Erectile response profiles of men using PDE5 inhibitors combined with intracavernosal injections as part of a penile rehabilitation program after radical prostatectomy.

BACKGROUND: Phosphodiesterase type 5 (PDE5) inhibitor labeling states that these agents should not be used in conjunction with other erectogenic medications for fear of priapism occurring. AIM: We explored the risk of priapism and prolonged erections in men in our post-radical prostatectomy (RP) penile injection program who were using regular PDE5 inhibitor and intracavernosal injections (ICIs) as part of their rehabilitation program. METHODS: The study cohort included men on penile injection therapy who (1) were taking tadalafil 5 mg daily or taking sildenafil 25 mg on noninjection days, (2) had an RP, (3) were using their respective PDE5 inhibitor regularly at the time of penile injection training, and (4) complied with the program instructions regarding penile injection use. Demographics, comorbidity details, PDE5 inhibitor dose and utilization, and injection dose and utilization data were collected. All patients underwent in-office injection training and used trimix (papaverine/phentolamine/prostaglandin E1) as the intracavernosal medication. OUTCOMES: Priapism was defined as a patient self-reported penetration hardness erection ≥4 hours in duration, while prolonged erection was defined as a penetration hardness erection lasting ≥2 hours. RESULTS: A total of 112 tadalafil users and 364 sildenafil users were compared. Mean age and duration post-RP were 62 ± 14 years and 5.2 ± 12 months, respectively, and there was no difference between tadalafil and sildenafil groups. The mean trimix dose was tadalafil 24 ± 24 units and sildenafil 31 ± 37 units (P < .05). Priapism occurred in 2 (1.7%) of 112 tadalafil users and 5 (1.4%) of 364 sildenafil users (P = .47). Excluding those men experiencing priapism on any occasion, those with any reported penetration hardness erection lasting ≥2 hours were 7 (6.3%) of 112 tadalafil users and 12 (3.3%) of 364 sildenafil users (P < .01). A total of 53% of these prolonged erections occurred within the first 6 injections at home (no difference between tadalafil and sildenafil groups). CLINICAL IMPLICATIONS: We emphasize the need for continued monitoring and education on proper injection techniques to minimize the risk of adverse events in ICI and PDE5 inhibitor combination therapy. STRENGTHS & LIMITATIONS: This study has a relatively large patient population with a considerable follow-up time. Additionally, the rigorous training, education, and monitoring of the participants, as well as the use of formal definitions for priapism and prolonged erections, enhances the accuracy and reliability of the results. However, there are some limitations, such as social desirability, confounding factors, and recall bias. CONCLUSION: There is no significant difference in the incidence of priapism in an ICI program in which men combine ICI with tadalafil or sildenafil. However, tadalafil patients had a higher rate of prolonged erections, which was found to occur mostly early during the titration phase.

Verumontanum Polyp in an Adult Man: Diagnosis by Ultrasonography.

The fibroepithelial polyp of the urethra is rare in adults. Hematuria and obstructive urinary symptoms are the most common findings. The investigation of these polyps usually includes imaging exams (voiding cystourethrography and ultrasonography) and urinary endoscopy. However, the diagnosis is primarily established by pathology. Ultrasonography can aid in diagnosis, as it can identify a polypoid lesion that can extend to the bladder neck, and cystourethroscopy allows the direct visualization of the lesion. We report this case of a polyp of the prostatic urethra in an adult male using prospective real-time sonographic diagnosis.

Effects of androgen deprivation therapy on cognitive functions in patients with metastatic prostate cancer: A multicentric, prospective study of the Society of Urological Surgery Andrology group.

AIMS OF THE STUDY: The aim of this study was to investigate the impact of testosterone deficiency on cognitive functions in metastatic prostate cancer patients receiving androgen deprivation therapy (ADT). METHODS: In this multicentric prospective study, 65 metastatic prostate cancer patients were evaluated. Demographic and clinical data were recorded. Cognitive functions were assessed using the Symbol Digit Modalities Test, the California Verbal Learning Test Second Edition, the Brief Visuospatial Memory Test-Revised, and the Trail Making Test. Depressive symptoms were assessed using the Beck Depression Inventory. Cognitive functions and depressive symptoms were recorded before the androgen deprivation therapy and at the 3- and 6-month follow-ups. RESULTS: At the basal cognitive assessment, the mean Symbol Digit Modalities Test, the California Verbal Learning Test Second Edition, the Brief Visuospatial Memory Test-Revised scores were 25.84 ± 17.54, 32.68 ± 10.60, and 17.63 ± 11.23, respectively, and the mean time for the Trail Making Test was 221.56 ± 92.44 seconds, and were similar at the 3-month, and 6-month controls (P > .05). The mean pretreatment, third and sixth month testosterone levels were 381.40 ± 157.53 ng/dL, 21.61 ± 9.09 ng/dL and 12.25 ± 6.45 ng/dL (P < .05), and the total PSA levels were 46.46 ± 37.83 ng/mL, 1.41 ± 3.31 ng/mL and 0.08 ± 0.14 ng/mL (P < .05), respectively. CONCLUSION: The ADT in patients with metastatic prostate cancer does not affect patients' cognitive functions and depressive symptoms. However, further prospective randomised studies with higher cohorts and longer follow-up periods are needed.

An Evaluation of a Clinical Care Pathway for the Management of Men With Nonorganic Erectile Dysfunction.

INTRODUCTION: There exists little literature on the outcomes of the medical management of men with erectile dysfunction (ED) with no overt organic etiology. AIM: This study was conducted to assess the outcomes of men with nonorganic ED treated medically. METHODS: All patients had normal hormone profiles and vascular assessment. All were given a trial of a phosphodiesterase type 5 inhibitor (PDE5i). If no improvement was experienced, intracavernosal injection (ICI) therapy was administered. All patients were encouraged to seek a consultation with a mental health professional. MAIN OUTCOME MEASURE: Patient demographics, medical comorbidities, hormone and hemodynamics assessments, and change in International Index of Erectile Function scores of patients were recorded. RESULTS: 116 men with a mean age or 38 ± 19 (range 16-57) years were studied. 21% had mild ED, 47% had moderate ED, and 32% had severe ED. 21% had seen a psychiatrist. 81% of patients responded to PDE5i with a penetration hardness erection on follow-up (mean duration of 7 ± 3 months postcommencement of PDE5i). However, only 68% of these were capable of a consistently good response. The mean Erectile Function domain score on PDE5i for the entire group improved from 18 ± 11 to 22 ± 6 (P = .01), and for PDE5i responders it was 27 ± 4 (P < .001). 28% of men (22 PDE5i failures and 10 with a mixed response to PDE5i) attempted ICI, all obtaining consistently functional erections. At a mean time point of 11 ± 5 months, 83% of those responding to PDE5i had ceased using PDE5i due to a lack of need. 11% of those using ICI continued to use them 6 months after starting ICI; the remainder had been transitioned back to PDE5i. Of the 29 patients in the latter subgroup, 66% were no longer using PDE5i consistently due to a lack of need. CLINICAL IMPLICATIONS: Not all men with nonorganic ED respond to PDE5i initially and many of those who respond do so only intermittently; such patients are potentially curable, using erectogenic pharmacotherapy for erectile confidence restoration, most men are capable of being weaned from drug therapy. STRENGTHS & LIMITATIONS: The strengths of the study are the large number of patients and the use of serial validated instruments to assess erectile function outcomes. As a weakness, despite normal hormone and vascular assessments, the diagnosis of nonorganic ED is still a presumptive one. CONCLUSION: Medical management of nonorganic ED utilizing the process of care model results in cure in a large proportion of such patients. The transient use of ICI in some patients permits successful PDE5i rechallenge. Jenkins LC, Hall M, Deveci S, et al. An Evaluation of a Clinical Care Pathway for the Management of Men With Nonorganic Erectile Dysfunction. J Sex Med 2019;16:1541-1546.

A survey of patient expectations regarding sexual function following radical prostatectomy.

OBJECTIVE: To assess the understanding of patients, who had previously undergone radical prostatectomy (RP), about their postoperative sexual function, as clinical experience suggests that some RP patients have unrealistic expectations about their long-term sexual function. PATIENTS AND METHODS: Patients presenting within 3 months of their open RP or robot-assisted laparoscopic prostatectomy (RALP) were questioned about the sexual function information that they had received preoperatively. Patients were questioned about erectile function (EF), postoperative ejaculatory status, orgasm, and postoperative penile morphology changes. Statistical analyses were performed to assess for differences between patients who underwent open RP vs RALP. RESULTS: In all, 336 consecutive patients (from nine surgeons) with a mean (SD) age of 64 (11) years had the survey instrument administered (216 underwent open RP and 120 underwent RALP). There were no significant differences in patient age or comorbidity profiles between the two groups. Only 38% of men had an accurate recollection of their nerve-sparing status. The mean (SD) elapsed time after RP at the time of postoperative assessment was 3 (2) months. RALP patients expected a shorter EF recovery time (6 vs 12 months, P = 0.02), a higher likelihood of recovery back to baseline EF (75% vs 50%, P = 0.01), and a lower potential need for intracavernosal injection therapy (4% vs 20%, P = 0.01). Almost half of all patients were unaware that they were rendered anejaculatory by their surgery. None of the RALP patients and only 10% of open RP patients recalled being informed of the potential for penile length loss (P < 0.01) and none were aware of the association between RP and Peyronie's disease. CONCLUSIONS: Patients who have undergone RP have largely unrealistic expectations about their postoperative sexual function.

Sildenafil citrate improves erectile function after castration in a rat model.

TAKE HOME MESSAGE: The administration of phosphodiesterase 5 inhibitor commencing at the time of castration might preserve erectile function. OBJECTIVE: To determine if sildenafil citrate treatment could improve erectile function after castration. To determine if sildenafil citrate treatment reduces collagenisation and apoptosis in erectile tissue after castration. MATERIALS AND METHODS: In all, 60 Sprague-Dawley rats were studied; the rats were divided into the following groups: sham - no orchidectomy (S), control - orchidectomy only (O) and treatment - orchidectomy plus sildenafil treatment (V), with 10 rats per group. Erectile haemodynamics assessment was done at 7 days (S7, O7, V7) and at 28 days (S28, O28, V28) yielding a total of six groupings. Functional assessment measured the mean maximum intracavernosal pressure-mean arterial pressure (ICP/MAP) ratio. TUNEL assay was used to define apoptotic indices (AIs) and Masson's trichrome staining was used to evaluate smooth muscle-collagen (SM-C) ratios. RESULTS: The S28 group had the highest and the O7 group the lowest ICP/MAP ratio, at a mean (sd) of 70 (6)% and 36 (6)%, respectively. Both treatment groups, V7 [42 (12)%] and V28 [49 (13)%] showed statistically significant improvements over their corresponding control groups: O7 [36 (6)%] and O28 [37 (9)%] (P < 0.05). However, ICP/MAP values for V7 and V28 remained significantly below the S28 group (P < 0.001). There were no significant differences in ICP/MAP values between the 28-day and 7-day ICP/MAP ratios within each group (S, O, V). There were no significant differences in SM-C ratio between the O and V groups (O7 vs V7, P = 0.45; O28 vs V28, P = 0.16). There were no significant differences in AIs between the O and V groups (O7 vs V7, P = 0.54; O28 vs V28, P = 0.8). CONCLUSIONS: Daily treatment with sildenafil improved erectile function in rats after castration. ICP/MAP ratios increased significantly in the treatment groups compared with the control groups with the greatest erectile function occurring 28 days from administration. In this series of experiments the improved erectile function recovery with sildenafil after surgical castration cannot be explained by smooth muscle protection and decreased collagenisation. The improved erectile function with sildenafil after surgical castration cannot be explained by reduced apoptosis in erectile tissue.

Factors predicting publication of sexual medicine abstracts presented at the annual meeting of the American Urological Association.

INTRODUCTION: At sexual medicine meetings throughout the world, hundreds of scientific abstracts are presented each year. To our knowledge, no previous studies have looked at the rate of publication of these studies in a peer-reviewed journal. AIM: To define the fate of abstracts presented at sexual medicine sessions at the annual meeting of the American Urological Association (AUA) and to describe the factors predicting ultimate publication in scientific journals. METHODS: All abstracts presented at the 2006 and 2007 AUA annual meeting were surveyed to find sexual medicine abstracts. Publication status as of October 2009 was assessed using the Medline database. Abstract parameters were recorded including number of authors, country of origin, clinical or basic research, and area of sexual research. Predictors of publication were analyzed using a multivariable model. MAIN OUTCOME MEASURE: Publication status of all sexual medicine abstracts presented at the 2006 and 2007 AUA annual meetings. RESULTS: A total of 208 sexual medicine abstracts were presented in 2006 and 2007. Fifty-one percent of these were published by October 2009. On univariate analysis, the predictors of publication in a peer-reviewed journal included the number of authors (r=0.22, P<0.01), studies pertaining to erectile dysfunction (RR 1.3, CI 1-1.8, P=0.05), and studies originating from academic centers (RR 2.7, CI 1.7-4.3, P<0.01). On multivariate analysis, the predictors of publication included the number of authors (OR 1.3, CI 1-1.4, P<0.01) and having a study originate from an academic center (OR 5.9, CI 2.8-12.7, P<0.01). CONCLUSIONS: Fifty-one percent of the sexual medicine abstracts presented at the 2006 and 2007 annual AUA meetings have been published within 2 to 3 years of the date of presentation. Studies originating from academic centers were six times more likely to be published in a peer-reviewed journal.

Ejaculation profiles of men following radiation therapy for prostate cancer.

OBJECTIVES: Radical prostatectomy (RP) is associated with anejaculation, which for some men is a source of bother and sexual dissatisfaction. Clinical experience has shown us some men after pelvic radiation therapy (RT) also experience anejaculation. This analysis was conducted to define the ejaculation profiles of men after RT for prostate cancer (PCa). METHODS: As a routine part of the sexual health evaluation for post-RT patients, men provided information regarding their ejaculatory function and orgasm. Analysis was conducted of a sexual medicine database reviewing demographic data, PCa factors, erectile, ejaculatory, and orgasmic function. Men with prior history of RP, cryotherapy, focal therapies, and androgen deprivation therapy (ADT) were excluded. Patients completed the International Index of Erectile Function (IIEF) questionnaire at follow-up visits commencing with the first posttreatment visit and specific attention was paid to the IIEF orgasm domain. RESULTS: Three hundred and sixty-four consecutive patients were included. Two hundred and fifty-two patients had external beam, and 112 patients had brachytherapy (BT). Mean age was 64 ± 11 (42-78) years and mean follow-up after RT was 6 ± 4.5 years. Mean prostate size at time of RT was 42 ± 21 g. Of the entire population, 72% lost the ability to ejaculate in an antegrade fashion after prostate RT by their last visit. The proportion experiencing anejaculation at 1, 3, and 5 years after RT was 16%, 69%, and 89%, respectively. For men with at least two IIEF questionnaires completed, the orgasm domain scores decreased dramatically over the follow-up period; orgasm domain scores (0-10): <12 months post-RT 7.4, 13-24 months 5.4, 25-36 months 3.2, >36 months 2.8 (P < 0.01). Multivariable analysis identified several factors predictive of failure to ejaculate: older age, ADT, RT dose > 100 Gy, and smaller prostates at the time of RT. CONCLUSIONS: The vast majority of men after prostate RT will experience anejaculation and should be counseled accordingly prior to undergoing therapy. We have identified predictive factors.

Efficacy of a penile variable tension loop for improving climacturia after radical prostatectomy.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Climacturia is present in ∼20-40% of men after radical prostatectomy, and adversely affects sexual satisfaction. Although several strategies have been proposed for the treatment of climacturia, none have been systematically studied to date. This observational study shows that use of a penile variable tension loop can significantly reduce the degree and frequency of orgasm-associated incontinence, and the associated distress experienced by patients and partners. Climacturia resolves completely in half the patients, and occurs occasionally or rarely in the remainder. OBJECTIVE: To define the impact of the use of a penile variable tension loop on climacturia and on the distress level experienced by patients and their partners as a result of climacturia. PATIENTS AND METHODS: All patients presenting for sexual function assessment after radical prostatectomy (RP) were questioned regarding climacturia. The study population consisted of men who had undergone RP < 6 months before initial evaluation, had reported having climacturia on ≥25% attempts where orgasm was achieved, had agreed to use the variable tension loop consistently, and continued to have climacturia when not using the loop at follow-up. Patients were interviewed regarding the frequency and degree of climacturia, and their own and their partner's distress levels secondary to climacturia, both with and without the use of the variable tension loop. RESULTS: The study population comprised 124 men. At baseline, the degree of climacturia was small, moderate, and large in 16%, 72%, 12% of patients, respectively, and 28%, 26% and 0%, respectively, at follow-up (all P < 0.01). Climacturia occurred rarely, occasionally, most of the time, or always in 15%, 48%, 16% and 21% of cases, respectively, at baseline, and 48% of patients experienced no climacturia with use of the variable tension loop. Distress was experienced by 14% and 61% of patients and partners at baseline, and 2% and 11% of patients and partners at follow up (P < 0.01). Severity of distress was significantly lower at follow-up for both partners and patients (P < 0.01). CONCLUSIONS: Climacturia is a common complication of radical prostatectomy. Application of the variable tension loop can result in a significant decrease in the frequency and volume of climacturia. Use of the variable tension loop is a simple and non-invasive strategy for relieving the distress associated with climacturia in patients who have undergone RP and their partners.

Exploring the association between erectile rigidity and treatment adherence with sildenafil.

INTRODUCTION: Erection hardness has been shown to correlate with increased self-confidence, sexual satisfaction, and improvement in psychosocial factors such as sexual and overall relationship. It is estimated that one-third of men using phosphodiesterase type 5 inhibitors (PDE5) cease use of medication after one prescription and one-half cease use by 6 months. AIM: This study was undertaken to explore the link between erection hardness and treatment adherence. METHODS: Men presenting with erectile dysfunction (ED) who were candidates for PDE5 therapy constituted the study population. They were assessed at the baseline regarding their erectile function (EF) and rigidity using autoquestionnaires. Patients then received regular follow-up using the same assessment tools and were also asked about continued use of PDE5. The final patient assessment was conducted at a time point no sooner than 12 months after commencing PDE5. Multivariable analysis was conducted to define predictors of continued PDE5 use. MAIN OUTCOME MEASURES: Patients were assessed using the International Index of Erectile Function (IIEF) questionnaire and the Erection Hardness Score (EHS). Adherence was defined as continued use of PDE5 at least once per month. RESULTS: One hundred eighty-six men were analyzed. The mean age and the duration of ED were 61 ± 22 and 2.2 ± 2.9 years, respectively. Sixty-three percent were married or partnered. The mean partner age was 52 ± 8 years. Of the 186 patients, 32% had one vascular comorbidity, 34% had two vascular comorbidities, 26% had three vascular comorbidities, and 6% had ≥ 4 vascular comorbidities. All patients were treated with sildenafil and were sexually active. The mean time to end-of-treatment (EOT) interview and repeat completion of questionnaires was 17 ± 4 months. At the baseline, 26% were EHS 3 (mild ED), 42% were EHS 2 (moderate ED), and 32% were EHS 1 (severe ED). The mean baseline EF domain score was 14 ± 10, and at the EOT, it was 22 ± 5 (P < 0.01). At the follow-up interview, 4% were EHS 1, 12% were EHS 2, 28% were EHS 3, and 56% were EHS 4. Overall, 67% of the men continued to use PDE5 at follow-up. The distribution of patients continuing to use PDE5 after commencement was 15% of those achieving EHS 1, 30% for EHS 2, 66% for EHS 3, and 82% for EHS 4. Based on logistic regression analysis, the factors predictive of continued PDE5 use were being partnered, partner age, frequency of sexual activity, a shift of ≥ 2 points on the EHS, and reaching level 4 on the EHS scale. CONCLUSION: There is an excellent relationship between erection hardness and adherence to PDE5 treatment. Driving men to greater erectile rigidity appears to translate into lower dropout rates.

Outcomes of the management of post-chemotherapy retroperitoneal lymph node dissection-associated anejaculation.

UNLABELLED: What's known on the subject? and What does the study add? Modern surgical techniques have allowed preservation of fertility in most patients after post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND), but some patients still have infertility after surgery. We reviewed our experience treating infertility in 26 men after PC-RPLND. Using a structured clinical pathway we obtained sperm in 81% of men for use in assisted reproduction. OBJECTIVE: To evaluate the effectiveness of a clinical pathway on sperm retrieval outcomes in patients presenting with infertility after post-chemotherapy (PC) retroperitoneal lymph node dissection (RPLND). PATIENTS AND METHODS: We carried out a retrospective review of patients with advanced testicular cancer, presenting with infertility after PC-RPLND in a large reproductive urology practice. We implemented a clinical pathway where pseudoephedrine was first administered. If this medication failed, electroejaculation (EEJ) and/or testicular sperm extraction (TESE) was carried out. The primary outcome was retrieval of sperm for use in assisted reproduction. RESULTS: Four men had retrograde ejaculation, of whom two converted to antegrade ejaculation with medical therapy. In all, 22 patients had failure of emission (FOE) and, of these, no patient converted to antegrade ejaculation with medication. In patients with FOE, sperm was found in 15/20 of those experiencing a successful EEJ. Seven patients underwent TESE for azoospermia on EEJ or no ejaculate on EEJ, three of whom had sperm found on TESE. Sperm was found for assisted reproduction in 81% (21/26) patients. CONCLUSIONS: There appears to be no role for the use of pseudoephedrine therapy in patients with FOE after PC-RPLND. The use of a structured clinical pathway may optimize patient care.

Androgen deprivation therapy before radical prostatectomy is associated with poorer postoperative erectile function outcomes.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Erectile dysfunction is a recognized complication of radical prostatectomy. Androgen deprivation therapy adversely impacts sexual function. Our study shows that the preoperative use of androgen deprivation therapy significantly reduces erectile function recovery after radical prostatectomy. The underneath pathophysiological mechanisms for this to occur are reviewed. OBJECTIVE: To define the impact of androgen deprivation therapy (ADT), undergone before radical prostatectomy (RP), on erectile function (EF) recovery. MATERIAL AND METHODS: A total of 38 consecutive patients presenting to a sexual medicine clinic after undergoing RP who had received ADT before RP (ADT+ group) were compared with a contemporary, age and comorbidity-matched cohort of 94 patients who did not receive ADT (ADT- group) before undergoing RP. Medical records were reviewed for demographics, comorbidity profiles and duration of ADT exposure. All the patients underwent Doppler penile ultrasonography within 6 months of RP and were administered the International Index of Erectile Function (IIEF) questionnaire. All the patients underwent evaluation of EF recovery. We analysed the incidence of venous leak (VL), mean IIEF EF domain score and proportion of men with EF domain scores ≥ 24 at 18 months after RP. RESULTS: The mean age, comorbidity profiles, median Gleason score, median pre-treatment PSA level, and mean time to evaluation after RP were similar between the two groups. The median duration of ADT exposure in the ADT+ group was 3 months. The incidence of VL within 6 months of surgery was 60% for the ADT+ and 20% for the ADT- group (P < 0.001). Likewise, the IIEF EF domain scores and proportion of men with EF domain scores ≥ 24 at 18 months were significantly lower in the ADT+ group, even when controlled for nerve-sparing status. CONCLUSION: Our data suggest that preoperative use of ADT adversely impacts EF outcomes and should therefore be avoided in the absence of robust data suggesting any oncological benefit.

Sexual bother following radical prostatectomyjsm.

INTRODUCTION: The literature on sexual bother in men with prostate cancer is conflicting. While some data indicate high bother from erectile dysfunction (ED) following prostate cancer treatments, other results suggest the life-saving nature of the treatment may mitigate ED concern. AIM: (i) To determine if sexual bother increases post radical prostatectomy (RP); (ii) To determine if men psychologically adjust to diminished erections; (iii) To identify baseline predictors of post-RP sexual bother. METHODS: We identified 183 men treated with RP who completed inventories including Erectile Function Domain (EFD) and Sexual Bother (SB) preoperatively and at 12 and 24 months postoperatively. Statistical analyses included repeated-measures analysis of variance and linear multiple regression. MAIN OUTCOME MEASURES: The EFD of the International Index of Erectile Function and the SB subscale from the Prostate-Health Related Quality-of-Life Questionnaire. RESULTS: The mean age of the sample was 58 +/- 7 years. The mean EFD scores decreased from baseline to the 24-month time point (24.8 vs. 16.7, P < 0.01). The mean SB scores increased from baseline to the 12 month time point (4.3 vs. 6.7, P < 0.01), and remained stable from the 12 month to 24 month time points (6.7 vs. 6.3, P = not significant [ns]). This was true for men with ED (EFD < 24) and without ED. Only 7% of men with ED moved from being "bothered" at 12 months to "no bother" at 24 months. There were no significant baseline predictors of sexual bother; baseline variables tested were: age, race, marital status, prostate-specific antigen (PSA) value, EFD, sexual desire, and intercourse satisfaction. The change in EFD scores was the only significant predictor of SB scores. CONCLUSIONS: Sexual bother increases post-RP, even in men with "good" erections postoperatively, and includes shame, embarrassment, and a reduction in general life happiness. Because men do not seem to "adjust" to ED, referral or evaluation should occur early in this population.

Can the International Index of Erectile Function distinguish between organic and psychogenic erectile function?

OBJECTIVE: To define the ability of the International Index of Erectile Function (IIEF) to differentiate between organic and psychogenic erectile dysfunction (ED). PATIENTS AND METHODS: Patients presenting for the evaluation and treatment of ED who had penile duplex Doppler ultrasonography (DUS) completed the IIEF questionnaire. Accepted ranges of the IIEF EF domain were used to grade baseline severity (severe, moderate and mild < or =11, 11-17, 18-25, respectively). Accepted criteria were used to define normality on DUS (peak systolic velocity >30 cm/s and end-diastolic velocity <5 cm/s). Patients with documented Peyronie's disease, hypogonadism and a history of radical prostatectomy were excluded. RESULTS: In all, 112 patients were enrolled, with a mean (sd) age and duration of ED of 56 (16) and 2 (0.6) years, respectively. The vascular risk-factor profile included diabetes in 15%, hypertension in 26% and hyperlipidaemia in 20%. The baseline severity of ED was mild, moderate and severe in 28%, 41% and 32% men, respectively. All patients had normal testosterone levels. Patients also with a normal DUS were diagnosed with psychogenic ED, in 50%, 13% and 17% of men with mild, moderate and severe ED by the IIEF, respectively. No patient with venous leak had mild ED, and 62% of men with venous leak had severe ED. CONCLUSIONS: These results indicate that the IIEF is not completely accurate in differentiating between organic and psychogenic ED, and that almost a fifth of men in this study population with severe ED by the IIEF had normal erectile haemodynamics. These data have potential ramifications for evaluating the baseline severity of ED in trials of erectogenic agents.

The impact of shock wave therapy at varied energy and dose levels on functional and structural changes in erectile tissue.

OBJECTIVES: Only minimal literature exists on consequences of shock wave therapy (SWT) on erectile function in treatment of Peyronie's disease (PD). This study was undertaken to define SWT impact at varied energy/dose levels at different time points on functional and structural changes in erectile tissue. METHODS: In 45 rats 2000 shock waves (sw) at 2 BAR were applied to the penis weekly sorted by one, two, and three sessions (high-dose/energy level, HD-1, HD-2, HD-3). Each group was followed for 1, 7, or 28 d before measuring intracavernosal pressure (ICP) and mean arterial pressure (MAP). Fifteen control animals (C1, C7, C28) underwent anesthesia alone. Another 15 animals were exposed to three SWT sessions applying 1000 sw at 1 BAR and analyzed identically (low-dose/energy level, LD-3-1, -7, -28). Terminal deoxynucleotidyl transferase biotin-dUTP nick-end labeling assay was used to define the apoptotic index (AI) and Masson's trichrome (MT) staining was prepared to evaluate smooth muscle-to-collagen ratios. RESULTS: ICP/MAP ratios for all C groups displayed a mean of 64%. All SWT groups demonstrated significantly reduced ICP/MAP ratios compared to their corresponding C groups (p<0.05). The LD-3 groups showed a trend toward improved ICP/MAP ratios. LD-3-28 demonstrated significant recovery compared to HD-3-28 (55+/-8% vs. 41+/-10%, p=0.004), but remained reduced compared to C28 (63+/-5%, p=0.03). No statistical differences were seen for MT staining in SWT groups compared to C (p>0.05). AIs for the LD-3 groups were significantly lower compared to the HD-3 groups (p<0.001), but all AIs were significantly increased compared to C groups (p<0.01). CONCLUSIONS: Overall, at both energy/dose levels, SWT resulted in a time- and treatment-dependent reduction of ICP/MAP ratios, which might be mediated partly through apoptosis and collagenization of corporal smooth muscle.

Sex after seventy: a pilot study of sexual function in older persons.

INTRODUCTION: Limited information is available regarding sexual functioning among adults aged 70 years and older. AIMS: To assess sexual functioning among older men and women, and ascertain patient-physician communication patterns about sexual functioning. METHODS: Prospective participants were approached prior to scheduled appointments with their primary care physician. In-depth sexual histories were obtained along with data on their demographic, medical, psychological, and cognitive status. MAIN OUTCOME MEASURES: Sexual functioning was assessed using standardized questionnaires, and simple yes/no questions were administered to ascertain information regarding patient-physician communication practices about sex. RESULTS: Of the 74 eligible patients approached, 50 (68%) participated. The participants had a mean age +/- standard deviation (SD) of 81 +/- 6 years and most (56%) were women. Eighteen percent of the women and 41% of the men were sexually active. The most commonly reported sexual activity was intercourse for men and masturbation for women. Among the women, the most commonly cited reason for being sexually inactive was "no desire," whereas for most men, it was "erectile dysfunction." Sexual function scores for women were low across each category (lubrication, desire, orgasm, arousal, pain, and satisfaction.) For men, low sexual function scores were found in the domains of erectile function, orgasm, and overall satisfaction, but not desire. Only 4% of the women (vs. 36% of men) reported initiating a discussion about sexual function with their physician in the past year, whereas 7% of the women (vs. 32% of men) reported that their physician inquired about the topic in the preceding year. Finally, 32% of the women (vs. 86% of men) felt that physicians should initiate discussions about sexual function. CONCLUSION: In this study of older adults, a minority reported current sexual activity. Among sexually inactive women, most did not wish to resume activity, whereas desire for sexual activity remained high among men, despite substantial problems with erectile dysfunction.

Penile length alterations following penile prosthesis surgery.

OBJECTIVE: Determine the impact of penile prosthetic surgery on penile length. METHODS: Stretched flaccid penile length was measured in men undergoing first-time penile implant surgery. Measurements were done before implantation and at 1 and 6 mo postoperatively. Patients were evaluated by the International Index of Erectile Function (IIEF) preoperatively and the IIEF and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) at 6 mo postoperatively. Patients also provided subjective assessment of penile changes at 6 mo postoperatively. Preoperative and postoperative IIEF and EDITS scores were compared as were the patients who complained of penile length loss with those who did not. RESULTS: Of the 56 patients, 50% were diabetic and 28.5% had previous radical prostatectomy; 78% of the implants were three-piece (Alpha-1, Mentor) and 22% were two-piece (Ambicor, American Medical Service). There were no statistically significant differences in penile length after the surgery compared to preoperative measurements. Forty of 56 patients (72%) reported a decrease in penile length, 10 of 50 (19%) reported no change, and 6 of 56 (9%) had a slight increase. Subjective penile length loss was more common in patients who had undergone radical prostatectomy before prosthesis implantation (32%). No statistical difference in EF domain scores occurred between patients who complained of penile length loss and those who did not; however, men complaining of length loss had lower IIEF satisfaction domain and EDITS scores. CONCLUSION: Penile prostheses do not have a negative impact on measured stretched flaccid penile length. Treatment satisfaction scores do not depend on subjective penile length loss.

Defining the clinical characteristics of Peyronie's disease in young men.

INTRODUCTION: Peyronie's disease (PD) is usually seen in men in their fifth decade of life. AIM: In this study, we investigated the characteristics of the disease in young men. MAIN OUTCOME MEASURES: The demographics, clinical features, and associated comorbidities of the patients with PD were retrospectively reviewed. METHODS: The findings were compared between men with the disease who were under 40 years of age with those over 40 years. Statistical analyses were conducted to define differentiating features between these two groups. RESULTS: Of the 296 patients, 32 were under the age of 40 years and 264 over 40 years. The mean duration of the disease was 2 +/- 4 and 6 +/- 8 months in the respective age groups. Fifty-six percent of the patients under the age of 40 years and 75% of the patients over this age presented with curvature (P < 0.01). Thirty-seven percent under 40 years and 12% men over 40 years had more than one plaque at presentation (P < 0.01). Dupuytren's contracture was seen only in patients over 40 years of age. Pain at presentation was found in 75% under the age of 40 years and in 65% over 40 years (P = 0.03). Trauma history was found in 18% under 40 years and in 5% over this age (P < 0.01). Statistical significant differences were found between the groups under and over the age of 40 years for hypertension (P < 0.01) and dyslipidemia (P < 0.01). Diabetes was noted in 50% of the patients under the age of 40 years and in 18% of the patients over this age (P < 0.001). Multivariate analysis of conditions associated in men with PD under 40 years of age showed statistical significant differences for diabetes (P = 0.015), presentation within 6 months (P = 0.004), and having multiple plaques (P = 0.008). CONCLUSIONS: Young men with PD are more likely to present at an earlier stage of the disease, to have diabetes, and to have more than one plaque at the time of presentation.

Erectile function profiles in men with Peyronie's disease.

PURPOSE: In this study we investigated the erectile function status of men presenting with Peyronie's disease. MATERIALS AND METHODS: Demographics of patients regarding age, duration of PD, nature of deformity and comorbidities were compared between the patients with PD, with and without erectile dysfunction. Patients with erectile dysfunction underwent dynamic infusion cavernosometry/cavernosography. The hemodynamic profile of patients presenting with combined PD and ED were analyzed and compared between those with onset of ED before and after diagnosis of PD. RESULTS: Of the 222 patients 78 had ED (35%) by self-report at presentation. The mean age of patients with PD and ED was 52 +/- 22 years old. Hypertension (71.5%), hyperlipidemia (60.4%) and smoking (49.2%) were the leading comorbidities in the entire group. Statistically significant differences were found between the groups with and without ED for hypertension (p = 0.02) and cigarette smoking (p = 0.009). Of 222 patients 45 (20%) had ED that predated PD onset (group 1) and 33 (15%) had ED that postdated the onset of PD (group 2). DICC showed normal hemodynamics in 14 of 78 patients (18%), arteriogenic insufficiency in 50 (64%) and corporoveno-occlusive dysfunction in 16 (20%). CVOD was evenly distributed between groups 1 and 2, whereas arteriogenic ED was significantly higher in group 1 (82%). Site specific leak was seen in 4 of 33 (12%), all group 2 patients. CONCLUSIONS: Patients in whom ED postdates the onset of PD are more likely to have normal erectile hemodynamics. Site specific leak is an uncommon contributor to PD and is seen only in the patients with PD in whom ED postdated PD onset. The leading vascular etiology of ED in PD is arteriogenic in older patients and those with greater associated comorbidities.

Sublingual sildenafil in the treatment of erectile dysfunction: faster onset of action with less dose.

BACKGROUND: The aim of the present study was to show the efficacy and safety of sublingual sildenafil and to determine whether lower doses cause the same effect with a faster onset of action in this mode of application. METHODS: Forty consecutive patients with erectile dysfunction for more than three months were included in the study. The mean age was 55 years (range, 25-65). Serum glucose and testosterone levels, lipid profile and erectile function scores were obtained in all patients. Twenty patients received placebos and the other 20 patients received 20 mg sublingual sildenafil in a double blind randomized design. RESULTS: The effect of sildenafil on erection was significantly higher than that of placebo. Sixty-five percent of patients (13/20) who received sublingual sildenafil achieved satisfying erections and coitus, whereas the rate was 15% in the placebo group (3/20). The mean onset of action with sublingual sildenafil was 15.5 min and lasted for an average of 40 min. Minimal headaches, sweating and flushing were noted as the side-effects. CONCLUSIONS: 20 mg sublingual sildenafil is safe and effective in the treatment of erectile dysfunction. Sublingual administration has some advantages as it is not effected by food ingestion and quickly appears in the circulation. These advantages provide a faster onset of action with a lower dose when compared to oral sildenafil. Sublingual use of sildenafil may be more cost-effective and possibly provides a more predictable onset of action.