Mixed Study Systematic Review and Meta-analysis of Sexuality and Sexual Rehabilitation in LGBTQI+ Adults Living With Chronic Disease.

OBJECTIVE: To systematically review how sexuality is experienced by lesbian, gay, bisexual, transgender, queer or questioning, intersex plus (other gender identifies and sexual orientations) (LGBTQI+) persons living with chronic disease. DATA SOURCES: PsycINFO, Embase, MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health, and Web of Science were searched from date of inception to November 2021 for English language publications. Reference lists of relevant publications were also searched. STUDY SELECTION: Eligible studies reported on sexuality among LGBTQI+ persons living with chronic disease. The search yielded 12,626 records; 665 full texts were assessed for eligibility and 63 documents included (59 unique studies). Study quality was rated using the Mixed Methods Appraisal Tool. DATA EXTRACTION: Characteristics of included studies were recorded independently by 2 authors. Differences were resolved through discussion or with a third author. DATA SYNTHESIS: A sequential, exploratory mixed-studies approach was used for synthesis. Pooled analysis indicated that among gay and bisexual men living with prostate cancer, 68.3% experienced erectile dysfunction and 62.9% had insufficient quality of erection to engage in anal sex. Among gay and bisexual men living with HIV or AIDS, 29.3% experienced loss of libido and 25.3% experienced erectile dysfunction. Although sexual dysfunction was common, LGBTQI+ persons had difficulty accessing appropriate sexual counseling and identified negative attitudes and heteronormative assumptions by health care providers as significant barriers to sexual health. Interventions to address sexuality focused entirely on reduction of risky sexual behavior among men living with HIV or AIDS. Women, transgender persons, and intersex persons were largely excluded from the research studies. CONCLUSIONS: Current understandings of the effect of chronic disease on LGBTQI+ sexuality are limited and mostly focus on the male sexual response. LGBTQI+ persons who experience difficulty with sexuality struggle to identify appropriate services, and there is an absence of evidence-based interventions to promote sexual health and well-being in this population.

Current trends in erectile rehabilitation after radical prostatectomy: Results from a worldwide survey.

We aimed to analyse the current trend of erectile rehabilitation (ER) following radical prostatectomy (RP) using a dedicated survey. An online survey was developed between July and September 2020, aiming to evaluate the ER protocols after RP in daily practice among urologists, andrologists, sexual medicine specialists and residents. We investigated demographics data, type of RP performed, and type, schedule, timing and duration of ER protocols. In total, 518 responders from 52 countries completed the survey. Surgical techniques reported were: 38.9% open, 22.9% laparoscopic and 38.2% robot-assisted RP. 33% of the responders begin ER at the catheter removal, 22% 1 month after surgery and 15% before surgery. Phosphodiesterase inhibitors were the most used medication as first-line treatment (99.4%). Tadalafil 20 mg was the most prescribed, and used daily in 48.2% of the cases, and 2-3 times/week in 46%. Intra-cavernosal injection of prostaglandin E1 was the second most common prescribed monotherapy (67.9%) followed by the association of phosphodiesterase inhibitors and vacuum-erection device (29.6%). The duration of ER was <6 months in 16.2%, between 6 and 11 months in 39%, between 12 and 18 months in 31.9%, between 19-24 months in 9.2% and >24 months in 3.7%. This study showed that the approach to ER after RP was inhomogeneous. International guidelines are urgently needed to standardise ER protocols.

Penile Rehabilitation Strategy after Nerve Sparing Radical Prostatectomy: A Systematic Review and Network Meta-Analysis of Randomized Trials.

PURPOSE: Despite the advances in nerve sparing and minimally invasive radical prostatectomy, erectile dysfunction remains an important adverse event after radical prostatectomy. Penile rehabilitation strategies have been developed to expedite and improve erectile function recovery. However, the differential efficacy and the best penile rehabilitation strategy are unclear as yet. We conducted a systematic review and network meta-analysis to investigate and compare the efficacy of different penile rehabilitation strategies. MATERIALS AND METHODS: A systematic search was performed in May 2020 using PubMed® and Web of Science™ databases according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) extension statement for network meta-analysis. Studies that compared the erectile function recovery rate and adverse events between penile rehabilitation treatment groups (eg medications, devices and actions) and control group were included. We used the Bayesian approach in the network meta-analysis. RESULTS: A total of 22 studies (2,711 patients) met our eligibility criteria. Out of 16 different penile rehabilitation strategies and schedules vs placebo, only pelvic floor muscle training (OR 5.21, 95% CrI 1.24-29.8) and 100 mg sildenafil regular doses, ie once daily or nightly (OR 4.00, 95% CrI 1.40-13.4) were associated with a significantly higher likelihood of erectile function recovery. The certainty of results for 100 mg sildenafil regular dose was moderate, while pelvic floor muscle training had low certainty. The sensitivity analysis confirmed that the regular high dose of phosphodiesterase-5 inhibitors regardless of type vs placebo (OR 2.09, 95% CrI 1.06-4.17) was associated with a significantly higher likelihood of erectile function recovery with a moderate certainty. The on-demand doses of phosphodiesterase-5 inhibitors were not proven to be more beneficial than placebo. Secondary outcomes such as adverse events were not analyzed due to incomplete data in the literature. However, no serious adverse events were reported in any of the studies. CONCLUSIONS: Sildenafil 100 mg regular dose is the best penile rehabilitation strategy to improve erectile function recovery rates after radical prostatectomy. Although pelvic floor muscle training has been shown to be effective in increasing the erectile function recovery rate, well designed randomized controlled trials with larger sample sizes are needed to confirm the presented early results. The on-demand dose of phosphodiesterase-5 inhibitors should not be considered as a penile rehabilitation strategy.

Application of Sex Aids in Men With Sexual Dysfunction: A Review.

BACKGROUND: Although sex aids have been used in clinical practice for ages, the scientific literature assessing their application in men with sexual dysfunction is limited. AIM: To summarize medical literature regarding scientific uses of the most common sex aids in men with sexual dysfunction and assess their clinical applicability. METHODS: An extensive literature review was performed with regard to the use of sex aids in sexual medicine. Our search included journal articles, books, and guidelines in different databases: Embase, PubMed, and Cochrane. The key words were "sex aids," "sex toys," "pornography," "lubricants," "constriction bands," "dildos," "vibrators," "vacuum devices," "external penile devices," and "sex swings" were searched. Date of last search was December 4, 2018. MAIN OUTCOME MEASURES: We assessed the utility of sex aids in men with sexual dysfunction and formulated recommendations for clinicians. RESULTS: Various sex aids are available for men with sexual dysfunction. We present a comprehensive review of the most common sex aids currently available: pornography, lubricants, constriction bands, dildos, vibrators, vacuum devices, external erectile support devices, and aids to positioning. We discuss their indications, outcomes, precautions, and complications. CLINICAL IMPLICATIONS: This review is intended to provide sexual medicine practitioners and academics an overview of sex aids for men with sexual dysfunction for use in both clinical practice and research. STRENGTHS & LIMITATIONS: This is a compilation of scientific data for a topic that has broad application in sexual medicine and yet has been poorly addressed in the scientific literature. Because of the lack of sufficient data and the heterogeneous nature of different sex aids, a systematic review could not be performed. CONCLUSION: Having a comprehensive understanding of the sexual dynamics of individuals and couples combined with the appropriate integration of sex aids may have a positive effect in the treatment of male sexual dysfunctions. Miranda EP, Taniguchi H, Cao DL, et al. Application of Sex Aids in Men With Sexual Dysfunction: A Review. J Sex Med 2019;16:767-780.

Acceptance and Commitment Therapy to Increase Adherence to Penile Injection Therapy-Based Rehabilitation After Radical Prostatectomy: Pilot Randomized Controlled Trial.

INTRODUCTION: Despite the importance of using penile injections as part of a penile rehabilitation program, men have difficulty complying with these programs. AIM: To test a novel psychological intervention based on Acceptance and Commitment Therapy for erectile dysfunction (ACT-ED) to help men utilize penile injections. METHODS: This pilot randomized controlled trial (RCT) recruited men who were beginning a standard care (SC) structured penile rehabilitation program following radical prostatectomy. The SC program instructed patients to use penile injections 2 to 3 times per week. Participants were randomized to SC+ACT-ED or SC+enhanced monitoring (EM). Over 4 months, patients in the SC+ACT-ED group received SC plus 4 ACT sessions and 3 ACT phone calls; those in the EM group received SC plus 7 phone calls from an experienced sexual medicine nurse practitioner. Participants were assessed at study entry and at 4 and 8 months. For this pilot study, the goal was to determine initial efficacy (ie, effect sizes, where d = 0.2 is small, d = 0.5 is medium, and d = 0.8 is large). MAIN OUTCOME MEASURE: Primary outcomes were feasibility and use of penile injections. Secondary outcomes were ED treatment satisfaction (ie, Erectile Dysfunction Inventory of Treatment Satisfaction, or EDITS), sexual Self-Esteem and Relationship (SEAR) quality, sexual bother (SB), and prostate cancer treatment regret. RESULTS: The 53 participants were randomized (ACT, n = 26; EM, n = 27). The study acceptance rate was 61%. At 4 months, the ACT-ED group utilized more penile injections per week (1.7) compared to the EM group (0.9) (d = 1.25; P = .001) and was more adherent to penile rehabilitation compared to the EM group (ACT, 44%; EM, 10%; relative risk [RR], 4.4; P = .02). These gains were maintained at 8 months for injections per week (ACT, 1.2; EM, 0.7; d = 1.08; P = .03) and approached significance for adherence (ACT, 18%; EM, 0%; P = .10). At 4 months, ACT-ED, compared to EM, reported moderate effects for greater satisfaction with ED treatment (d = 0.41; P = .22), greater sexual self-esteem (d = 0.54; P = .07) and sexual confidence (d = 0.48; P = .07), lower sexual bother (d = 0.43; P = .17), and lower prostate cancer treatment regret (d = 0.74; P = .02). At 8 months, moderate effects in favor of ACT-ED were maintained for greater sexual self-esteem (d = 0.40; P = .19) and less treatment regret (d = 0.47; P = .16). CLINICAL IMPLICATIONS: ACT concepts may help men utilize penile injections and cope with the effects of ED. STRENGTHS AND LIMITATIONS: Strengths include use of an innovative intervention utilizing ACT concepts and pilot RCT. Limitations include the pilot nature of the study (eg, small samples size, lack of statistical power). CONCLUSION: ACT-ED is feasible and significantly increases the use of penile injections. ACT-ED also shows promise (moderate effects) for increasing satisfaction with penile injections and sexual self-esteem while decreasing sexual bother and prostate cancer treatment regret. Nelson CJ, Saracino RM, Napolitano S, et al. Acceptance and Commitment Therapy to Increase Adherence to Penile Injection Therapy-Based Rehabilitation After Radical Prostatectomy: Pilot Randomized Controlled Trial. J Sex Med 2019; 19:1398-1408.

Adherence and barriers to penile rehabilitation over 2 years following radical prostatectomy.

BACKGROUND: A variety of penile rehabilitation (PR) therapies are available to improve post-prostatectomy erectile dysfunction (ED) with mixed results. It is uncertain how adherent men are to PR therapies. The aim of this study is to determine adherence to and identify barriers to PR treatment. METHODS: A longitudinal cross-sectional approach was used in men who underwent radical prostatectomy over 2 years. Men were instructed to take a PDE5 inhibitor (PDE5i) three times per week, and if required, utilize a vacuum constriction device (VCD) daily. Outcomes were measured by multiple validated questionnaires. In addition, penile stretched length, side effects, compliance to PR regimen & barriers to participation were documented. RESULTS: Seventy-seven patients were enrolled, however only 49 completed evaluation at 3 or more timepoints and were included in analysis. This cohort was an average age of 58.1 years (±7.7), had robotic laparoscopic radical prostatectomy (91.7%), and had bilateral nerve sparing procedures (95.8%). Majority (62.5%) reported normal SHIM pre-operatively, however 79% used PDE5i. Erectile function as measured by IIEF and Erection Hardness Rating were negatively affected post-operatively, with gradual improvement in parameters throughout the 24 month follow up. Of the participants who had normal pre-op SHIM, only 23.1 and 28.6% regained baseline function at 1 and 2 years, respectively. Orgasm was significantly diminished immediately post-operatively, however, at the end of the study period only 37% of men reported diminished climax and no men reported absent orgasm. Adherence to penile rehabilitation therapies declined overtime. Men took oral PDE5i on average 2.3 times weekly at 12 and 24 months (p < 0.001). Men used the VCD 2.3-3.9 days a week, which declined overtime (p = 0.014). CONCLUSIONS: Improvement in erectile and orgasm parameters was observed over time, but most men did not return to baseline function. Despite comprehensive instructions and a frequent follow up schedule, PDE5i and VCD adherence was poor. High attrition rates were noted with only 55.8% of men remaining at 12 months and 45% of men completing 24 months. The most common barriers to PR adherence were cost, inconvenience and perceived ineffectiveness.

Erectile dysfunction, physical activity and physical exercise: Recommendations for clinical practice.

Erectile dysfunction could be an early sign of endothelial dysfunction and, therefore, of cardiovascular disease, with which it shares many risk factors. Among reversible risk factors, physical inactivity is one of the most important. Regular physical exercise has been shown to improve erectile function through different mechanisms involving glucose and lipid metabolism, regulation of arterial pressure, production of nitric oxide and hormonal modulation. Furthermore, exercise shows a synergistic effect with the drugs commonly used in the treatment of impotence. Since many patients with erectile dysfunction may have underlying cardiovascular disease, the evaluation of individual cardiovascular risk is mandatory before prescribing physical exercise. When exercise is not contraindicated, the most appropriate protocol must be chosen, considering the individual characteristics of the patient. Both aerobic and anaerobic/resistance protocols have proven effective. However, meta-analytic studies show that aerobic exercise with moderate-to-vigorous intensity is the most effective in improving erection. Testosterone is an important modulator of physical performance, and its blood levels must always be evaluated in patients with erectile dysfunction.

Effects of perioperative pelvic floor muscle training on early recovery of urinary continence and erectile function in men undergoing radical prostatectomy: a randomized clinical trial.

AIMS: Radical prostatectomy (RP) can result in urinary incontinence (UI) and erectile dysfunction (ED), which negatively impact quality of life (QoL). This study aimed to evaluate the effects of a perioperative pelvic floor muscle training (PFMT) program versus usual care on early recovery of urinary continence and erectile function after RP. MATERIALS AND METHODS: Of 59 eligible men, 31 were randomly allocated into 2 groups: Group 1 (Control, N=15) received usual post-RP care; and Group 2 (Physical therapy, N=16) received two pre-RP physical therapist-guided PFMT sessions, including exercises and electromyographic biofeedback, and verbal and written instructions to continue PFMT until RP, which was then resumed after urethral catheter removal. The International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) and the 5-item version of the International Index of Erectile Function (IIEF-5) questionnaire were used to evaluate UI and ED, respectively. RESULTS: Demographic characteristics were similar in both groups. Three months after RP, the UI rate was 72.7% and 70.0% in Groups 1 and 2, respectively (P >0.05). The severity and frequency of UI and its impact on QoL were evaluated by the ICIQ-Short Form, with scores of 6.9±6.26 in Group 1 and 7.0±5.12 in Group 2 (P >0.05). The IIEF-5 scores were similar in Groups 1 and 2 (5.73±7.43 vs. 6.70±6.68, respectively) (P >0.05). CONCLUSION: Our pre-RP protocol of two physical therapist-assisted sessions of PFMT plus instructions did not signifi cantly improve urinary continence or erectile function at 3 months after RP.

[Attitudes of prostate cancer patients towards postoperative penile rehabilitation and their influencing factors].

OBJECTIVE: To investigate the attitudes of prostate cancer (PCa) patients towards postoperative penile rehabilitation and their influencing factors. METHODS: Seventy-nine PCa patients underwent radical prostatectomy from January through June 2017 and all received a questionnaire investigation before surgery on IIEF-5 and their attitudes towards postoperative penile rehabilitation. We analyzed the reasons for the patients' rejection of postoperative penile rehabilitation. RESULTS: Totally 56 (71%) of the patients accepted and the other 23 (29%) refused postoperative penile rehabilitation. The factors influencing their attitudes towards penile rehabilitation mainly included age (P = 0.023), income (P = 0.040), tumor stage (P = 0.044), and preoperative sexual activity (P = 0.004). The patients who accepted penile rehabilitation had significantly higher IIEF-5 scores than those who refused it (14.75 ± 0.88 vs 8.48 ± 1.16, P = 0.000 2). During the follow-up period, only 29 (36.7%) of the patients bought the vacuum erection device but not the other 50 (63.3%). The tumor stage (P = 0.004), income (P < 0.01) and preoperative androgen-deprivation therapy (P = 0.039) significantly influenced the patients' decision on the purchase of the device. Relevant admission education achieved a 45% decrease in the number of the patients unwilling to accept penile rehabilitation for worrying about its negative effect on cancer treatment, a 25% decrease in those rejecting penile rehabilitation because of age, and a 20% decrease in those refusing it due to the tumor stage. The cost of treatment was an important reason for the patients' rejection of postoperative penile rehabilitation. CONCLUSIONS: The tumor stage and income are the main factors influencing PCa patients' decision on postoperative penile rehabilitation. Relevant admission education and reduced cost of rehabilitation are important for popularization of postoperative penile rehabilitation in PCa patients.

Effect of Starting Penile Rehabilitation with Sildenafil Immediately after Robot-Assisted Laparoscopic Radical Prostatectomy on Erectile Function Recovery: A Prospective Randomized Trial.

PURPOSE: It has not been clearly proved in real practice whether early rehabilitation with phosphodiesterase type 5 inhibitors starting immediately after radical prostatectomy improves erectile function recovery more effectively than delayed treatment with the same regimen. We performed a prospective randomized trial to identify this. MATERIALS AND METHODS: Patients with prostate cancer and an IIEF-5 (International Index of Erectile Function-5) preoperative score of 17 or greater were randomly assigned to receive sildenafil 100 mg regularly twice per week for 3 months immediately after urethral catheter removal as the early group or only 3 months after nerve sparing robot-assisted laparoscopic radical prostatectomy as the delayed group. The study primary end point was the full erectile function recovery rate, defined as an IIEF-5 score of 17 or greater, during the 12 months. RESULTS: Of the 120 randomized patients the proportion who achieved full recovery was significantly higher during the 12 months in the early group than in the delayed group (ß = 0.356, p <0.001, generalized estimating equation). After 9 months postoperatively the proportion of patients who achieved full recovery steadily increased to 41.4% at 12 months in the early group while patients in the delayed group showed no further improvement. Thus, full recovery was achieved in only 17.7% of patients at 12 months. Only early sildenafil treatment independently improved full recovery at 12 months (HR 2.943, p = 0.034). CONCLUSIONS: Our trial provides clinical data to suggest that earlier rehabilitation with phosphodiesterase type 5 inhibitors can contribute to the recovery of erectile function after radical prostatectomy in the clinical setting.

Penile rehabilitation for postprostatectomy erectile dysfunction.

BACKGROUND: Despite efforts to preserve the neurovascular bundles with nerve-sparing surgery, erectile dysfunction remains common following radical prostatectomy. Postoperative penile rehabilitation seeks to restore erectile function but results have been conflicting. OBJECTIVES: To evaluate the effects of penile rehabilitation strategies in restoring erectile function following radical prostatectomy for prostate cancer. SEARCH METHODS: We performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase), the Cochrane Library, Web of Science, clinical trial registries (ClinicalTrials.gov, International Clinical Trials Registry Platform) and a grey literature repository (Grey Literature Report) from their inception through to 3 January 2018. We also searched the reference lists of other relevant publications and abstract proceedings. We applied no language restrictions. SELECTION CRITERIA: We included randomised or quasi-randomised trials with a parallel or cross-over design. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. Two review authors independently screened the literature, extracted data, assessed risk of bias and rated quality of evidence according to GRADE on a per-outcome basis. Primary outcomes were self-reported potency, erectile function measured by validated questionnaires (with potency defined as an International Index of Erectile Function (IIEF-EF) score of 19 or greater and or an IIEF-5 of score of 17 or greater) and serious adverse events. For all quality of life assessments on a continuous scale, higher values indicated better quality of life. MAIN RESULTS: We included eight randomised controlled trials with 1699 participants across three comparisons. This abstract focuses on the primary outcomes of this review only.Scheduled phosphodiesterase type 5 inhibitors (PDE5I) versus placebo or no treatmentScheduled PDE5I may have little or no effect on short-term (up to 12 months) self-reported potency (risk ratio (RR) 1.13, 95% confidence interval (CI) 0.91 to1.41; very low quality evidence), which corresponds to 47 more men with self-reported potency per 1000 (95% CI 33 fewer to 149 more) and short-term erectile function as assessed by a validated instrument (RR 1.11, 95% CI 0.80 to 1.55; very low quality evidence), which corresponds to 28 more men per 1000 (95% CI 50 fewer to 138 more), but we are very uncertain of both of these findings. Scheduled PDE5I may result in fewer serious adverse events compared to placebo (RR 0.32, 95% CI 0.11 to 0.94; low quality evidence), though this does not appear biologically plausible and may represent a chance finding. We are also very uncertain of this finding. We found no long-term (longer than 12 months) data for any of the three primary outcomes.Scheduled PDE5I versus on-demand PDE5I Daily PDE5I appears to result in little to no difference in both short-term and long-term (greater than 12 months) self-reported potency (short term: RR 0.97, 95% CI 0.62 to 1.53; long term: RR 1.00, 95% CI 0.60 to 1.67; both very low quality evidence); this corresponds to nine fewer men with self-reported short-term potency per 1000 (95% CI 119 fewer to 166 more) and zero fewer men with self-reported long-term potency per 1000 (95% CI 153 fewer to 257 more). We are very uncertain of these findings. Daily PDE5I appears to result in little to no difference in short-term and long-term erectile function (short term: RR 1.00, 95% CI 0.65 to 1.55; long term; RR 0.74, 95% CI 0.48 to 1.14; both very-low quality evidence), which corresponds to zero men with short-term erectile dysfunction per 1000 (95% CI 80 fewer to 125 more) and 119 fewer men with long-term erectile dysfunction per 1000 (95% CI 239 fewer to 64 more). We are very uncertain of these findings. Scheduled PDE5I may result in little or no effects on short-term adverse events (RR 0.69 95% CI 0.12 to 4.04; very low quality evidence), which corresponds to seven fewer men with short-term serious adverse events (95% CI 18 fewer to 64 more), but we are very uncertain of these findings. We found no long-term data for serious adverse events.Scheduled PDE5I versus scheduled intraurethral prostaglandin E1At short-term follow-up, daily PDE5I may result in little or no effect on self-reported potency (RR 1.10, 95% CI 0.79, to 1.52; very low quality evidence), which corresponds to 46 more men per 1000 (95% CI 97 fewer to 241 more). Daily PDE5I may result in a small improvement of erectile function (RR 1.64, 95% CI 0.84 to 3.20; very low quality evidence), which corresponds to 92 more men per 1000 (95% CI 23 fewer to 318 more) but we are very uncertain of both these findings. We found no long-term (longer than 12 months) data for any of the three primary outcomes.We found no evidence for any other comparisons and were unable to perform any of the preplanned subgroup analyses based on nerve-sparing approach, age or baseline erectile function. AUTHORS' CONCLUSIONS: Based on mostly very-low and some low-quality evidence, penile rehabilitation strategies consisting of scheduled PDE5I use following radical prostatectomy may not promote self-reported potency and erectile function any more than on demand use.

Penile Rehabilitation Therapy Following Radical Prostatectomy: A Meta-Analysis.

BACKGROUND: Penile rehabilitation, defined as the use of any drug or device at or after radical prostatectomy to maximize erectile function recovery, is commonly used for post-prostatectomy erectile dysfunction; however, conflicting results based on each study make it difficult to give a recommendation for clinical practice. AIM: To clarify the effect of oral phosphodiesterase type 5 inhibitors (PDE5is), vacuum erection devices, intracorporeal injection therapy, and the combination of these treatments on penile rehabilitation. METHODS: A comprehensive publication search was done through the PubMed and Embase databases up to February 8, 2017. The reference lists of the retrieved studies also were investigated. Data were analyzed using STATA 12.0. A fixed- or random-effects model was used to calculate the overall combined odds ratio (OR) or standard mean differences (SMDs). Publication bias was assessed using the Begg and Egger tests. OUTCOMES: Change in sexual function before and after treatment. RESULTS: After screening, 11 randomized controlled trials and 5 case-control studies were included. The overall meta-analysis showed that penile rehabilitation with PDE5is, vacuum erection devices, and intracorporeal injection significantly increased the number of patients with erectile function improvement (OR = 2.800, 95% CI = 1.932-4.059, P = .000) and International Index of Erectile Function (IIEF) score (SMD = 5.896, 95% CI = 4.032-7.760, P = .000). In subgroup analysis based on study design, randomized controlled trials and case-control studies showed that penile rehabilitation increased the number of patients with erectile function improvement (randomized controlled trials: OR = 2.154, 95% CI = 1.600-2.895, P = .000; case-control studies: OR = 2.800, 95% CI = 1.932-4.059, P = .000). Subgroup analysis for PDE5i treatment also only demonstrated an increased patient response rate (OR = 2.161, 95% CI = 1.675-2.788, P = .000) and IIEF scores (SMD = 0.922, 95% CI = 0.545-1.300, P = .000). However, after PDE5i washout, there was no improvement of spontaneous erectile function (OR = 1.027, 95% CI = 0.713-1.478, P = .610). CLINICAL TRANSLATION: This study provides information about the efficacy of penile rehabilitation that can help clinicians decide treatment strategies. STRENGTHS AND LIMITATIONS: This meta-analysis has higher statistical power than each study. Preoperative patient characteristics, various treatment methods, and different follow-up times might bring bias to pooled effects. CONCLUSION: Our meta-analysis confirmed that administration of PDE5is, vacuum erection devices, and intracorporeal injection after radical prostatectomy can increase erection function during treatments. However, current evidence does not support that penile rehabilitation with PDE5is can improve recovery of spontaneous erectile function. Further studies with adequate follow-up and larger samples should be conducted to generate a comprehensive conclusion. Liu C, Lopez DS, Chen M, Wang R. Penile Rehabilitation Therapy Following Radical Prostatectomy: A Meta-Analysis. J Sex Med 2017;14:1496-1503.

Sexual Rehabilitation After Treatment for Prostate Cancer-Part 1: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015).

INTRODUCTION: Sexual dysfunction is common in patients after radical prostatectomy (RP) for prostate cancer. AIM: To provide the International Consultation for Sexual Medicine (ICSM) 2015 recommendations concerning prevention and management strategies for post-RP erectile function impairment in terms of preoperative patient characteristics and intraoperative factors that could influence erectile function recovery. METHODS: A literature search was performed using Google and PubMed databases for English-language original and review articles published up to August 2016. MAIN OUTCOME MEASURES: Levels of evidence (LEs) and grades of recommendations (GRs) based on a thorough analysis of the literature and committee consensus. RESULTS: Nine recommendations are provided by the ICSM 2015 committee on sexual rehabilitation after RP. Recommendation 1 states that clinicians should discuss the occurrence of postsurgical erectile dysfunction (temporary or permanent) with every candidate for RP (expert opinion, clinical principle). Recommendation 2 states that validated instruments for assessing erectile function recovery such as the International Index of Erectile Function and Expanded Prostate Cancer Index Composite questionnaires are available to monitor EF recovery after RP (LE = 1, GR = A). Recommendation 3 states there is insufficient evidence that a specific surgical technique (open vs laparoscopic vs robot-assisted radical prostatectomy) promotes better results in postoperative EF recovery (LE = 2, GR = C). Recommendation 4 states that recognized predictors of EF recovery include but are not limited to younger age, preoperative EF, and bilateral nerve-sparing surgery (LE = 2, GR = B). Recommendation 5 states that patients should be informed about key elements of the pathophysiology of postoperative erectile dysfunction, such as nerve injury and cavernous venous leak (expert opinion, clinical principle). CONCLUSIONS: This article discusses Recommendations 1 to 5 of the ICSM 2015 committee on sexual rehabilitation after RP. Salonia A, Adaikan G, Buvat J, et al. Sexual Rehabilitation After Treatment for Prostate Cancer-Part 1: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017;14:285-296.

Sexual Rehabilitation After Treatment For Prostate Cancer-Part 2: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015).

INTRODUCTION: Sexual dysfunction is common in patients after radical prostatectomy (RP) for prostate cancer. AIM: To provide the International Consultation for Sexual Medicine (ICSM) 2015 recommendations concerning management strategies for post-RP erectile function impairment and to analyze post-RP sexual dysfunction other than erectile dysfunction. METHODS: A literature search was performed using Google and PubMed database for English-language original and review articles published up to August 2016. MAIN OUTCOME MEASURES: Levels of evidence (LEs) and grades of recommendations (GRs) are provided based on a thorough analysis of the literature and committee consensus. RESULTS: Nine recommendations are provided by the ICSM 2015 committee on sexual rehabilitation after RP. Recommendation 6 states that the recovery of postoperative erectile function can take several years (LE = 2, GR = C). Recommendation 7 states there are conflicting data as to whether penile rehabilitation with phosphodiesterase type 5 inhibitors improves recovery of spontaneous erections (LE = 1, GR = A). Recommendation 8 states that the data are inadequate to support any specific regimen as optimal for penile rehabilitation (LE = 3, GR = C). Recommendation 9 states that men undergoing RP (any technique) are at risk of sexual changes other than erectile dysfunction, including decreased libido, changes in orgasm, anejaculation, Peyronie-like disease, and changes in penile size (LE = 2, GR = B). CONCLUSION: This article discusses Recommendations 6 to 9 of the ICSM 2015 committee on sexual rehabilitation after RP. Salonia A, Adaikan G, Buvat J, et al. Sexual Rehabilitation After Treatment For Prostate Cancer-Part 2: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017;14:297-315.

[Value of non-sexual penile erection for penile rehabilitation in men with erectile dysfunction].

Erectile dysfunction (ED) is a common male disease. Some related studies show that the prevalence of ED is nearly 52% in men aged 40 to 70 years and is increasing among younger males. Hypoxia is now considered to be an independent risk factor for ED and the mechanisms of hypoxia inducing ED are varied and complicated. Recently, an idea in penile rehabilitation has attracted much attention, which aims at improving erectile function by increasing oxygen supply to the cavernosum and reducing tissue fibrosis and apoptosis. The approaches to achieve non-sexual penile erection by increasing oxygen supply to the cavernosum, such as behavior therapy, medication, vacuum constriction device, and intracavernous injection, can simulate normal sexual erection and help patients with penile rehabilitation. This review focuses on the strategies for non-sexual penile erection in penile rehabilitation.

Erectile Dysfunction.

Erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. It is common, affecting at least 12 million U.S. men. The five-question International Index of Erectile Function allows rapid clinical assessment of ED. The condition can be caused by vascular, neurologic, psychological, and hormonal factors. Common conditions related to ED include diabetes mellitus, hypertension, hyperlipidemia, obesity, testosterone deficiency, and prostate cancer treatment. Performance anxiety and relationship issues are common psychological causes. Medications and substance use can cause or exacerbate ED; antidepressants and tobacco use are the most common. ED is associated with an increased risk of cardiovascular disease, particularly in men with metabolic syndrome. Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia are recommended initial lifestyle interventions. Oral phosphodiesterase-5 inhibitors are the firstline treatments for ED. Second-line treatments include alprostadil and vacuum devices. Surgically implanted penile prostheses are an option when other treatments have been ineffective. Counseling is recommended for men with psychogenic ED.

Prospective evaluation of postoperative penile rehabilitation: penile length/girth maintenance 1 year following Coloplast Titan inflatable penile prosthesis.

INTRODUCTION: The most prevalent long-term complaint after successful inflatable penile prosthesis (IPP) surgery is reduction of penile length. The purpose of this study was to evaluate penile measurements in patients whose implantation experience included the aggressive new length measurement technique (NLMT) coupled with postoperative IPP rehabilitation (daily inflation) of the implant for 1 year. Moreover, we aimed to document objective data concerning dimensional changes of the phallus over time. Postoperative IPP rehabilitation has been discussed and presented at meetings, but no multi-institutional prospective data have been published. AIM: Our goal was to assess results using the Coloplast Titan IPP, with NLMT, and postoperative rehabilitation. METHODS: After IRB approval, we conducted a prospective, three-center study of 40 patients who underwent IPP placement, with NLMT for end organ failure erectile dysfunction with the Coloplast Titan IPP. The patient was instructed to inflate daily for 6 months and then inflate maximally for 1-2 hours daily for 6-12 months. Fifteen penile measurements were taken before and immediately after surgery and at follow-up visits. MAIN OUTCOME MEASURE: Penile length measurements after implantation compared with 12 months postimplantation. RESULTS: Penile measurement changes were statistically significantly improved at 12 months as compared with immediately postoperative and at 6 months. A total of 64.5% of subjects were satisfied with their length at 1 year, and 74.2% had perceived penile length that was longer (29%) or the same (45.2%) as prior to the surgery; 61.3% and 16.1% of subjects had increased and unchanged satisfaction, respectively, with penile length as compared with prior to IPP surgery. All but two subjects (93.4%) were satisfied with the overall function and dimensions of their IPP. CONCLUSION: This study suggests using the Coloplast Titan IPP with aggressive cylinder sizing, and a postoperative penile rehabilitation inflation protocol may help optimize patient satisfaction and erectile penile measurements.

Men's experience with penile rehabilitation following radical prostatectomy: a qualitative study with the goal of informing a therapeutic intervention.

BACKGROUND: Erectile rehabilitation (ER) following radical prostatectomy (RP) is considered an essential component to help men regain erectile functioning; however, many men have difficulty adhering to this type of program. This qualitative study explored men's experience with ER, erectile dysfunction (ED), and ED treatments to inform a psychological intervention designed to help men adhere to ER post-RP. METHODS: Thirty men, 1-to-3-years post-RP, who took part in an ER program, participated in one of four focus groups. Thematic analysis was used to identify the primary themes. RESULTS: Average age was 59 years (standard deviation = 7); mean time since surgery was 26 months (standard deviation = 6). Six primary themes emerged: (1) frustration with the lack of information about postsurgery ED; (2) negative emotional impact of ED and avoidance of sexual situations; (3) negative emotional experience with penile injections and barriers leading to avoidance; (4) the benefit of focusing on the long-term advantage of ER versus short-term anxiety; (5) using humor to help cope; and (6) the benefit of support from partners and peers. CONCLUSIONS: Men's frustration surrounding ED can lead to avoidance of sexual situations and ED treatments, which negatively impact men's adherence to an ER program. The theoretical construct of acceptance and commitment therapy was used to place the themes into a framework to conceptualize the mechanisms underlying both avoidance and adherence in this population. As such, acceptance and commitment therapy has the potential to serve as a conceptual underpinning of a psychological intervention to help men reduce avoidance to penile injections and adhere to an ER program.

A randomised controlled trial of a couples-based sexuality intervention for men with localised prostate cancer and their female partners.

OBJECTIVE: The diagnosis and treatment of prostate cancer is followed by substantive sexual morbidity. The optimal approach for intervening remains unclear. METHODS/DESIGN: A three-arm randomised control trial was undertaken with 189 heterosexual couples where the man had been diagnosed with prostate cancer and treated surgically. The efficacy of peer-delivered telephone support versus nurse-delivered telephone counselling versus usual care in improving both men's and women's sexual adjustment was investigated. Assessments were undertaken at baseline (pre-test) with follow-up at 3, 6 and 12 months. RESULTS: At 12 months, men in the peer (p = 0.016) and nurse intervention (p = 0.008) were more likely to use medical treatments for erectile dysfunction (ED) than men in the usual care arm. Men in the nurse intervention more frequently used oral medication for ED than men in usual care (p = 0.002). No significant effects were found for sexual function, sexuality needs, sexual self-confidence, masculine self-esteem, marital satisfaction or intimacy. CONCLUSION: Although peer and nurse couples-based interventions can increase use of medical treatments for ED, this may not translate into better sexual or relationship outcomes. More research is needed into the optimal timing of interventions to improve sexual outcomes for men with prostate cancer and to identify the subpopulations that will benefit from them.

Conservative management for postprostatectomy urinary incontinence.

BACKGROUND: Urinary incontinence is common after radical prostatectomy and can also occur in some circumstances after transurethral resection of the prostate (TURP). Conservative management includes pelvic floor muscle training with or without biofeedback, electrical stimulation, extra-corporeal magnetic innervation (ExMI), compression devices (penile clamps), lifestyle changes, or a combination of methods. OBJECTIVES: To determine the effectiveness of conservative management for urinary incontinence up to 12 months after transurethral, suprapubic, laparoscopic, radical retropubic or perineal prostatectomy, including any single conservative therapy or any combination of conservative therapies. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register (5 February 2014), CENTRAL (2014, Issue 1), EMBASE (January 2010 to Week 3 2014), CINAHL (January 1982 to 18 January 2014), ClinicalTrials.gov and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (both searched 29 January 2014), and the reference lists of relevant articles. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials evaluating conservative interventions for urinary continence in men after prostatectomy. DATA COLLECTION AND ANALYSIS: Two or more review authors assessed the methodological quality of the trials and abstracted data. We tried to contact several authors of included studies to obtain extra information. MAIN RESULTS: Fifty trials met the inclusion criteria, 45 in men after radical prostatectomy, four trials after TURP and one trial after either operation. The trials included 4717 men of whom 2736 had an active conservative intervention. There was considerable variation in the interventions, populations and outcome measures. Data were not available for many of the pre-stated outcomes. Men's symptoms improved over time irrespective of management.There was no evidence from eight trials that pelvic floor muscle training with or without biofeedback was better than control for men who had urinary incontinence up to 12 months after radical prostatectomy; the quality of the evidence was judged to be moderate (for example 57% with urinary incontinence in the intervention group versus 62% in the control group, risk ratio (RR) for incontinence after 12 months 0.85, 95% confidence interval (CI) 0.60 to 1.22). One large multi-centre trial of one-to-one therapy showed no difference in any urinary or quality of life outcome measures and had narrow CIs. It seems unlikely that men benefit from one-to-one PFMT therapy after TURP. Individual small trials provided data to suggest that electrical stimulation, external magnetic innervation, or combinations of treatments might be beneficial but the evidence was limited. Amongst trials of conservative treatment for all men after radical prostatectomy, aimed at both treatment and prevention, there was moderate evidence of an overall benefit from pelvic floor muscle training versus control management in terms of reduction of urinary incontinence (for example 10% with urinary incontinence after one year in the intervention groups versus 32% in the control groups, RR for urinary incontinence 0.32, 95% CI 0.20 to 0.51). However, this finding was not supported by other data from pad tests. The findings should be treated with caution because the risk of bias assessment showed methodological limitations. Men in one trial were more satisfied with one type of external compression device, which had the lowest urine loss, compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remained undetermined as no trials involving these interventions were identified. AUTHORS' CONCLUSIONS: The value of the various approaches to conservative management of postprostatectomy incontinence after radical prostatectomy remains uncertain. The evidence is conflicting and therefore rigorous, adequately powered randomised controlled trials (RCTs) which abide by the principles and recommendations of the CONSORT statement are still needed to obtain a definitive answer. The trials should be robustly designed to answer specific well constructed research questions and include outcomes which are important from the patient's perspective in decision making and are also relevant to the healthcare professionals. Long-term incontinence may be managed by an external penile clamp, but there are safety problems.