to a great deal of anxiety and distress.

What you can see in your patient's eyes? Review of ocular manifestations of HIV in HAART era.

The early diagnosis and treatment of ocular disease to prevent morbidity and mortality of patients with human immunodeficiency virus (HIV) is of paramount importance. Since the advent of highly active antiretroviral therapy (HAART), the incidence of ocular complications of HIV has decreased and their manifestations and natural course are also modified. This has been observed in the face of emerging immune recovery, which per se has brought new difficulties in the process of diagnosing and management of the ocular disease. Conditions such as immune recovery uveitis could affect eyes with history of opportunistic disease with a potential to cause vision loss; with this regard, differentiation of the inflammatory process from infective causes is essential. The other sexually contracted diseases are also to be included in this complex picture because of their contribution to the clinical picture and also sharing common routes of transmission with HIV. There is very little doubt that visual deterioration would further deteriorate the already compromised quality of life of this group of patients. In this review, authors wish to provide evidence available in the medical literature around the visual health issues in HIV-infected patients and raise awareness towards the changing pattern of the ocular disease in the HAART era.

Neonatal herpes in herpes simplex virus type 2 and HIV-seropositive pregnant patients; the role of preventive measures in the absence of clinical disease of herpes.

There is very little knowledge about how herpes simplex virus (HSV) seropositivity of HIV-positive mothers could complicate the occurrence of neonatal herpetic disease, in the absence of genital ulcers, in this group of patients. We present a case of fatal disseminated neonatal herpes infection in a baby, born to a HIV-positive patient, and wish to discuss the potential need for changes in the management of this group of patients during pregnancy. Disseminated HSV disease is a rare, yet serious condition in newborns of HSV-infected mothers, and women with HIV infection have shown to frequently shed more HSV DNA in their genital secretions, even in the absence of active herpetic ulcers. This is the first case report of this rare association and, as a result, the evidence in support of our hypothesis has been extrapolated from other studies.

Are we missing mumps epididymo-orchitis?

Mumps epididymo-orchitis has not been recorded as a cause of testicular symptoms without systemic features (including parotitis). The aim of the present study was to assess if we were missing cases in the genitourinary clinic during a previous outbreak of mumps in the community. During a prospective pilot study from November 2005 to February 2006, all patients presenting with symptoms or signs of epididymo-orchitis were studied. These patients were assessed for previous exposure to mumps virus or vaccine, and any current evidence of systemic illness. All patients included had a full sexual health screen (loop test, chlamydia polymerase chain reaction [PCR], gonorrhoea culture, HIV and Venereal Disease Research Laboratory [test]/Treponema pallidum particle agglutination assay), urinary tract infection excluded by urinalysis and mid-stream specimen of urine (MSSU) and mumps serology (Immunoglobulin M [IgM] and Immunoglobulin G [IgG]) performed. Twenty-three patients met inclusion criteria. Their ages ranged from 16 to 50 years, average 30.8 years. All had symptoms of these, 18 had testicular pain, eight swelling, (four had both pain and swelling) and three also had dysuria. On examination, 12 had tenderness, seven swelling, (two both tenderness and swelling) and six had no signs. Seventeen denied history of mumps, one patient had a record of vaccination and five described fever. None had parotid swelling. Three patients were chlamydia PCR positive, two had candida cultured, three had non-specific urethritis (>10 polymorphonuclear leucocyte/high powered field) and 13 had negative sexually transmitted infection screen (one known HIV-positive). Three had positive IgM mumps serology and two were IgG-positive. It is important to include mumps in the differential of epididymo-orchitis and to be aware of outbreaks in the community that may present with genital symptoms, as the management and partner notification will be different.

The syphilis outbreak in Northern Ireland.

Since the late 1990s, there has been a resurgence of infectious syphilis, with notable outbreaks in Brighton, Manchester, London and Dublin, predominantly among men who have sex with men (MSM). We report a similar outbreak in Northern Ireland. Genitourinary (GU) medicine clinic attendees were assessed from 1 July 2000 to 30 June 2005 to identify those who met the agreed criteria for primary, secondary or early latent syphilis. In total, 161 individuals were diagnosed with syphilis and 121 were MSM. Sixteen individuals indicated a contact in Dublin as the likely source of infection. Thirty were identified through contact tracing. Over half contracted the infection through oral intercourse. Most (106) had one or two partners in the previous three months. Twelve cases were HIV positive (nine were aware of their status at the time of presumed infection). In conclusion, initially, cases acquired their infection in Dublin and, as the outbreak gained momentum, syphilis was contracted within Northern Ireland. The cohort was not generally associated with a high number of sexual contacts, multiple anonymous partners or specific locations. The challenge is to educate both patients and health-care professionals to sexual health issues; specifically, the risk associated with casual oral sex by MSM.

Early clinical experience of dolutegravir in an HIV cohort in a larger teaching hospital.

Dolutegravir (DTG) is the third HIV integrase inhibitor (INI) available for prescription in Belfast since July 2014. It has shown high virological efficacy in both treatment-naïve and -experienced patients. We carried out a retrospective case chart analysis of HIV-1-positive adults commenced on DTG between July 2014 and September 2015. Patients were identified from records as either treatment-naïve or antiretroviral therapy (ART) experienced. Outcomes included: (1) virological response (HIV-1 RNA viral load at 0, 4, 8 and 12 weeks), (2) immunological response (CD4+ cell count at 0, 4, 8 and 12 weeks) and (3) tolerability (side effects and discontinuation). The main exclusion criteria were patients transferring care already established on DTG from other treatment centres or inadequate follow-up information (defined as attendance at <50% of clinical and serological follow-up visits). One hundred and fifty-seven commenced DTG out of 823 patients on ART; 106 (68%) were switched to DTG from another regimen, and 51 (32%) were ART-naïve. One naïve and 14 treatment-experienced patients were excluded from the analysis due to failure to attend clinical follow-up. Analysis of HIV-1 RNA viral load (HIV-1 VL) was divided into three groups: 50 new starters, 68 suppressed at switch and 24 not suppressed at switch. New starters: Baseline median HIV-1 RNA VL 71,259 copies/mL (19,536Q25-196,413Q75); 73% were virally undetectable (HIV-1 RNA VL <70 copies/mL) by week 4. Switching patients: Of those with an HIV-1 RNA undetectable viral load prior to switching, two were detectable with a mean viral load of 443,730 copies/mL after four weeks. Of the 24 patients detectable at switch (median HIV-1 VL 2212 [311Q25-43,467Q75]), 10 were detectable after four weeks. For those with a recordable viraemia, the median HIV-1 VL reduced to 376 (220Q25-1181Q75). At week 12, four patients were detectable with a median VL of 12,390 (567Q25-52,285Q75). Overall, 56 (35%) reported side effects; 40 (25%) reported either difficulty with low mood, anxiety or sleep disturbance. Sixteen (10%) discontinued DTG, with 13 (8%) due to intolerable side effects. DTG is a useful drug in naïve or switch patients. It has the potential to effectively suppress the viral load within the first four weeks of treatment and thus reduces infectiousness. Within the cohort, DTG was generally well tolerated but side effects such as low mood, anxiety and sleep disturbance were high, with 8% of patients discontinuing treatment.

Sildenafil citrate potentiates the hypotensive effects of nitric oxide donor drugs in male patients with stable angina.

OBJECTIVE: We sought to study the effects of a single oral dose of sildenafil citrate (50 mg) on blood pressure (BP) in men taking the nitric oxide (NO) donor drugs isosorbide mononitrate (ISMN) or glyceryl trinitrate (GTN) for stable angina. BACKGROUND: Sildenafil, a selective phosphodiesterase type 5 inhibitor, is an orally effective treatment for erectile dysfunction. The presence of phosphodiesterases in the vasculature suggests the possibility of an interaction between sildenafil and NO donor drugs. METHODS: Two double-blind, placebo-controlled, randomized, two-way crossover trials were undertaken. Sixteen male patients received oral ISMN (20 mg twice a day) for five to seven days before their dose of sildenafil or placebo and continued receiving ISMN daily until administration of the alternate drug seven days later. For the second study, 15 male patients received sublingual GTN (500 microg) 1 h after sildenafil or placebo on each of two study days, which were seven days apart. Sitting or standing BP was measured before and for 6 h after the administration of the study drug. RESULTS: The effects of sildenafil plus ISMN on BP (standing mean maximum reductions from baseline in systolic/diastolic BP, -52/-29 mm Hg) were greater than the effects of placebo plus ISMN on BP (-25/-15 mm Hg; p < 0.001). Sildenafil plus GTN also resulted in greater sitting mean maximum reductions from baseline in systolic/diastolic BP (-36/-21 mm Hg) compared with placebo plus GTN (-26/-12 mm Hg; p < 0.01). CONCLUSIONS: Coadministration of sildenafil with ISMN or GTN produced significantly greater reductions in BP than ISMN or GTN alone. Based on these data, sildenafil should not be administered to patients taking nitrates.

Patient-acquired hepatitis B and HIV following erectile dysfunction therapy.

This is believed to be the first reported case of HIV and hepatitis B acquired heterosexually using erectile dysfunction drugs.

The absorption of zinc from a standardized meal in alcoholics and in normal volunteers.

The mean serum zinc in 30 normal volunteers was 12.8 mumol/l (SE +/- 0.3) and in 30 alcoholic subjects was 10.7 mumol/l (SE +/- 0.6) (p less than 0.005). Postprandial changes in serum zinc were studied in these volunteers and alcoholics who were divided into three groups. After a standardized meal with no added zinc there was a sustained postprandial fall in serum zinc in 10 normal volunteers (23%) and in 10 alcoholic subjects (19%). After a standardized meal supplemented with 25 mg zinc there was a similar rise in postprandial serum zinc concentration in 10 alcoholic subjects and 10 normal volunteers. After a standardized meal supplemented with 50 mg zinc there were lower serum zinc concentrations in 10 alcoholic subjects when compared with 10 normal volunteers. These lower postprandial serum zinc concentrations in alcoholics may suggest a reduced absorptive capacity for zinc in alcoholics.

Efficacy and safety of oral sildenafil (Viagra) in men with erectile dysfunction caused by spinal cord injury.

OBJECTIVE: To evaluate the efficacy and safety of 50-mg doses of sildenafil during a 28-day period in patients with erectile dysfunction caused by spinal cord injury (cord level range, T6 through L5). BACKGROUND: Sildenafil is an orally active, potent, and selective inhibitor of phosphodiesterase type 5, an important regulator of cyclic guanosine monophosphate in the human corpus cavernosum. METHODS: To be included in this double-blind, placebo-controlled study, all patients had to be able to achieve at least a partial reflexogenic erectile response to penile vibratory stimulation. The study utilized a single triangular sequential trial design. A total of 27 patients were randomized to receive 50 mg of sildenafil or placebo, taken orally as required (not more than once daily) approximately 1 hour before sexual activity. RESULTS: After 28 days of treatment, nine of 12 patients (75%) on sildenafil and one of 14 patients (7%) on placebo reported that treatment had improved their erections (p=0.0043). Furthermore, eight of 12 patients (67%) on sildenafil and two of 13 patients (15%) on placebo indicated that they wished to continue treatment (p=0.018). A significant improvement in satisfaction with their sex life was reported by patients taking sildenafil (p=0.012). No patients discontinued treatment due to adverse events. CONCLUSION: Oral sildenafil, taken as required (not more than once daily), significantly improves the quality of erections and satisfaction with sex life in men with erectile dysfunction caused by a spinal cord injury between T6 and L5.

Gastrointestinal hormones in anorexia nervosa.

A study was undertaken of fasting and post-prandial blood levels of glucose and a number of gastrointestinal hormones in patients with anorexia nervosa. After an overnight fast their blood levels of glucose, insulin and pancreatic glucagon were significantly lower than those of age-sex matched healthy volunteers. There were no significant differences in the levels of gastrin, total glucagon-like immunoreactivity, vasoactive intestinal polypeptide, pancreatic polypeptide, secretin and gastric inhibitory polypeptide. Serial blood samples were taken for up to two hours after the ingestion of a standard mixed meal (450 kcal) and these showed a significant glucose intolerance, a reduced and delayed insulin response, and a reduced release of gastric inhibitory polypeptide, as compared with the controls. There was an increased release of pancreatic polypeptide but the difference in the post-prandial hormone profile between patients and controls for gastrin did not reach statistical significance.

Sildenafil citrate (Viagra) in erectile dysfunction: near normalization in men with broad-spectrum erectile dysfunction compared with age-matched healthy control subjects.

OBJECTIVES: To evaluate the efficacy, safety, and tolerability of sildenafil in men with broad-spectrum erectile dysfunction (ED), with reference to age-matched healthy control subjects. METHODS: One hundred eleven patients were enrolled in a randomized, double-blind, placebo-controlled, parallel-group, 12-week, flexible-dose study. Efficacy assessments included the International Index of Erectile Function (IIEF), a global assessment question, and patient event log data. In a separate, nontreatment study, 109 control subjects also completed the IIEF. RESULTS: Mean IIEF scores at baseline were significantly lower for patients with ED than for control subjects without a history of ED. After treatment, mean IIEF scores for patients receiving sildenafil approached values observed in control subjects and were significantly higher than mean scores for patients receiving placebo (P<0.01). Responses to the global assessment question and patient log data corroborated the IIEF results. Sildenafil was well tolerated, with no discontinuations because of adverse events. CONCLUSIONS: The results indicate that sildenafil, an effective oral therapy for the treatment of broad-spectrum ED, is associated with a near normalization of patient erectile function.

A shared care approach to the management of erectile dysfunction in the community.

Erectile dysfunction (ED) affects men of all ages and results in considerable distress and impact on quality of life for those who suffer from it. As ED is associated with a wide variety of under-lying conditions and cardiovascular co-morbidities, there is a requirement for diversity of treatment options and several factors must be considered to customise and optimise therapy. In the ideal holistic approach to management of the ED patient, both primary care and specialist physicians have an important role to play. This article reports on a sequential approach for the diagnosis and treatment of ED, with an emphasis on 'shared care'. The deliberations are based on a pan-European inter-disciplinary group that met at the Lygon Arms, UK on 22 February 2002.