Prevalence, classifications and factors associated with sexual dysfunction among adult cancer patients on chemotherapy at the Uganda Cancer Institute, Mbarara.

BACKGROUND: Sexual dysfunction is a social challenge that devastates many people, including cancer patients. However, among the numerous reported side effects of chemotherapy sexual dysfunction is the least studied and reported. The chemotherapeutics used among cancer patients are potential risk factors for the development of sexual dysfunction, and such an understanding of these risk factors can lead to numerous interventions to bypass their effects on sexual activity. OBJECTIVE: The goal of this study was to determine the prevalence, classification and factors associated with sexual dysfunction among cancer patients receiving chemotherapy. METHODS: A cross-sectional study was conducted among 214 cancer patients at the Mbarara Regional Referral Hospital in southwestern Uganda for a period of 3 months from August to October 2023. A systematic sampling technique was employed in the study; a questionnaire was used to collect patient data. The standardized female sexual function index and international index of erectile function tools were used to classify types of sexual dysfunctions among women and men, respectively. Sexual dysfunction-associated factors were analyzed by logistic regression using Stata version 17. RESULTS: A total of 127 males and 87 females with a median age of 50 years were enrolled. Overall (42.1%) of the patients, (54.3%) males and (24.1%) females experienced sexual dysfunction. (33.9%) of male reported overall sexual dissatisfaction, while among female (18.4%) patients reported decreased sexual desire. while others reported reduced arousal and vaginal pain. Multivariate logistic regression revealed the following independent risk factors for sexual dysfunctions: male sex (AOR 3.99, 95% CI 1.93-8.25; p value = 0.001), gastrointestinal cancer (AOR 3.46, 95% CI 1.34-8.93; p value = 0.010) and anthracyclines use (AOR 4.26, 95% CI 1.02, 17.76; p value = 0.047). CONCLUSIONS: Our findings suggest that there is a high prevalence of sexual dysfunction among cancer patients at the Mbarara Regional Referral Hospital. In male patients, overall sexual dissatisfaction is the most prevalent, while decreased sexual desire is prevalent in females. Routine screening of sexual functions should be encouraged for all patients receiving chemotherapies. Males patients, those diagnosed with gastrointestinal cancers and those receiving regimens containing anthracyclines should be more closely monitored for sexual dysfunction.

Pseudoephedrine for ejaculatory dysfunction after retroperitoneal lymph node dissection in testicular cancer.

OBJECTIVE: To assess the impact of ejaculatory dysfunction (EjD; failure of emission or retrograde ejaculation) on health-related quality of life (HRQoL) after retroperitoneal lymph node dissection (RPLND) for testicular cancer and explore the efficacy of pseudoephedrine hydrochloride as treatment. PATIENTS AND METHODS: In a single arm, phase II trial, patients at ≥6 months after RPLND were invited to complete patient-reported outcome measures (European Organisation for Research and Treatment of Cancer [EORTC] quality of life questionnaire [QLQ]-30-item core, EORTC QLQ-testicular cancer-26, and Brief Male Sexual Function Inventory) evaluating HRQoL and sexual function in follow-up (ACTRN12622000537752/12622000542796). If EjD was reported, post-ejaculatory urine ± semen analysis was undertaken. In eligible patients, pseudoephedrine hydrochloride 60 mg was administered orally every 6 h for six doses. The primary endpoint was sperm count >39 million sperm/ejaculate (>5th centile) following treatment. The trial was powered to detect a clinically relevant 36% achieving sperm count of >39 million sperm/ejaculate. Secondary endpoints included semen volume >1.5 mL, total motile sperm count, safety, and HRQoL impacts. RESULTS: Of the 58 patients enrolled, the median (interquartile range [IQR]) age was 35 (29-41) years, with a median (IQR) of 37 (18-60) months from RPLND. EjD was reported in 33 (57%), including 27/52 (52%) receiving follow-up at our centre. There were no differences in global HRQoL; however, role functioning (P = 0.045), sexual problems (P < 0.005), and sexual enjoyment (P = 0.005) was poorer if EjD was present. In all, 24/33 (73%) patients with EjD consented to pseudoephedrine treatment. Of 22 evaluable patients, four (18%) achieved a sperm count of >39 million/ejaculate (P = 0.20), and four (18%) had a semen volume of >1.5 mL (P = 0.20). There was a mean increase of 105 million sperm/ejaculate (P = 0.051) and 1.47 mL increase in semen volume (P = 0.01). No safety concerns arose. CONCLUSION: Ejaculatory dysfunction is common after RPLND but did not impact global HRQoL in our cohort. Pseudoephedrine improved EjD for some; however, its efficacy was lower than expected. Pseudoephedrine may be considered on an individualised basis.

Antidepressant nonadherence and sexual dysfunction among young adult males: the cross-sectional YAMAN study.

PURPOSE: Selective serotonin reuptake inhibitors are associated with high rates of nonadherence and sexual dysfunction, yet the correlation between these findings in young adult men is poorly characterized. We aimed to evaluate if young adult men are less willing to adhere to antidepressant treatment due to intolerable side effects, such as sexual dysfunction. METHODS: Deidentified, compensated survey that assessed baseline demographics, PHQ-8 and GAD-7 scores, attitudes towards antidepressant medication side effects, and perceptions of antidepressant medications including selective serotonin reuptake inhibitors, bupropion, and mirtazapine. RESULTS: From 665 delivered surveys, 505 respondents completed their survey (response rate: 76%), of which 486 were included for final analysis. After seeing common side effect profiles, our sample's willingness to take sexual function-sparing agents, such as bupropion or mirtazapine, was significantly greater than selective serotonin reuptake inhibitors (p < 0.001), with no significant difference between bupropion and mirtazapine (p = 0.263). The negative influence of erectile dysfunction and anorgasmia scored significantly higher than other common antidepressant side effects like weight gain, nausea, and dry mouth (range: p < 0.001, p = 0.043). With the exception of insomnia, participants indicated that experiencing sexual dysfunction while taking an antidepressant medication would lead to nonadherence at a significantly higher frequency than any other side effect assessed (range: p < 0.001, p = 0.005). CONCLUSION: The risk of experiencing sexual side effects when taking antidepressants could lead young adult men to become nonadherent to these medications. Strategies to augment the effectiveness of antidepressants, such as shared decision-making and the use of sexual function-sparing agents, are critical.

Pelvic Floor Dysfunction in Transgender Men on Gender-affirming Hormone Therapy: A Descriptive Cross-sectional Study.

INTRODUCTION AND HYPOTHESIS: The objective of this research is to explore the effects of hormone therapy using testosterone on pelvic floor dysfunction (PFD) in transgender men. We hypothesize that PFD might be prevalent among transgender men undergoing hormone therapy. Therefore, this study was aimed at verifying the frequency of these dysfunctions. METHODS: A cross-sectional study was conducted between September 2022 and March 2023 using an online questionnaire, which included transgender men over 18 years old who underwent gender-affirming hormone therapy. Volunteers with neurological disease, previous urogynecology surgery, active urinary tract infection, and individuals without access to the internet were excluded. The questionnaire employed validated tools to assess urinary symptoms, such as urinary incontinence (UI), as well as sexual dysfunction, anorectal symptoms, and constipation. The data were analyzed descriptively and presented as frequencies and prevalence ratios with their respective confidence intervals (95% CI), mean, and standard deviation. RESULTS: A total of 68 transgender men were included. Most participants had storage symptoms (69.1%), sexual dysfunction (52.9%), anorectal symptoms (45.6%), and flatal incontinence (39.7%). Participants with UI symptoms reported moderate severity of the condition. CONCLUSIONS: Transgender men on hormone therapy have a high incidence of PFD (94.1%) and experience a greater occurrence of urinary symptoms (86.7%).

Symptomatic androgen deficiency and sexual dysfunctions in male patients receiving alectinib for ALK-positive advanced non-small cell lung cancer.

BACKGROUND: It is reported that treatment with anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) induces hypogonadism both in male patients with ALK-positive cancer and in murine models. METHODS: In this study, three groups, including an experimental group of male patients with ALK-positive, advanced non-small cell lung cancer (ANSCLC) who were receiving alectinib (cohort A), a control group of female patients with ALK-positive ANSCLC who were receiving alectinib (cohort B), and a control group of male patients with ALK-negative ANSCLC (cohort C), prospectively underwent a full hormone assessment for androgen deficiency at 8 weeks after the start of treatment and in case of reported suspected symptoms. Patients with major sexual dysfunctions were referred to an endocrinologist. RESULTS: Ninety-five patients were consecutively enrolled onto the study. Among sixty-eight male patients, both median total testosterone levels (2.93 vs. 4.92 ng/ml; p = .0001) and free testosterone levels (0.11 vs. 0.17 pg/ml; p = .0002) were significantly lower in ALK-positive ANSCLC patients in cohort A compared with ALK-negative patients in cohort C; conversely, median FSH (10.32 vs. 17.52 mUI/ml; p = .0059) and LH levels (4.72 vs. 7.49 mUI/ml; p = .0131) were significantly higher in cohort C compared to cohort A. Median inhibin B levels were higher in ALK-positive male patients (74.3 vs. 44.24 pg/ml; p = .0038), but all patients had inhibin B values within the normal range. The percentage of male patients who had positive scores on the Androgen Deficiency in Aging Males (ADAM) questionnaire was 62% in cohort A and 26.8% in cohort C, including eight patients who reported at least one major symptom and were referred to Andrology Unit. No significant differences in the endocrine assessment were reported between cohorts A and B. CONCLUSIONS: Symptoms of androgen deficiency should be tracked in male patients with ALK-positive ANSCLC who are receiving alectinib, and testosterone replacement should be considered, as appropriate.

Characteristics of systemic testosterone therapy for female hypoactive sexual desire disorder-a claims database analysis.

BACKGROUND: Testosterone therapy (TTh) is recommended for postmenopausal women with hypoactive sexual desire disorder (HSDD); however, there remain insufficient data to support use of TTh in premenopausal women with sexual dysfunction. AIM: In this study, we used a large national database to evaluate prescribing trends of TTh for women with HSDD. METHODS: We conducted a cohort analysis of information from electronic health records acquired from the data network TriNetX Diamond. The study cohort consisted of women 18-70 years of age with a diagnosis of HSDD. We analyzed trends of testosterone prescriptions, routes of testosterone administration, and coadministration of testosterone with estrogen. OUTCOMES: Despite an increase in rates of testosterone prescriptions for HSDD, there remains a high degree of variability in the duration of treatment, route of administration, and coadministration of estrogen with significant underprescription of testosterone. RESULTS: Our query of the TriNetX database led to the identification of 33 418 women diagnosed with HSDD at a mean age of 44.2 ± 10.8 years, among whom 850 (2.54%) women received a testosterone prescription. The testosterone prescriptions were highly variable with regard to duration and route of administration and coadministration with estrogen. For all patients until 2015, the prevalence of testosterone prescriptions for HSDD showed a positive quadratic relation was observed. Since 2015 a linear increase in prevalence was observed, with the highest rate of increase for patients aged 41-55 years. CLINICAL IMPLICATIONS: The findings of this study reveal a significant need for further research investigating the optimal use of TTh to enhance the sexual health of women with HSDD, and further studies on the long-term effects of testosterone use must be undertaken to ensure that patients have access to safe and effective treatment. STRENGTHS AND LIMITATIONS: Limitations to this study include patient de-identification and lack of availability of testosterone dosage data. However, this study also has many strengths, including being the first, to our knowledge, to characterize the prescribing trends of testosterone for women with HSDD. CONCLUSION: Testosterone therapy should be considered as a potential therapy for premenopausal female patients with HSDD. Further studies on the long-term effects of testosterone use must be undertaken to address disparities in the management of HSDD and to ensure patients can access treatment.

Initial observations on sexual dysfunction as a symptom of chemotherapy-induced peripheral neuropathy.

Introduction: Peripheral neuropathy (PNP) in feet and/or hands and sexual dysfunction are common side effects of cancer therapies. In patients with other diseases, there is evidence of an association between peripheral nervous system disorders and sexual dysfunction due to the impact of impaired neuronal control on genital organ sensitivity. In cancer patient interviews, it has now been observed that PNP and sexual dysfunction may be related. The aim of the study was to investigate the potential association between PNP, sexual dysfunction, and physical activity behavior. Methods: Ninety-three patients with PNP of the feet and/or hands were interviewed in August/September 2020 in a cross-sectional study regarding medical history, sexual dysfunction and functionality of the genital organs. Results: Thirty-one persons who participated in the survey provided seventeen evaluable questionnaires (four men, thirteen women). Nine women (69%) and three men (75%) reported sensory disorders of the genital organs. Three men (75%) had erectile dysfunction. All men who had sensory symptoms of the genital organs received chemotherapy, and one man also received immunotherapy. Eight women were sexually active. Five (63%) of them reported genital organ symptoms and mainly lubrication disorders. Four (80%) of the five sexually inactive women reported genital organ symptoms. Eight of the nine women with sensory symptoms of the genital organs received chemotherapy, and one woman received immunotherapy. Discussion: Our limited data suggest genital organ sensory symptoms in chemotherapy and immunotherapy patients. Genital organ symptoms do not appear to be directly related to sexual dysfunction, and the association between PNP and genital organ symptoms appears to be more pronounced in sexually inactive women. Chemotherapy could cause sensory symptoms of the genital organs and sexual dysfunction by damaging genital organ nerve fibers. Chemotherapy and anti-hormone therapy (AHT) could trigger a disturbance of the hormone balance, which in turn could be causative for sexual dysfunction. It remains open whether the cause of these disorders is the symptomatology of the genital organs or the altered hormone balance. The significance of the results is limited due to the small number of cases. To our knowledge, this study is the first of its kind in cancer patients and allows a better understanding of the association between PNP, sensory symptoms of the genital organs, and sexual dysfunction. Conclusion: In order to be able to narrow down the cause of these initial observations in cancer patients more precisely, larger studies are needed that can relate the influence of cancer therapy-induced PNP, physical activity level and hormone balance to sensory symptoms of the genital organs and sexual dysfunction. The methodology of further studies should take into account the frequent problem of low response rates in surveys on sexuality.

Hormone therapy in the treatment of breast cancer and main outcomes in sexuality

Hormone-dependent breast cancer has growth factors that respond positively to the hormones estrogen and progesterone. Thus, adjuvant endocrine therapy causes decreased or undetectable serum levels of these hormones. However, this treatment can have side effects that compromise the sexual health of patients, such as dyspareunia, vaginal dryness and decreased libido. In this scenario, the objective of this work was to document the main outcomes in sexuality in women after treatment for hormonepositive breast cancer. Thus, this is an integrative literature review, in which the following databases were used: U.S. National Library of Medicine (PubMed), Virtual Health Library (BVS), SCOPUS and Scientific Electronic Library Online (SCIELO), using the descriptors: "sexuality", "antineoplastic agents, hormonal" and "breast neoplasms", joined by the Boolean operator "AND". Full articles published in the last 5 years (2017-2022) were included; written in Portuguese or English. Articles dealing with non-hormone-dependent or metastatic breast cancer, or with patients younger than 18 years, or articles that did not answer the research question were excluded. In total, 26 articles were identified, of which 7 comprised the final sample of this review. A total of 3,850 women participated in the included studies. The main sexual dysfunctions found were: dyspareunia, hot flashes, decreased libido, vaginal dryness, breast tenderness, self-image concerns and hair loss. The symptom vaginal dryness was the most prevalent, mentioned in 71.4% of the articles included. In view of the adverse effects listed in this review, there is a need to carry out more studies on this topic, since the diagnosis of this comorbidity brings clinical, psychological, emotional, sociocultural and economic outcomes for the patient. Thus, a multidisciplinary team must assertively address these complaints to improve the overall quality of life of these women (AU)

Sexual dysfunction in people treated with long-acting injectable antipsychotics in monotherapy or polypharmacy: a naturalistic study.

Sexual dysfunction, psychosis, and antipsychotics are known to be related, but the precise association between them is still unknown. Most evidence about the prevalence of sexual dysfunction in people treated with antipsychotic drugs comes from studies with restrictive samples. That is why our main objective was to determine the prevalence of sexual dysfunction in a real-life sample of outpatients treated with antipsychotics, considering gender. A cross-sectional naturalistic study was developed, including people treated with long-acting injectable antipsychotics, with or without other psychotropic drugs. Participants were interviewed to assess sexual satisfaction through a Likert scale (0 to 10) and the presence of sexual dysfunction (the Psychotropic-Related Sexual Dysfunction Questionnaire, PRSexDQ-SALSEX). The participants also had a blood test to determine prolactin (men and women) and testosterone levels (men only). A total of 131 people participated in the study (90 men and 41 women). Some extent of sexual dysfunction was found in 62.2% of men and 51.2% of women. The most frequent sexual dysfunction symptom for both genders was the loss of libido (45%). Hyperprolactinemia was present in 56% of men and 61% of women. The presence of sexual dysfunction was associated with higher doses of antipsychotics, hyperprolactinemia, and smoking in men and with smoking and hyperprolactinemia in postmenopausal women. This study provides real-life evidence of sexual dysfunction and hyperprolactinemia in persons treated with long-acting injectable antipsychotics segregated by gender. The high rates of sexual dysfunction and hyperprolactinemia detected corroborate the need to consider these aspects in clinical practice.

Risk of Depression Associated With Finasteride Treatment.

BACKGROUND: Finasteride is one of several inhibitors of the 5α-reductase that converts testosterone to dihydrotestosterone used to treat hair loss and benign prostatic enlargement. Emerging clinical observations indicate that such treatment may be associated with depression, anxiety, and possibly increased suicidal risks, in addition to sexual dysfunction, even after its discontinuation. METHODS: We carried out a systematic review of reports pertaining to association of finasteride treatment with clinical depression or other adverse psychiatric effects. We analyzed reported risks of depression by pooling of rates and by meta-analysis of comparisons of subjects treated with finasteride or not. FINDINGS: Crude pooled rates of depressive symptoms with versus without finasteride were 3.33% (confidence interval, 3.22%-3.44%) versus 2.54% (2.44%-2.64%); random-effects meta-analysis yielded an odds ratio of 2.14 (1.40-3.27) (both P < 0.0001). In addition, risk of suicidal ideation or behavior was greater with versus without finasteride (21.2% [21.0%-21.5%] vs 14.0% [13.8%-14.2%], P < 0.0001), and risk of sustained sexual dysfunction was high (60.1% [37.3%-82.9%]). CONCLUSIONS: The findings support a growing impression that finasteride is associated with adverse psychiatric effects that can persist in association with sexual dysfunction after discontinuing finasteride treatment.

Evidence-based approaches for the management of side-effects of adjuvant endocrine therapy in patients with breast cancer.

The growing availability of more effective therapies has contributed to an increased survival of patients with breast cancer. In hormone receptor-positive early disease, increased survival is strongly correlated with the use of adjuvant endocrine therapy, but this therapy can cause side-effects that have major consequences in terms of treatment adherence and patients' quality of life. In premenopausal breast cancer survivors, these side-effects might be even more prominent due to the abrupt suppression of oestrogen associated with the most intense endocrine therapies. An important ambition of cancer care in the 21st century is to recover pre-cancer quality of life and emotional and social functions, which is only possible through the mitigation of the side-effects of anticancer treatments. This Review presents a comprehensive summary of the efficacy and safety data of the available interventions (hormonal and non-hormonal pharmacological strategies, non-pharmacological approaches, and complementary and alternative medicine) to control selected side-effects associated with adjuvant endocrine therapy (hot flashes, sexual dysfunction, weight gain, musculoskeletal symptoms, and fatigue), providing updated, evidence-based approaches for their management.

Sexual function in men undergoing androgen deprivation therapy.

Androgen deprivation therapy (ADT) has a deleterious effect on sexual functions and general well-being in men. Despite this evidence, however, patient and couple knowledge about ADT side effects as well as their management is poor. Similar considerations can be made for physician endorsement of management strategies. In this paper, we summarize and critically discuss available evidence regarding the possible associations between ADT and sexual dysfunction as well as the best therapeutical options. Preclinical data show that ADT is associated with penile contractility impairment as well as lower response to phosphodiesterase type 5 inhibitors (PDE5i). Available data indicate that ADT resulted in a five to sixfold increased risk of reduced libido and in a threefold increased risk of ED confirming the main role of testosterone in regulating sexual desire. Despite this evidence, sexuality remains an important aspect of health and well-being for men and their partner. The best therapeutical options depend on patient and couple desires and needs. When nonpenetrative erections are still possible, nonpenetrative activities should be encouraged to maintain sexual intimacy. A combined and personal educational program including the collaboration of different professional figures (including general physicians, oncologists, andrologists, sexologists, and psychologists) trained in sexual medicine is advisable in order to provide the best support to subjects undergoing ADT.

The majority of Danish breast cancer survivors on adjuvant endocrine therapy have clinically relevant sexual dysfunction: a cross-sectional study.

BACKGROUND: Impairments in sexual function are common among breast cancer survivors (BCSs), particularly in BCSs receiving adjuvant endocrine therapy (AET). Whether these impairments cause distress, thus qualifying for a more clinically relevant diagnosis of sexual dysfunction (SD), is inadequately described among BCSs and represents an important research gap. Hence, the primary aim of this study was to estimate the prevalence of clinically relevant SD, in this context: impairments with associated distress, and to identify factors associated with SD among BCSs on AET. Secondly, to explore the extent of distress caused by specific impairments in sexual function. MATERIALS AND METHODS: In this cross-sectional study of BCSs on adjuvant treatment with endocrine therapy for at least three months, participants completed an online survey comprising standardized measures of sexual and psychosocial function. Female Sexual Function Index (FSFI) and Sexual Complaint Screener - Women (SCS-W) were used to asses clinically relevant SD. Multiple regression analyses were performed to identify factors significantly associated with SD. RESULTS: In total, 333 BCSs with a mean age of 58.7 years were included in the study, of whom 227 were sexually active. Among sexually active BCSs, 134 (59%) met the criteria for having clinically relevant SD, of whom 78 (58%) perceived cancer treatment as the primary reason for their sexual problems. Factors associated with SD included vaginal dryness (adjusted OR= 2.25, 95% CI: 1.52-3.34, p < .01) and psychological well-being (adjusted OR= 1.11, 95% CI: 1.03-1.18, p < .01). Age was not related to neither prevalence of SD nor the level of distress caused by any impairment, with exception of low sexual desire. Pain in relation to intercourse was the most distressing impairment. CONCLUSION: SD was highly prevalent among sexually active BCSs on AET. Sexual health is important to address independent of the woman's age.

Reproductive health in patients with epilepsy.

The aim of the present study was to review existing knowledge on the impact of epilepsy in reproductive health of both sexes. Extensive searches of relevant documentation published until February 2020 were retrieved from PubMed and Google Scholar literature in English or in other languages with an English abstract. In females, epilepsy may lead to estrogen and androgen level abnormalities. Women with epilepsy may develop Polycystic Ovaries Syndrome (PCOS), anovulatory cycles, and menstrual disorders. In men, epilepsy may cause sex hormone dysregulation and influence spermatogenesis. Males with epilepsy may also suffer from sexual dysfunction. Antiepileptic drugs (AEDs) have adverse effects on peripheral endocrine glands, influence hormones' biosynthesis and protein binding, diminish the bioactivity of serum sex hormones, and lead to secondary endocrine disorders related to changes concerning body weight and insulin sensitivity. Valproic acid (VPA) was the first recognized AED to cause disturbances potentially due to metabolic changes and increasing weight. Women taking VPA may develop PCOS, while men may have sperm abnormalities and/or sexual dysfunction. Liver enzyme inducing AEDs may also cause menstrual and sexual disorders in women and sexual dysfunction in men. Newer AEDs are much safer but studies still suggest reduced sexuality and erectile dysfunction.

The effect of paternal exposure to immunosuppressive drugs on sexual function, reproductive hormones, fertility, pregnancy and offspring outcomes: a systematic review.

BACKGROUND: Information regarding the possible influence of immunosuppressive drugs on male sexual function and reproductive outcomes is scarce. Men diagnosed with immune-mediated diseases and a wish to become a father represent an important neglected population since they lack vital information to make balanced decisions about their treatment. OBJECTIVE AND RATIONALE: The aim of this research was to systematically review the literature for the influence of paternal immunosuppressive drug use on many aspects of male sexual health, such as sexual function, fertility, pregnancy outcomes and offspring health outcomes. SEARCH METHODS: A systematic literature search was performed in the bibliographic databases: Embase (via Elsevier embase.com), MEDLINE ALL via Ovid, Cochrane Central Register of Trials (via Wiley) and Web of Science Core Collection. Additionally, Google Scholar and the Clinical trial registries of Europe and the USA were searched. The databases were searched from inception until 31 August 2019. The searches combined keywords regarding male sexual function and fertility, pregnancy outcomes and offspring health with a list of immunosuppressive drugs. Studies were included if they were published in English and if they included original data on male human exposure to immunosuppressive drugs. A meta-analysis was not possible to perform due to the heterogeneity of the data. OUTCOMES: A total of 5867 references were identified, amongst which we identified 161 articles fulfilling the eligibility criteria. Amongst these articles, 50 included pregnancy and offspring outcomes and 130 included sexual health outcomes. Except for large Scandinavian cohorts, most of the identified articles included a small number of participants. While a clear negative effect on sperm quality was evident for sulfasalazine and cyclophosphamide, a dubious effect was identified for colchicine, methotrexate and sirolimus. In three articles, exposure to tumour necrosis factor-α inhibitors in patients diagnosed with ankylosing spondylitis resulted in improved sperm quality. The information regarding pregnancy and offspring outcomes was scant but no large negative effect associated with paternal immunosuppressive drug exposure was reported. WIDER IMPLICATIONS: Evidence regarding the safety of immunosuppressive drugs in men with a wish to become a father is inconclusive. The lack of standardisation on how to evaluate and report male sexual function, fertility and reproduction as study outcomes in men exposed to immunosuppressive drugs is an important contributor to this result. Future research on this topic is needed and should be preferably done using standardised methods.

Post-finasteride syndrome

Abstract Finasteride is a 5α-reductase enzyme inhibitor that has been approved for the treatment of male androgenic alopecia since 1997. Over time, it has been considered a safe and well-tolerated drug with rare and reversible side effects. Recently there have been reports of adverse drug-related reactions that persisted for at least three months after discontinuation of this drug, and the term post-finasteride syndrome arose. It includes persistent sexual, neuropsychiatric, and physical symptoms. Studies to date cannot refute or confirm this syndrome as a nosological entity. If it actually exists, it seems to occur in susceptible people, even if exposed to small doses and for short periods, and symptoms may persist for long periods. Based on currently available data, the use of 5α-reductase inhibitors in patients with a history of depression, sexual dysfunction, or infertility should be carefully and individually assessed.

Sexual Motivators and Endorsement of Models Describing Sexual Response of Men Undergoing Androgen Deprivation Therapy for Advanced Prostate Cancer.

BACKGROUND: Androgen deprivation therapy (ADT) administered against metastatic prostate cancer has significant side effects including sexual dysfunction. AIM: To assess sexual interest and motivators for sex during ADT and to find out what model of sexuality best describes the sexual experience for men during this treatment. METHODS: A questionnaire was mailed to patients who had received ADT for ≥6 months. Patients were asked to choose all relevant entities from a list of sexual motivators and between models of sexuality described by Masters and Johnson (excitement and physical experiences), Kaplan (sexual desire), and Basson (intimacy and closeness to partner). Erectile function was assessed by the Erection Hardness Scale, and sexual satisfaction was measured on a scale from 0 to 10. OUTCOMES: Sexual activity, erectile function, sexual satisfaction, and motivators for sexual interest in the study subjects as well as the proportion of participants who endorsed either of the 3 models of sexuality. RESULTS: A total of 173 men were invited, and 76 returned the questionnaires (44%). The median age was 76 (range 69-80) years, and the median duration of ADT was 30 months. A total of 62 men had been sexually active before ADT, and of these, 2 were still active. Another 29 were interested in sexual activity. 3 men endorsed the Masters and Johnson model, whereas the remaining participants did not endorse any of the models. The motivators for sexual interest were feeling an emotional connection to the partner (n = 16), sexual desire (n = 10), satisfaction of the partner (n = 8), fear that the partner would leave (n = 4), achieving orgasm (n = 3), and a desire to feel masculine (n = 1). No one was interested in sexual activity to reduce stress or to maintain confidence. Only 1 patient had erections sufficient for penetrative intercourse, and the median sexual satisfaction for the entire group was 0 (interquartile range: 0-5). CLINICAL IMPLICATIONS: Sexuality and sexual function should be addressed in men undergoing ADT. STRENGTHS & LIMITATIONS: The main strength of our study is that we are the first to explore both motivators for sexual activity and endorsement of sexual models in men undergoing ADT. The study is limited by the relatively low number of participants and the response rate of 44%. CONCLUSION: ADT is detrimental to sexual function. However, many patients maintain an interest in sexual activity, which does not fit our established models. Rather, factors such as keeping an emotional connection with a partner play a role. Fode M, Mosholt KS, Nielsen TK, et al. Sexual Motivators and Endorsement of Models Describing Sexual Response of Men Undergoing Androgen Deprivation Therapy for Advanced Prostate Cancer. J Sex Med 2020;17:1538-1543.

People smoke for nicotine, but lose sexual and reproductive health for tar: a narrative review on the effect of cigarette smoking on male sexuality and reproduction.

PURPOSE: To systematically review the impact of smoking habits on cardiovascular (CV) as well as on male sexual and reproductive function and to provide updated evidence on the role of electronic cigarettes (e-Cig) on the same topics. METHODS: A comprehensive Medline, Embase, and Cochrane search was performed including the following words: smoking, CV system, CV risk, erectile dysfunction (ED), and male fertility. Publications from January 1, 1969 up to February 29, 2020 were included. RESULTS: Smoking has a tremendous negative impact on CV mortality and morbidity. Current smoking behavior is also negatively associated with erectile dysfunction (ED) and impaired sperm parameters. E-Cig can release significantly lower concentrations of harmful substances when compared to regular combustible cigarettes. Whether or not the latter can result in positive CV, sexual, and fertility outcomes is still under study. Preliminary studies showed that exposure to e-Cig leads to lower vascular damage when compared to the traditional cigarette use. However, data on the long-term effects of e-Cig are lacking. Similarly, preliminary data, obtained in animal models, have suggested a milder effect of e-Cig on erectile function and sperm parameters. CONCLUSION: Available evidence showed that e-Cig are much less dangerous when compared to the traditional tobacco use. However, it should be recognized that the risk related to e-Cig is still higher when compared to that observed in non-smoking patients. Hence, e-Cig should be considered as a potential tool, in the logic of harm reduction, to reduce the CV, sexual and fertility risk in patients refractory to the fundamental, healthy choice to definitively quit smoking.

Update of the position paper on arterial hypertension and erectile dysfunction.

: Sexual health is an integral part of overall health, and an active and healthy sexual life is an essential aspect of a good life quality. Cardiovascular disease and sexual health share common risk factors (arterial hypertension, diabetes mellitus, dyslipidemia, obesity, and smoking) and common mediating mechanisms (endothelial dysfunction, subclinical inflammation, and atherosclerosis). This generated a shift of thinking about the pathophysiology and subsequently the management of sexual dysfunction. The introduction of phosphodiesterase type 5 inhibitors revolutionized the management of sexual dysfunction in men. This article will focus on erectile dysfunction and its association with arterial hypertension. This update of the position paper was created by the Working Group on Sexual Dysfunction and Arterial Hypertension of the European Society of Hypertension. This working group has been very active during the last years in promoting the familiarization of hypertension specialists and related physicians with erectile dysfunction, through numerous lectures in national and international meetings, a position paper, newsletters, guidelines, and a book specifically addressing erectile dysfunction in hypertensive patients. It was noted that erectile dysfunction precedes the development of coronary artery disease. The artery size hypothesis has been proposed as a potential explanation for this observation. This hypothesis seeks to explain the differing manifestation of the same vascular condition, based on the size of the vessels. Clinical presentations of the atherosclerotic and/or endothelium disease in the penile arteries might precede the corresponding manifestations from larger arteries. Treated hypertensive patients are more likely to have sexual dysfunction compared with untreated ones, suggesting a detrimental role of antihypertensive treatment on erectile function. The occurrence of erectile dysfunction seems to be related to undesirable effects of antihypertensive drugs on the penile tissue. Available information points toward divergent effects of antihypertensive drugs on erectile function, with diuretics and beta-blockers possessing the worst profile and angiotensin receptor blockers and nebivolol the best profile.

Post-finasteride syndrome: a surmountable challenge for clinicians.

Post-finasteride syndrome (PFS) is a constellation of serious adverse side effects manifested in clinical symptoms that develop and persist in patients during and/or after discontinuing finasteride treatment in men with pattern hair loss (androgenetic alopecia) or benign prostatic hyperplasia. These serious adverse side effects include persistent or irreversible sexual, neurological, physical and mental side effects. To date, there are no evidence-based effective treatments for PFS. Although increasing number of men report persistent side effects, the medical community has yet to recognize this syndrome nor are there any specific measures to address this serious and debilitating symptoms. Here we evaluate the scientific and clinical evidence in the contemporary medical literature to address the very fundamental question: Is PFS a real clinical condition caused by finasteride use or are the reported symptoms only incidentally associated with but not caused by finasteride use? One key indisputable clinical evidence noted in all reported studies with finasteride and dutasteride was that use of these drugs is associated with development of sexual dysfunction, which may persist in a subset of men, irrespective of age, drug dose or duration of study. Also, increased depression, anxiety and suicidal ideation in a subset of men treated with these drugs were commonly reported in a number of studies. It is important to note that many clinical studies suffer from incomplete or inadequate assessment of adverse events and often limited or inaccurate data reporting regarding harm. Based on the existing body of evidence in the contemporary clinical literature, the author believes that finasteride and dutasteride induce a constellation of persistent sexual, neurological and physical adverse side effects, in a subset of men. These constellations of symptoms constitute the basis for PFS in individuals predisposed to epigenetic susceptibility. Indeed, delineating the pathophysiological mechanisms underlying PFS will be of paramount importance to the understanding of this syndrome and to development of potential novel therapeutic modalities.