Unmet Sexual Health Resource Needs and Preferences for Interventions to Address These Needs Among Female Partners of Patients With Prostate Cancer.

OBJECTIVE: To characterize unmet sexual health resource needs and preferences for interventions to address unmet needs among female partners of patients with prostate cancer (PCa), given the significant negative impact of PCa on the sexual health of partners. METHODS: We conducted an exploratory sequential mixed methods study of female partners recruited from multiple U.S. clinical locations, websites, and support groups for caregivers. We first conducted semistructured in-depth interviews. Qualitative results informed development of a cross-sectional survey, which was administered to a larger sample of partners. RESULTS: Overall, 12 and 200 female partners participated in the qualitative and quantitative portions of the study. Major emergent themes from interviews were the benefits and drawbacks of technology-based interventions, the importance of sexual health resources throughout the PCa journey, and a desire for sexual health support groups that include partners. In the survey, the most common sexual health topics that partners wanted more information about were male libido problems (30.0%), erectile dysfunction (26.5%), and female libido and arousal problems (24.5%). Additionally, 41.5% wanted more information about sexual health websites, 35.0% about partners-only support groups, 29.5% about support groups for couples, and 23.5% about sexual medicine specialists. CONCLUSIONS: To our knowledge, this is the largest study to date on female partners' unmet sexual health resource needs and preferences for sexual health interventions. Partners prefer technology-based interventions, desire sexual health-focused support groups, and want more information about a variety of sexual issues and specialists who treat them.

Understanding the sexual health perceptions, concerns, and needs of female partners of prostate cancer survivors.

BACKGROUND: Prostate cancer (PCa) and its treatments can have a significant negative impact on the sexual health of survivors and couples, but few studies have specifically examined the impact of PCa-related sexual dysfunction on female partners of survivors. AIM: Our objective was to perform a qualitative study to comprehensively characterize female partners' perceptions of the implications of PCa on their sex lives, as well as partners' sexual health concerns and unmet needs. METHODS: We conducted semi-structured telephone interviews about sexual health and unmet needs with female partners of PCa survivors recruited from multiple clinical locations and support groups for PCa caregivers from September 2021 to March 2022. Interviews were audio-recorded, transcribed verbatim, and independently coded. Participants were recruited until thematic saturation was achieved. OUTCOMES: Outcomes of this study were female partner sexual health concerns and unmet needs. RESULTS: Among 12 participants, the median age was 65 (range 53 to 81) years, 9 were White, the median time since their partner's PCa diagnosis was 2.25 years (range 11 months to 20 years), and a majority reported that their partner had undergone radical prostatectomy, radiation, and/or hormonal therapy. Major emergent themes pertained to the significant impact of age- and PCa-related sexual dysfunction on female sexual quality of life, the dyadic nature of sexual dysfunction and recovery, the role of the partner in coping with and adjusting to sexual dysfunction, difficulties communicating about sexual dysfunction in an intimate relationship, a lack of physician-led sexual health counseling and support, and the benefit of peer interactions and proactive information seeking in addressing unmet sexual health needs. CLINICAL IMPLICATIONS: Future efforts should continue to explore the impact of PCa on partner sexual health and address unmet needs through sexual health education and support. STRENGTHS AND LIMITATIONS: In this study, we identified female partners' sexual health concerns both related to and independent of PCa survivor sexual health. Limitations include exclusion of male partners of survivors and potential responder bias, as partners who agreed to participate may have experienced more sexual health concerns. CONCLUSION: We found that female partners experience PCa-related sexual dysfunction as a couple's disease, grief due to age- and PCa-related sexual losses, and a lack of physician-led sexual health counseling and information. Our results highlight the importance of including partners of PCa survivors in the sexual recovery process and of developing sexual care programs to address partners' unmet sexual health needs.

Unmet Sexual Health Needs of Patients and Female Partners Following Diagnosis and Treatment for Prostate Cancer.

BACKGROUND: Prostate cancer (PCa) and its treatment can have significant and pervasive sexual side effects for patients and their partners; however, partner needs are not well understood, and most resources do not incorporate partner priorities. AIM: Our objective was to perform a qualitative study to identify unmet sexual needs of patients and female partners after PCa diagnosis. METHODS: We conducted a qualitative study of posts to the Inspire Us TOO Prostate Cancer Online Support and Discussion Community. Overall, 6,193 posts were identified in the Sexual Health & Intimacy forum of the community, of which 661 posts were from female authors. A random sample of 10% (n = 66) of posts from female partners and an equal number of randomly selected posts from male patients were analyzed. OUTCOMES: We assessed sexual health themes among patients and female partners. RESULTS: Multiple themes emerged that were unique to female partners of PCa survivors. These included expanding the sexual repertoire, feeling invisible, contextualizing sexual intimacy within the broader picture of survival, and addressing relationship concerns. Patients and their partners also shared common sexual health themes, including coming to terms with changes in sexual function and frustration with clinicians. Both patients and their partners use online health communities to get support and share their experiences with sexual recovery and use of sexual aids. Psychosocial treatments were infrequently mentioned, and may be particularly helpful to address partner concerns. CLINICAL IMPLICATIONS: A common concern for couples was not receiving sufficient information from healthcare providers regarding sexual side effects from PCa and its treatment. STRENGTHS AND LIMITATIONS: Strengths of the study include leveraging a unique data source to address an understudied topic of sexual health concerns among partners after PCa diagnosis. However, members of an online community may not be representative of all couples facing PCa. Also, this analysis is limited to female partners of patients with PCa, and further study is underway to examine the sexual health needs among gay and bisexual couples. CONCLUSION: Both patients and female partners have many unmet sexual health needs during PCa survivorship, and designing interventions to incorporate partner perspectives may improve the management of sexual side effects of PCa for couples. Li R, Wittmann D, Nelson CJ, et al. Unmet Sexual Health Needs of Patients and Female Partners Following Diagnosis and Treatment for Prostate Cancer. J Sex Med 2022;19:1797-1803.

Phosphodiesterase Type-5 Inhibitor Prescription Patterns in the United States Among Men With Erectile Dysfunction: An Update.

BACKGROUND: While phosphodiesterase type-5 inhibitors (PDE5Is) are highly effective for the treatment of erectile dysfunction (ED) and well tolerated, updated data on prescription patterns have been limited in real-world settings. AIM: To describe men in the United States who are prescribed PDE5Is for ED treatment and to evaluate patterns of initiation, switching, and treatment overlap. METHODS: This retrospective claims study used MarketScan Commercial and Medicare Supplement Databases from January 1, 2010, to December 31, 2015, to identify initial PDE5I claims (index date) for sildenafil, tadalafil, and/or vardenafil. Adults aged ≥18 years with ED were identified between July 1, 2010, and December 31, 2014, allowing for a 6-month preindex and 12-month follow-up period from the index date. OUTCOMES: Outcomes included patient demographics and treatment-related patterns after treatment initiation. RESULTS: A total of 106,206 identified patients met all inclusion criteria. Of these, 51,694, 40,193, and 14,319 had initial claims for sildenafil, tadalafil, and vardenafil, respectively. Mean age was 50.35 years, and comorbidities included dyslipidemia (44.17%), hypertension (43.09%), diabetes (15.32%), and depression (10.61%). More patients (48.67%) initiated on sildenafil than tadalafil (37.85%) or vardenafil (13.48%). Rate of switching was lower in the 60 days after the end of day supply of the initial prescription in the sildenafil cohort (2.71%) compared with the tadalafil (2.81%) and vardenafil (3.88%) cohorts (P < .001 for sildenafil vs tadalafil or vardenafil). Treatment overlap was lower in the sildenafil cohort (0.35%) than in the tadalafil (0.75%) and vardenafil (0.62%) groups (P < .001 for sildenafil vs tadalafil or vardenafil). CLINICAL IMPLICATIONS: These findings provide insight into updated patterns of PDE5I prescriptions in the United States and may aid in clinical decision-making. STRENGTHS & LIMITATIONS: Strengths include the large sample size, long data coverage period, and the real-world nature of the study. Limitations include the retrospective study design, use of data collected with a primary focus of claims, and lack of further details regarding reasons that drive switching. Actual rates of ED and impact on prescription patterns may be underestimated because the claims database only captured patients electing to visit a health-care provider. CONCLUSION: Among men with ED in the United States, rates of switching and treatment overlap were low for all PDE5Is but were found to be the lowest for sildenafil compared with tadalafil and vardenafil. Mulhall JP, Chopra I, Patel D, et al. Phosphodiesterase Type-5 Inhibitor Prescription Patterns in the United States Among Men With Erectile Dysfunction: An Update. J Sex Med 2020;17:941-948.

Predictors of Satisfaction in Men After Penile Implant Surgery.

INTRODUCTION: Despite the high satisfaction with penile implant (PI) surgery reported in the literature, a significant proportion of patients remain dissatisfied. AIM: To evaluate satisfaction after PI surgery, using a single question and a scoring system. Furthermore, we attempted to define factors that predicted high patient satisfaction. METHODS: The study population consisted of all patients undergoing PI surgery between 2009 and 2015. Comorbidity, demographic, and implant information were recorded. Complications recorded included: minor (requiring no re-operation) such as penile or scrotal hematoma, superficial wound breakdown; major (requiring hospitalization or re-operation) such as device infection, erosion, and mechanical malfunction. Patient satisfaction was defined using a single question posed to the patient 6 months after surgery using a 5-point Likert scale (5 being the most satisfied). Descriptive statistics were used to define complication rates and multivariable analysis (MVA) was performed to define predictors of high satisfaction (score ≥ 4), including presence and degree of complications, Peyronie's disease (PD), diabetes mellitus (DM), number of vascular comorbidities, body mass index (BMI) > 30, and patient age. MAIN OUTCOME MEASURE: Patients with a major complication, with or without an additional minor complication, had a higher likelihood of being dissatisfied (25%) compared to patients with no complication or only minor complication 1.9% (no complications) and 3.7% (only minor complications), P < .001. RESULTS: 902 patients were analysed. Mean age was 56.6 ± 10.6 years. Mean BMI was 30 ± 5. Comorbidity profile was diabetes 75%, dyslipidaemia 44%, hypertension 33%, cigarette smoking 32%, and PD 34%. 76% had a malleable implant (MPP) and 24% an inflatable implant (IPP). 31% had a minor complication and 9% a major complication. 93% had high satisfaction (score ≥4). Patients with any complication had a reduced rate of high satisfaction (97.5% vs 87.7%; P < .001) and even more pronounced with a major complication (96.7% vs 64.2%; P < .001). On MVA, only the absence of a major complication was a significant predictor of high satisfaction (OR 20, 95% CI 9-50, P < .001). CONCLUSION: A high percentage of men are satisfied after penile implant surgery. Only the presence of a major complication is linked to a lower likelihood of achieving high satisfaction. Habous M, Tal R, Tealab A, et al. Predictors of Satisfaction in Men After Penile Implant Surgery. J Sex Med 2018;15:1180-1186.

Exploring the Optimal Erectile Function Domain Score Cutoff That Defines Sexual Satisfaction After Radical Prostatectomy.

INTRODUCTION: The International Index of Erectile Function (IIEF) is the gold standard validated instrument for defining erectile function (EF) and its response to treatment. The EF domain (EFD) contains six questions and is a sensitive and specific measurement of treatment-related changes in EF. The EFD score has been widely used as a primary assessment end point for clinical trials of EF recovery after radical prostatectomy (RP). Various EFD scores have been used to define functional erections. Recently, an EFD score of at least 22 has been used as a threshold in major post-RP penile rehabilitation studies. AIM: To define the EFD score that optimally defines "functional" erections after RP. METHODS: We assessed men 24 months after RP using the IIEF and specifically analyzed the scores of the EFD and intercourse satisfaction domain (ISD). MAIN OUTCOME MEASURES: We used two questions on satisfaction (score = 0-5) and enjoyment (score = 0-5) from the ISD to classify IS (score = 0-10). We tested the following intercourse satisfaction classifications: ISD score equal to 10, ISD score of at least 8, and a score of at least 4 for the ISD questions on satisfaction and enjoyment. We used the classification that produced the largest area under the curve (AUC) using a receiver operating characteristic (ROC) curve. Then, we used a three-step process to determine the optimal EFD score cutoff using sensitivity and specificity analysis. RESULTS: One hundred seventy-eight men had an average age at RP of 58 ± 7 years and a 24-month EFD score of 20 ± 9. Sixty-four percent had complete nerve-sparing surgery, 35% had partial nerve-sparing surgery, and 1% had the nerves fully resected. Thirty-three percent had laparoscopic RP and 67% had open RP. The ROC curves produced AUCs of 0.80 (ISD score = 10), 0.85 (ISD score ≥ 8), and 0.86 (ISD scores for satisfaction and enjoyment ≥ 4; P < .001 for all comparisons). Using the IS criterion of ISD scores for satisfaction and enjoyment of at least 4 (largest AUC), the sensitivity and specificity values were 0.89 and 0.66 for an ESD score equal to 22, 0.78 and 0.71 for a score equal to 23, 0.78 and 0.80 for a score equal to 24, 0.77 and 0.82 for a score equal to 25, and 0.73 and 0.85 for a score equal to 26. The scores of 24 and 25 met the criteria outlined in the first two steps of analysis. The score of 24 was selected as the cutoff using face valid judgment and the previous literature. CONCLUSION: These data support an EFD score of 24 as a valid cutoff defining "functional" erection in men with erectile dysfunction after RP. These data are important for clinicians in counseling patients and to researchers to define inclusion criteria and treatment end points for trials of erectile dysfunction after RP. Terrier JE, Muhall JP, Nelson CJ. Exploring the Optimal Erectile Function Domain Score Cutoff That Defines Sexual Satisfaction After Radical Prostatectomy. J Sex Med 2017;14:804-809.

Three-Dimensional Photography for Quantitative Assessment of Penile Volume-Loss Deformities in Peyronie's Disease.

BACKGROUND: Non-curvature penile deformities are prevalent and bothersome manifestations of Peyronie's disease (PD), but the quantitative metrics that are currently used to describe these deformities are inadequate and non-standardized, presenting a barrier to clinical research and patient care. AIM: To introduce erect penile volume (EPV) and percentage of erect penile volume loss (percent EPVL) as novel metrics that provide detailed quantitative information about non-curvature penile deformities and to study the feasibility and reliability of three-dimensional (3D) photography for measurement of quantitative penile parameters. METHODS: We constructed seven penis models simulating deformities found in PD. The 3D photographs of each model were captured in triplicate by four observers using a 3D camera. Computer software was used to generate automated measurements of EPV, percent EPVL, penile length, minimum circumference, maximum circumference, and angle of curvature. The automated measurements were statistically compared with measurements obtained using water-displacement experiments, a tape measure, and a goniometer. OUTCOMES: Accuracy of 3D photography for average measurements of all parameters compared with manual measurements; inter-test, intra-observer, and inter-observer reliabilities of EPV and percent EPVL measurements as assessed by the intraclass correlation coefficient. RESULTS: The 3D images were captured in a median of 52 seconds (interquartile range = 45-61). On average, 3D photography was accurate to within 0.3% for measurement of penile length. It overestimated maximum and minimum circumferences by averages of 4.2% and 1.6%, respectively; overestimated EPV by an average of 7.1%; and underestimated percent EPVL by an average of 1.9%. All inter-test, inter-observer, and intra-observer intraclass correlation coefficients for EPV and percent EPVL measurements were greater than 0.75, reflective of excellent methodologic reliability. CLINICAL TRANSLATION: By providing highly descriptive and reliable measurements of penile parameters, 3D photography can empower researchers to better study volume-loss deformities in PD and enable clinicians to offer improved clinical assessment, communication, and documentation. STRENGTHS AND LIMITATIONS: This is the first study to apply 3D photography to the assessment of PD and to accurately measure the novel parameters of EPV and percent EPVL. This proof-of-concept study is limited by the lack of data in human subjects, which could present additional challenges in obtaining reliable measurements. CONCLUSION: EPV and percent EPVL are novel metrics that can be quickly, accurately, and reliably measured using computational analysis of 3D photographs and can be useful in describing non-curvature volume-loss deformities resulting from PD. Margolin EJ, Mlynarczyk CM, Muhall JP, et al. Three-Dimensional Photography for Quantitative Assessment of Penile Volume-Loss Deformities in Peyronie's Disease. J Sex Med 2017;14:829-833.

Exploratory Decision-Tree Modeling of Data from the Randomized REACTT Trial of Tadalafil Versus Placebo to Predict Recovery of Erectile Function After Bilateral Nerve-Sparing Radical Prostatectomy.

BACKGROUND: Understanding predictors for the recovery of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) might help clinicians and patients in preoperative counseling and expectation management of EF rehabilitation strategies. OBJECTIVE: To describe the effect of potential predictors on EF recovery after nsRP by post hoc decision-tree modeling of data from A Study of Tadalafil After Radical Prostatectomy (REACTT). DESIGN, SETTING, AND PARTICIPANTS: Randomized double-blind double-dummy placebo-controlled trial in 423 men aged <68 yr with adenocarcinoma of the prostate (Gleason ≤7, normal preoperative EF) who underwent nsRP at 50 centers from nine European countries and Canada. INTERVENTION: Postsurgery 1:1:1 randomization to 9-mo double-blind treatment with tadalafil 5mg once a day (OaD), tadalafil 20mg on demand, or placebo, followed by a 6-wk drug-free-washout, and a 3-mo open-label tadalafil OaD treatment. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Three decision-tree models, using the International Index of Erectile Function-Erectile Function (IIEF-EF) domain score at the end of double-blind treatment, washout, and open-label treatment as response variable. Each model evaluated the association between potential predictors: presurgery IIEF domain and IIEF single-item scores, surgical approach, nerve-sparing score (NSS), and postsurgery randomized treatment group. RESULTS AND LIMITATIONS: The first decision-tree model (n=422, intention-to-treat population) identified high presurgery sexual desire (IIEF item 12: ≥3.5 and <3.5) as the key predictor for IIEF-EF at the end of double-blind treatment (mean IIEF-EF: 14.9 and 11.1), followed by high confidence to get and maintain an erection (IIEF item 15: ≥3.5 and <3.5; IIEF-EF: 15.4 and 7.1). For patients meeting these criteria, additional non-IIEF-related predictors included robot-assisted laparoscopic surgery (yes or no; IIEF-EF: 19.3 and 12.6), quality of nerve sparing (NSS: <2.5 and ≥2.5; IIEF-EF: 14.3 and 10.5), and treatment with tadalafil OaD (yes and no; IIEF-EF: 17.6 and 14.3). Additional analyses after washout and open-label treatment identified high presurgery intercourse satisfaction as the key predictor. CONCLUSIONS: Exploratory decision-tree analyses identified high presurgery sexual desire, confidence, and intercourse satisfaction as key predictors for EF recovery. Patients meeting these criteria might benefit the most from conserving surgery and early postsurgery EF rehabilitation. Strategies for improving EF after surgery should be discussed preoperatively with all patients; this information may support expectation management for functional recovery on an individual patient level. PATIENT SUMMARY: Understanding how patient characteristics and different treatment options affect the recovery of erectile function (EF) after radical surgery for prostate cancer might help physicians select the optimal treatment for their patients. This analysis of data from a clinical trial suggested that high presurgery sexual desire, sexual confidence, and intercourse satisfaction are key factors predicting EF recovery. Patients meeting these criteria might benefit the most from conserving surgery (robot-assisted surgery, perfect nerve sparing) and postsurgery medical rehabilitation of EF. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01026818.

Analysis of the Interobserver Variability in Penile Length Assessment.

INTRODUCTION: Many men seek penile augmentation treatments-a standard tool for their counseling is to inform them of what is "normal." Although some studies suggest good correlation between stretched and erect penile length, those that have measured stretched and erect length simultaneously have shown significant variability. AIM: To assess the accuracy of differing penile measurements with multiple observers. METHODS: We recruited 201 adult men (mean age 49.6 years) who achieved full erection using intracavernosal injection. MAIN OUTCOME MEASURES: Penile measurements were taken by one of seven andrology specialists in a private, temperature-controlled (21°C, 72°F) environment. Stretched flaccid and erect length and circumference were measured. We analyzed the accuracy of each flaccid measurement using the erect measurements as a reference, for the overall patient population and for each observer. RESULTS: The mean underestimate of length from stretched flaccid to erect was 2.64 cm (21.4%) and girth 2.27 cm (19.5%). Interobserver variability ranged from a mean underestimate of 16-27% (length) and 15-27% (girth). CONCLUSIONS: In this large, multicenter, multi-observer study of penis size, flaccid measurements underestimated erect size. It also seems likely that there is significant interobserver variability. We believe erect penis measurements should be used for men being considered for treatment of small penis anxiety.

Concordance between patient and physician assessment of the magnitude of Peyronie's disease curvature.

INTRODUCTION: The magnitude of penile deformity is a critically important factor in Peyronie's disease, as it is associated with increased difficulty in penetrative sexual intercourse and in turn with negative psychosocial consequences. Deformity magnitude also influences treatment choice when surgical correction is indicated. AIM: To determine the concordance between patient and physician assessment of magnitude of penile curvature in men with Peyronie's disease. METHODS: Patient assessment of curvature was obtained at initial interview. Physician assessment was performed using intracavernosal injection-assisted erection using a goniometer applied during excellent penile rigidity. MAIN OUTCOME MEASURES: Patient and physician assessments of penile curvature. RESULTS: The sample consisted of 192 men with a mean age of 54 ± 12 years old. Mean curvature on patient and physician assessment was 33 ± 17 and 36 ± 18 degrees, respectively. Only 49% of patients (94) correctly assessed their curvature, whereas 35% underestimated and 16% overestimated it. CONCLUSIONS: Only half of PD patients accurately assess their penile curvature, with more than twice as many patients underestimating it than overestimating it. These data suggest that patient self-reporting of penile curvature should not be used as a clinical marker or end point in Peyronie's disease trials.

Erectile dysfunction after plaque incision and grafting: short-term assessment of incidence and predictors.

INTRODUCTION: Plaque incision and grafting (PIG) surgery for Peyronie's disease (PD) is a recognized management strategy. One of the recognized complications of PIG surgery is the development of postoperative erectile dysfunction (ED). AIM: To determine the incidence of ED after PIG surgery and attempt to define predictors of ED development. METHODS: All patients underwent preoperative cavernosometry. Grafting was performed with either cadaveric pericardium (Tutoplast) or intestinal submucosa (Surgisis). Prior to 2006, the procedure used an H-type incision, whereas after this date, the Egydio approach has been used. MAIN OUTCOME MEASURES: Men undergoing PIG completed preoperative and 6-month postoperative International Index of Erectile Function (IIEF) questionnaires. RESULTS: 56 patients were analyzed. Mean patient and partner ages were 57 ± 22 and 54 ± 18 years, respectively. Mean duration of PD at the time of PIG was 22 ± 9 months. Seventy-five percent had curvature alone, 11% had hourglass/indentation deformity, and the remainder had combined curvature/indentation. Mean preoperative curvature was 52 ± 23°. Fifty-two had grafting with Tutoplast, while four had grafting with Surgisis. All men at baseline were capable of generating a penetration rigidity erection. Preoperatively, 50% of men had cavernosal insufficiency and 21% had venous leak (baseline and postoperative erectile function [EF] domain scores were 23 ± 4 and 17 ± 9, respectively [P < 0.01]). Forty-six percent of men experienced a ≥6-point decrease in EF domain score after PIG. The predictors of a ≥6-point reduction in IIEF-EF domain score on multivariable analysis were degree of preoperative curvature, type of plaque incision, patient age, and baseline venous leak. Conclusions. Almost one-half of men had significant reduction in their erectile rigidity after PIG. Reduction was predicted by larger baseline curvature, the Egydio plaque incision technique, older patient age, and the presence of venous leak at baseline. Based on these data, we discourage older men, those with venous leak, and those with profound curvature from considering PIG surgery.

The erection hardness score and its relationship to successful sexual intercourse.

INTRODUCTION: The Erection Hardness Score (EHS), recently validated, was developed in 1998 as a simple (one-item) method to quantify erection outcome data. Although it is intuitive that erection hardness and successful sexual intercourse (SSI) are related, the link has not been directly established. OBJECTIVE: To evaluate the relationship between erection hardness (assessed by EHS) and SSI, establishing the EHS as a clinically useful tool. METHODS: The data set (N = 307) was from a multinational, double-blind, placebo-controlled trial (with open-label extension) of sildenafil citrate in men with erectile dysfunction. MAIN OUTCOME MEASURES: Event-based modeling used every intercourse attempt and the EHS to estimate the odds ratio of SSI between adjacent EHS categories. Mean-based modeling used mean EHS per patient to determine its relationship to percentage of SSI. Mediation-based modeling used mean EHS and mean percentage of SSI over the double-blind phase to estimate the direct effect of sildenafil treatment on SSI and the indirect effect of sildenafil treatment on SSI via erection hardness. RESULTS: The odds of SSI for EHS 3 (hard enough for penetration but not completely hard) were 41.9 times (95% confidence interval [CI], 33.0-53.2; P < 0.0001) that for EHS 2 (hard but not hard enough for penetration), and the odds of SSI for EHS 4 (completely hard and fully rigid) were 23.7 times (95% CI, 19.5-28.9; P < 0.0001) that for EHS 3. The percentage of SSI increased approximately curvilinearly with the increase in mean EHS, from almost 60% at EHS 3 to 78.5% at EHS 3.5 and to 93.1% at EHS 4. The indirect effect of sildenafil treatment on SSI via erection hardness accounted for almost 90% of the total effect on SSI (P < 0.0001). CONCLUSION: The close and direct relationship between erection hardness and SSI supports the broader use of the EHS-a simple, valid, reliable, and responsive measure-in clinical practice.

Assessment of comparative treatment satisfaction with sildenafil citrate and penile injection therapy in patients responding to both.

OBJECTIVE: To survey patient satisfaction, using validated questionnaires, in a group of men with erectile dysfunction who had used and responded to both sildenafil citrate and intracavernosal injection (ICI) therapy. PATIENTS AND METHODS: In all, 300 patients on ICI therapy were mailed questionnaire packets containing a survey enquiring about the patients' medical history, and two sets of the International Index of Erectile Function (IIEF) and the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) sexual function surveys. If patients were using sildenafil alternating with ICI they were asked to complete the IIEF and EDITS questionnaires for each therapy. To identify only patients who had an adequate response to each agent, a score of >/=22 on the EF domain of the IIEF for sildenafil and ICI was required for inclusion in the final analysis. RESULTS: In all, 178 packets were evaluable; 123 men (69%) responded to ICI but not sildenafil, and 11 (6%) responded only to sildenafil and not ICI, leaving 37 patients who responded to both; these patients comprised the study population. There was no difference in EF domain score of the IIEF between the treatments; EDITS scores were significantly higher for ICI therapy than for sildenafil (P < 0.001). CONCLUSIONS: In patients who alternate the use of sildenafil and ICI therapy, satisfaction appears to be higher with ICI, although the erectogenic performance is similar. This suggests that patient satisfaction does not depend solely on erection performance, and that patients might benefit from various treatment options.

Assessment of penile vibratory stimulation as a management strategy in men with secondary retarded orgasm.

OBJECTIVES: To evaluate the effectiveness of penile vibratory stimulation for the management of retarded orgasm. Retarded orgasm, a condition characterized by difficulty achieving orgasm and ejaculation, is one of the most recalcitrant of the male sexual dysfunctions. Currently, no evidence-based treatments have been proven to ameliorate this condition. METHODS: Men who had a complete inability to achieve an orgasm during sexual relations in the previous 3 months were instructed in the use of penile vibratory stimulation. The men's responses were measured by self-report of orgasm function and using the orgasm and satisfaction domains of the International Index of Erectile Function. The responses were assessed at baseline (admission into the study) and at 3 and 6 months. RESULTS: A total of 36 men met the inclusion criteria, and 72% reported the restoration of orgasm. These responders reported that orgasm during sexual relations occurred 62% of the time. A statistically and clinically significant increase occurred in the orgasm and satisfaction domains of the International Index of Erectile Function between the baseline visit and the 3-month follow-up visit. These gains were sustained at 6 months. CONCLUSIONS: Penile vibratory stimulation is an effective treatment for retarded orgasm. Penile vibratory stimulation should be integrated into current cognitive-behavioral sex therapy techniques to achieve maximal effectiveness and satisfaction.

The economic effect of switching from sildenafil to another phosphodiesterase type 5 inhibitor.

Patients who could benefit from additional education about treatments for erectile dysfunction (ED) may prematurely discontinue or switch ED medications, resulting in unnecessary resource utilization. In a retrospective cohort study using a large, aggregated health claims database, the costs associated with switching from sildenafil to another phosphodiesterase type 5 (PDE-5) inhibitor were compared with those for patients refilling sildenafil. Of the 15,584 patients with an index sildenafil claim, 10,863 had a second PDE-5 inhibitor prescription (10,137 for sildenafil, 726 for vardenafil or tadalafil). Erectile dysfunction-attributable costs in the six-month preindex period were similar (P = .72), but postindex six-month ED costs were higher in patients who initially switched from sildenafil (dollar 173.38) versus patients who refilled sildenafil (dollar 131.51; P < .001). Regression analysis estimated that corrected ED-attributable and overall costs were 41% (P < .001) and 43% (P < .001) higher for patients who switched versus those who refilled sildenafil, respectively.

Assessment of the impact of sildenafil citrate on lower urinary tract symptoms in men with erectile dysfunction.

INTRODUCTION: Sildenafil citrate is an effective and well-tolerated oral erectogenic medication. Through phosphodiesterase type 5 (PDE5) inhibition, it induces relaxation in penile smooth muscle, resulting in erection. Due to its mild affinity for other PDE enzymes, it may cause smooth muscle relaxation in a number of other organs. Recent data suggest an association between erectile dysfunction (ED) and lower urinary tract symptoms (LUTS). Anecdotally some patients cite improvement in LUTS while using sildenafil. AIM: This study was conducted to assess the impact of Viagra on LUTS, using the International Prostate Symptom Score (IPSS) questionnaire. MAIN OUTCOME MEASURE: International Index of Erectile Function (IIEF) and IPSS inventories. METHODS: Men presenting to a sexual dysfunction clinic who were candidates and opted for treatment with sildenafil completed the IIEF and IPSS. Men with the IPSS scores greater than 10 were enrolled and completed the IPSS and IIEF questionnaires at least 3 months after the commencement of sildenafil. Comparisons were made between pre- and posttreatment scores in the IPSS and erectile function (EF) domain of the IIEF. RESULTS: Forty-eight men were enrolled, with a mean age of 62 +/- 11 years. The mean improvement in the EF domain score was 7 points (P = 0.01). The mean improvement in the IPSS score was 4.6 points (P = 0.013) and in quality of life (QOL) score was 1.4 points (P = 0.025). In total, 60% of men improved their IPSS score, and 35% had at least a 4-point improvement in their score. The mean number of uses of sildenafil per week was 2.0 +/- 0.6. No significant correlation was seen between the degree of the IPSS improvement and baseline IPSS, baseline EF domain score, or magnitude of improvement in EF domain score. CONCLUSIONS: These data indicate a positive impact of Viagra on men with mild to moderate LUTS. It is presumed, although unproven, that the medication's effect is mediated through bladder neck/prostatic smooth muscle relaxation.

Cavernous nerve stimulation and interposition grafting: a critical assessment and future perspectives.

The sexual dysfunction that results from radical prostatectomy for carcinoma of the prostate is well established, with the degree of macroscopic preservation of the cavernous nerves tied to the degree of postoperative recovery of erectile function that is possible. In addition to the use of preoperative neuroprotective drugs and postoperative erectogenic agents, intraoperative nerve stimulation and grafting offer promise. Nerve stimulation may serve as a predictor of postoperative potency, and nerve grafting offers a potential way to correct the damage that occurs during wide resection. This article reviews the current literature on these intraoperative measures and discusses the need for additional studies of their potential benefits in prostatectomy candidates.

Serial assessment of efficacy and satisfaction profiles following penile prosthesis surgery.

PURPOSE: Penile implants are associated with a high level of patient satisfaction. Studies to date have failed to use instruments that accurately record patient satisfaction data. We used 2 validated instruments to assess the chronology of efficacy and satisfaction profiles in men undergoing penile prosthetic surgery. MATERIALS AND METHODS: Men who elected penile implant surgery were administered the International Index of Erectile Function (IIEF) questionnaire preoperatively, and 3, 6 and 12 months postoperatively as well as the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire 3, 6 and 12 months postoperatively. Comparison was done of preoperative and postoperative values for the overall IIEF, IIEF erectile function domain, IIEF satisfaction domain and EDITS. All surgeries were primary and in all patients an inflatable implant device was placed. RESULTS: A total of 96 men with a mean age of 56 years were enrolled in the study. All 12-month scores were statistically significantly higher than baseline scores. The 12-month values were statistically higher than 6-month values for the IIEF satisfaction domain and for EDITS. CONCLUSIONS: This study indicates that implant surgery causes a dramatic improvement in erectile function. It also indicates that satisfaction increases in year 1 after implant surgery with significant improvements in the second half of year 1. Current efforts are aimed at following this cohort of patients in an even more long-term fashion as well as evaluating partner satisfaction profiles. These findings should permit clinicians to provide penile prosthesis candidates with optimistic and realistic expectations for implant device function and postoperative satisfaction.