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.

Luteinizing Hormone Suppression Profiles in Men Treated With Exogenous Testosterone.

BACKGROUND: Due to the negative feedback mechanism involved in the hypothalamic-pituitary-gonadal axis, testosterone therapy (TTh) may result in suppression of luteinizing hormone (LH) secretion, but clinical experience demonstrates the level of LH suppression is variable. AIM: We sought to define the relationship between TTh and LH levels, specifically predictors of LH suppression in men on TTh. METHODS: We performed a retrospective analysis of a prospectively maintained database of patients with testosterone deficiency (TD) treated with TTh. Patient demographic and clinical data including vascular risk factor (VRF) status were collected. Serum total T and LH levels before TTh and after ≥3 months (m) were recorded. LH suppression was defined as serum LH level <1.0 IU/ml. MAIN OUTCOME MEASURES: Predictors of LH suppression were searched though a series of logistic regression models assessing suppression status at the final observation, and then a series of Cox proportional hazards models assessing time to first suppression were performed. RESULTS: A total of 227 patients with mean age of 58±14 years at time of TTh initiation were included in our analysis. Just under half of subjects received transdermal T as the only modality (n = 101, 44%), while one third (n = 77, 34%) received intramuscular only, and the remainder (n = 49, 22%) received both modalities during follow-up. The mean baseline LH level was 10 ± 12 IU/ml. The percent of men who had baseline LH level above 1 IU/ml and at any given point of TTh was 84% and 78%, respectively, thus 22% of men had suppressed LH levels on TTh considering the definition of LH <1 IU/ml. Most men (73%) had a suppressed LH level of <1 IU/ml at least once during follow-up. In the final adjusted model for LH suppression, intramuscular route (OR = 2.44), baseline LH (OR = 0.94), estradiol (OR = 1.05) remained significant. CLINICAL IMPLICATIONS: LH suppression profiles may be relevant for dose titration during TTh and perhaps to minimize testicular atrophy. STRENGTHS & LIMITATIONS: A strict definition for TD was applied using LCMS for T measurements and patients had long-term follow-up. CONCLUSION: While 73% of patients had at least one LH <1 IU/ml during TTh, only 22% maintained suppressed throughout the treatment. Miranda EP, Schofield E, Matsushita K, et al. Luteinizing Hormone Suppression Profiles in Men Treated With Exogenous Testosterone. J Sex Med 2022;19:1359-1365.

Use, Misuse and Abuse of Testosterone and Other Androgens.

INTRODUCTION: For several decades, testosterone and its synthetic derivatives have been used for anabolic and androgenic purposes. Initially restricted to professional bodybuilders, these substances gradually became more popular with recreational weightlifters. Considering its increasing prevalence, the consumption of anabolic androgenic steroids (AAS) has become a matter of great concern. Although most side effects are mild and reversible, some of them can cause permanent damage or can be potentially life threatening. OBJECTIVES: To review and summarize medical literature regarding misuse and abuse of testosterone and other androgens, in order to provide evidence-based information on the main topics related to this subject, such as how to identify and how to deal with these patients, and to elucidate the multiple possible adverse effects secondary to this practice. METHODS: Key studies were retrieved from PubMed (1989-2021) with reference searches from relevant articles. Search terms included "hypogonadism", "anabolic androgenic steroids", "androgens", "misuse AND testosterone", "abuse AND testosterone", and "side effects AND testosterone". RESULTS: There is a significant lack of information in the peer-reviewed literature describing demographic data, implications for different organ systems and the management of current or former AAS users; however, androgen abuse has been already linked to a wide variety of cardiovascular diseases, metabolic, endocrine, neurological, psychiatric and liver disorders. Despite all this, most physicians still feel uncomfortable and hesitate to discuss the issue with patients. CONCLUSIONS: The chronic use of high doses of AAS is associated with adverse effects in several organ systems; however, there are still many gaps in our knowledge about the long-term consequences of this practice and how to deal with these patients. Healthcare professionals have a crucial role in combating this public health problem, recognizing and preventing the spread of androgen abuse. Linhares BL, Miranda EP, Cintra AR, et al. Use, Misuse and Abuse of Testosterone and Other Androgens. Sex Med Rev 2022;10:583-595.

Use, Misuse and Abuse of Testosterone and Other Androgens.

INTRODUCTION: For several decades, testosterone and its synthetic derivatives have been used for anabolic and androgenic purposes. Initially restricted to professional bodybuilders, these substances gradually became more popular with recreational weightlifters. Considering its increasing prevalence, the consumption of anabolic androgenic steroids (AAS) has become a matter of great concern. Although most side effects are mild and reversible, some of them can cause permanent damage or can be potentially life threatening. OBJECTIVES: To review and summarize medical literature regarding misuse and abuse of testosterone and other androgens, in order to provide evidence-based information on the main topics related to this subject, such as how to identify and how to deal with these patients, and to elucidate the multiple possible adverse effects secondary to this practice. METHODS: Key studies were retrieved from PubMed (1989-2021) with reference searches from relevant articles. Search terms included "hypogonadism", "anabolic androgenic steroids", "androgens", "misuse AND testosterone", "abuse AND testosterone", and "side effects AND testosterone". RESULTS: There is a significant lack of information in the peer-reviewed literature describing demographic data, implications for different organ systems and the management of current or former AAS users; however, androgen abuse has been already linked to a wide variety of cardiovascular diseases, metabolic, endocrine, neurological, psychiatric and liver disorders. Despite all this, most physicians still feel uncomfortable and hesitate to discuss the issue with patients. CONCLUSIONS: The chronic use of high doses of AAS is associated with adverse effects in several organ systems; however, there are still many gaps in our knowledge about the long-term consequences of this practice and how to deal with these patients. Healthcare professionals have a crucial role in combating this public health problem, recognizing and preventing the spread of androgen abuse.

Phosphodiesterase Type 5 Inhibitors and Visual Side Effects: A Narrative Review.

Phosphodiesterase type 5 inhibitors such as sildenafil citrate and tadalafil are well known for the treatment of erectile dysfunction. However, their use in the presence of pulmonary hypertension can cause ophthalmologic side effects, including non-arteritic optic ischemic neuropathy, chorioretinopathy, glaucoma, and optic atrophy. The present review aimed to identify these visual side effects and provide recommendations. We identified articles published from January 2000 to March 2019 on diseases arising from the management of sexual dysfunction in urology or pulmonary hypertension in pneumonia that could cause pathologic alterations in eye structure based on a literature search of the MEDLINE electronic database using keywords for the most common adverse effects and different kinds of phosphodiesterase 5 inhibitors. After applying the exclusion criteria, we selected 36 of the 77 articles initially identified to write the narrative review and added 20 additional articles to completely describe the pathological entities. Phosphodiesterase type 5 inhibitors can cause side effects in the eye including ocular surface abnormalities, increased intraocular pressure and glaucoma, uveitis, non-arteritic ischemic neuropathy, chorioretinopathy, retinal occlusion, and visual field changes. There is an increased need for well-performed studies to better understand these side effects, which are common due to the wide use of sildenafil.

Laparoscopic pyeloplasty as an alternative to nephrectomy in adults with poorly functioning kidneys due to ureteropelvic junction obstruction.

OBJECTIVES: To evaluate outcomes of laparoscopic pyeloplasty (LP) in adults with poorly functioning kidney due to ureteropelvic junction obstruction (UPJO). METHODS: A retrospective comparative analysis was performed between adult patients who underwent LP due to UPJO with differential renal function (DRF) ≤ 15% and DRF > 15%. LP success rate and complications were assessed. LP success was defined as symptoms improvement and DRF improvement or stabilization. DRF and estimated glomerular filtration rate (eGFR) were analyzed before and 12 months after surgery to evaluate renal function recovery. DRF was estimated using Tc-99 m DMSA renal scintigraphy. RESULTS: Among 121 LP performed in the study period at our institution, 15 and 42 were included in the DRF ≤ 15% and DRF > 15% groups, respectively. At a median follow-up of 17.8 months, all patients with DRF ≤ 15% reported symptoms improvement. LP success rate was 86.7% and 90.5% (p = 0.65) for patients with DRF ≤ 15% and DRF > 15%, respectively. There were no complications in the DRF ≤ 15% group, while there were three complications recorded in the DRF > 15% group (Clavien 2 and 3b). In the DRF ≤ 15% group, mean pre-operative and post-operative DRF was 9.5% ± 3.6 and 10.5% ± 7.8 (p = 0.49), respectively. Median pre-operative and post-operative eGFR was 68.5 ml/min and 79.8 ml/min (p = 0.93), respectively. Two patients had DRF improvement after LP. CONCLUSIONS: LP in adult patients with UPJO and poor function kidneys is an effective and safe procedure. DRF recovery is seen in a minority of the patients; however, LP is an alternative to nephrectomy.

A Randomized, Controlled, 3-Arm Trial of Pharmacological Penile Rehabilitation in the Preservation of Erectile Function After Radical Prostatectomy.

BACKGROUND: Although the concept of penile rehabilitation after radical prostatectomy (RP) has been advocated for decades, there is little definitive evidence regarding its utility or the best strategy to optimize patient outcomes. AIM: The goal of this study is to analyze the ability of 3 different pharmacological strategies to preserve the ability of men to achieve spontaneous (non-medication assisted) erections after bilateral nerve-sparing RP. METHODS: This IRB- and FDA-approved study studied penile rehabilitation in a 3-arm fashion with a target enrollment of 200 patients. (i) Control arm: nightly placebo with sildenafil 100 mg on demand for sexual relations (up to 6 pills/month); (ii) nightly sildenafil arm: nightly sildenafil 50 mg and sildenafil 100 mg on demand for sexual relations (up to 6 pills/month); (iii) combination therapy arm: nightly sildenafil 50 mg (5 nights/week) plus intracavernosal injections twice/week. Inclusion criteria included bilateral nerve-sparing surgery, normal serum total testosterone, and good preoperative baseline erectile function as measured by the erectile function domain score of the IIEF (EFD) (≥24). Patients were followed with a medication use diary and the IIEF questionnaire at 6 weeks, 3 m, 6 m, 12 m, 18 m and 24 m. OUTCOMES: A difference was seen in the IIEF-EFD scores between the 3 groups at 24 months after RP. Secondary end points include the time to return of spontaneous functional erections, the time for patients to respond to oral erectogenic therapy, and the proportion of patients who have normalization of their IIEF-EFD scores. RESULTS: The study was interrupted because of failure to recruit the target study population in a reasonable timeframe. A total of 76 subjects with median age of 57 (IQR: 51, 63) years and mean IIEF-EFD of 29 (IQR: 27, 30) were initially randomized, but at 24 months, the sample sizes by group were (i) n = 4; (ii) n = 18; and (iii) n = 10, with median IIEF-EFD 24 (IQR: 18, 28), 24 (IQR: 18, 28), and 21 (IQR: 9, 26), respectively. There was no statistical difference among the groups in the final analysis. CLINICAL IMPLICATIONS: Definitive evidence for the ability of different pharmacological rehabilitation strategies to improve long-term EF outcomes might never be available. STRENGTHS & LIMITATIONS: This was a well-designed randomized and 3-arm designed trial intended to provide decisive evidence regarding the utility of penile rehabilitation. Failure to recruit the target population is the main limitation. CONCLUSION: The limited number of patients in the present trial precludes definitive interpretation. However, results indicate how challenging it is to conduct true rehabilitation studies. Miranda EP, Benfante N, Kunzel B, et al. A Randomized, Controlled, 3-Arm Trial of Pharmacological Penile Rehabilitation in the Preservation of Erectile Function After Radical Prostatectomy. J Sex Med 2021;18:423-429.

Domestic violence and substance abuse during COVID19: A systematic review.

INTRODUCTION: As COVID-19 develops around the world, numerous publications have described the psychiatric consequences of this pandemic. Although clinicians and healthcare systems are mainly focused on managing critically ill patients in an attempt to limit the number of casualties, psychiatric disease burden is increasing significantly. In this scenario, increased domestic violence and substance abuse have been recently reported. OBJECTIVE: The objective of this study is to perform a systematic review of the literature regarding the consequences of severe acute respiratory syndrome-CoV-2 infection in terms of domestic violence and substance abuse, and compare incidences found. MATERIALS AND METHODS: We conducted a literature search using the preferred reporting items for systematic reviews and meta-analyses guidelines. The keywords included "domestic violence," "substance abuse" AND "COVID-19," including multiple variants from December 2019 through June 2020. An extensive bibliographic search was carried out in different medical databases: Pubmed, EMBASE, LILACS, medRxiv, and bioRxiv. Titles and abstracts were reviewed according to the eligibility criteria. The risk of bias in the retrieved articles was assessed by the Joanna Briggs Institute's critical assessment instrument. RESULTS: A total of 1505 papers were initially retrieved after consulting the selected databases. After browsing through titles and abstracts, 94 articles were initially included considering the predefined eligibility criteria. After a more detailed analysis, only six scientific articles remained in our selection. Of these, three were evaluating domestic violence against children, while the other three were about substance abuse. CONCLUSION: There is not enough evidence to support the concept that COVID-19 has led to an increase in the rates of domestic violence and substance abuse. The initial decrease in violence reports might not translate into a real reduction in incidence but in accessibility. Apparently, there has been a slight increase in alcohol and tobacco abuse, especially by regular users, which also requires confirmatory studies. The inconsistency between expert opinon articles and the actual published data could be a result of the limited time since the beginnging of the crisis, the fact that psychitaric patients have been chronically exposed to stressful situatons, and a possible stimulated increase in demand for psychatric consultations.

Standardization of penile hemodynamic evaluation through color duplex-doppler ultrasound.

INTRODUCTION: The vascular evaluation of the erectile function through Color Duplex-Doppler Ultrasound (CDDU) of the penis can benefit the therapeutic decision-making process. Unfortunately, there is no standard procedure for CDDU conduction, a fact that results in high result-interpretation variability. OBJECTIVE: The aims of this review are to promote greater standardization during CDDU of the penis and discuss the fundamental principles for its accurate conduction. METHODS: CDDU is initially conducted with the penis in the flaccid state; the whole penis must be assessed (images at B mode) with a high-frequency linear transducer (7.5-18 MHz). Intracavernous injection of vasodilating agents (prostaglandin E1, papaverine, phentolamine) is performed to induce a rigid erection. Serial measurements at different times should be taken during the CDDU session and penile rigidity must be assessed in each evaluation. RESULTS: It is important to monitor the erection response after the vasoactive agent (hardness scale), and scanning during the best-quality erection should be contemplated. Manual self-stimulation, audiovisual sexual stimulation (AVSS), and vasoactive agent re-dosing protocols must be taken into account to reduce the influence of psychogenic factors and to help the patient to get the hardest erection possible. Such measurements contribute to the maximal relaxation of the erectile tissue, so the hemodynamic parameters are not underestimated. CONCLUSIONS: CDDU is a relevant specialized tool to assess patients with erectile dysfunction; therefore, this guideline will help to standardize and establish uniformity in its conduction and interpretation, taking into consideration the complexity and heterogeneity of CDDU evaluations of the penis.

Standardization of penile hemodynamic evaluation through color duplex-doppler ultrasound

SUMMARY INTRODUCTION: The vascular evaluation of the erectile function through Color Duplex-Doppler Ultrasound (CDDU) of the penis can benefit the therapeutic decision-making process. Unfortunately, there is no standard procedure for CDDU conduction, a fact that results in high result-interpretation variability. OBJECTIVE: The aims of this review are to promote greater standardization during CDDU of the penis and discuss the fundamental principles for its accurate conduction. METHODS: CDDU is initially conducted with the penis in the flaccid state; the whole penis must be assessed (images at B mode) with a high-frequency linear transducer (7.5-18 MHz). Intracavernous injection of vasodilating agents (prostaglandin E1, papaverine, phentolamine) is performed to induce a rigid erection. Serial measurements at different times should be taken during the CDDU session and penile rigidity must be assessed in each evaluation. RESULTS: It is important to monitor the erection response after the vasoactive agent (hardness scale), and scanning during the best-quality erection should be contemplated. Manual self-stimulation, audiovisual sexual stimulation (AVSS), and vasoactive agent re-dosing protocols must be taken into account to reduce the influence of psychogenic factors and to help the patient to get the hardest erection possible. Such measurements contribute to the maximal relaxation of the erectile tissue, so the hemodynamic parameters are not underestimated. CONCLUSIONS: CDDU is a relevant specialized tool to assess patients with erectile dysfunction; therefore, this guideline will help to standardize and establish uniformity in its conduction and interpretation, taking into consideration the complexity and heterogeneity of CDDU evaluations of the penis.

RESUMO INTRODUÇÃO: A avaliação vascular da função erétil por meio da ultrassonografia com Doppler colorido do pênis (UDCP) pode trazer benefícios na tomada de decisão. Infelizmente, a falta de padronização na condução de UDCP resulta em alta variabilidade do exame, além de poder comprometer a interpretação dos resultados. OBJETIVO: Os objetivos desta revisão são promover uma maior padronização durante o UDCP e discutir os princípios fundamentais para sua correta condução e interpretação. MÉTODOS: O UDCP é conduzido inicialmente com o pênis no estado flácido; todo o pênis deve ser avaliado (imagens no modo B) com um transdutor linear de alta frequência (7,5-18 MHz). A injeção intracavernosa de agentes vasodilatadores (prostaglandina E1, papaverina, fentolamina) é realizada para induzir uma ereção rígida. Medições seriais em momentos diferentes podem ser realizadas durante a sessão da UDCP e a rigidez peniana deve ser estimada em cada avaliação. RESULTADOS: É importante monitorar a resposta da ereção após o agente vasoativo (escala de rigidez), bem como realizar avaliação hemodinâmica durante a ereção de melhor qualidade. Os protocolos de estimulação sexual manual e audiovisual (AVSS) e redosagem de agente vasoativo devem ser levados em consideração para reduzir a influência de fatores psicogênicos e ajudar o paciente a obter a ereção mais rígida possível. Tais medidas contribuem para o relaxamento máximo do tecido erétil, de modo que os parâmetros hemodinâmicos não são subestimados. CONCLUSÕES: O UDCP é uma ferramenta especializada relevante para avaliar pacientes com disfunção erétil; portanto, esta diretriz ajudará a padronizar e estabelecer uniformidade em sua condução e interpretação, se considerarmos a complexidade e a heterogeneidade das avaliações do pênis por UDCP

A Critical Analysis of Methodology Pitfalls in Duplex Doppler Ultrasound in the Evaluation of Patients With Erectile Dysfunction: Technical and Interpretation Deficiencies.

BACKGROUND: Penile duplex Doppler ultrasound (PDDU) is a minimally invasive tool to evaluate erectile hemodynamics in patients with erectile dysfunction (ED). Despite decades of use, there is still a large variability in PDDU protocols, and a high rate of false diagnosis is reported. AIM: Review of PDDU methodology in the published literature addressing protocol heterogeneity, technical and interpretation challenges. METHODS: A PubMed literature search was performed using the search terms "penile doppler ultrasound", "penile duplex ultrasound" or "penile ultrasound", and "Erectile dysfunction". Studies were analyzed for the presence of the following elements in reporting of the PDDU protocol: (i) intracavernosal vasoactive agents used, (ii) use of a redosing protocol, (iii) means of rigidity assessment, (iv) report of at-home best-quality erection, (v) normative criteria for peak systolic velocity (PSV) and end-diastolic velocity (EDV), and (vi) use of time-based hemodynamics assessment. Inclusion criteria were studies available in English, from 2005 onwards, and with full text. Exclusion criteria were review, descriptive or short communication articles, animal studies, and studies in populations other than those with ED. OUTCOMES: A critical review of the heterogeneity in published literature was performed to guide a structured discussion of methodological challenges and to create a list of recommendations. RESULTS: Significant heterogeneity was seen in key methodological aspects. Fifty percent of studies reported the use of prostaglandin E1 only, and 12% of studies did not mention the agent used. Redosing as part of the PDDU protocol was mentioned in only 26% of studies. The majority (56%) did not mention any form of rigidity assessment. The most frequently used grading system was the Erection Hardness Score (14%). Overall, most studies (59%) used a timed-base protocol for hemodynamic assessment. No clear consensus was defined for normative criteria for PSV and EDV, 39% defining a normal PSV as ≥30 cm/s, and 57% using EDV values ≤5 cm/sec as normal. CLINICAL IMPLICATIONS: The absence of standardization has led to inadequate reporting of key factors which has rendered data interpretation and comparison between studies challenging. STRENGTHS AND LIMITATIONS: Our strengths include an extensive review of literature, with a structured analysis of the impact of each methodological pitfall. Our main limitation is the fact that protocol reporting, and not its application, was assessed. CONCLUSION: Despite its widespread use, analysis of the literature on PDDU use in the ED population shows marked protocol heterogeneity, rendering data interpretation a problem. Nascimento B, Miranda EP, Terrier JE, et al. A Critical Analysis of Methodology Pitfalls in Duplex Doppler Ultrasound in the Evaluation of Patients With Erectile Dysfunction: Technical and Interpretation Deficiencies. J Sex Med 2020;17:1416-1422.

Late-onset hypogonadism: Prostate safety.

BACKGROUND: There have always been concerns regarding testosterone replacement therapy and prostate safety because of the central role of testosterone in prostate tissue. Even though there is a body of evidence supporting that the benefits of testosterone replacement therapy outbalance the risks of prostate disease, this matter is still debatable and represents a common concern among testosterone prescribers. OBJECTIVES: The aim of this article was to review the influence of testosterone on prostate pathophysiology and discuss the potential impact of testosterone replacement therapy on the most common prostate pathologies, including benign prostatic hyperplasia and prostate cancer. MATERIALS AND METHODS: We have performed an extensive PubMed review of the literature examining the effects of testosterone replacement therapy on the prostate and its most common affections, especially in terms of safety. RESULTS: Testosterone replacement therapy has been shown to improve components of metabolic syndrome and decrease prostate inflammation, which is related to the worsening of lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia. Studies evaluating the link between testosterone replacement therapy and benign prostatic hyperplasia/LUTS have mostly demonstrated no change in symptom scores and even some benefits. There are a significant number of studies demonstrating the safety of testosterone replacement therapy in individuals with late-onset hypogonadism and a history of prostate cancer. The most recently published guidelines have already acknowledged this fact and do not recommend against T treatment in this population, particularly in non-high-risk disease. CONCLUSION: Testosterone replacement therapy could be considered for most men with late-onset hypogonadism regardless of their history of prostate disease. However, a discussion about the risks and benefits of testosterone replacement therapy is always advised, especially in men with prostate cancer. Appropriate monitoring is mandatory.

Audiovisual Sexual Stimulation Improves Diagnostic Accuracy of Penile Doppler Ultrasound in Patients With Erectile Dysfunction.

INTRODUCTION: Although penile Doppler ultrasound (PDU) is a useful tool in evaluating erectile dysfunction (ED), an optimal erectile response might be limited because of an increased sympathetic discharge. Audiovisual sexual stimulation (AVSS) has been suggested to help improving PDU performance. AIM: To evaluate the use of AVSS as a tool to improve diagnostic accuracy of PDU studies. METHODS: A total of 40 men (mean age: 61.8 ± 10.2 years) with ED were enrolled. PDU sessions were performed in a randomized fashion as follows: session A under intracavernous injection (ICI) alone and session B under ICI and AVSS with 7-day interval between sessions. Peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) were measured 5, 10, 15, and 20 minutes after ICI. MAIN OUTCOME MEASURE: Comparisons between PSV, EDV, and RI values were performed with and without AVSS. Univariable and multivariable analyses including clinical and demographic parameters were performed to evaluate predictors of an abnormal PDU. RESULTS: 23 patients performed the first session without AVSS, and 17 performed the first session with AVSS. EDV and RI were better in AVSS session (p = 0.022 and 0.019). PSV was not influenced by AVSS (p = 0.768). The proportion of patients whose diagnosis was changed because of the AVSS was 4 of 40 (10.0%, 95% confidence interval [CI]: 2.8-23.7%). Of 12 patients with venous leak observed on the PDU without AVSS, 3 turned into normal after AVSS (25.0%, 95% CI: 5.5-57.2%). Of 4 men with arterial insufficiency observed on the PDU on ICI alone, 1 became normal after AVSS (25.0%, 95% CI: 0.6-80.6%). International Index of Erectile Function-5 scores were lower in patients with abnormal PDU (6.3 ± 3.3 vs 12.0 ± 5.8, p=0.003). On multivariable analysis, DM and International Index of Erectile Function-5 scores were the only independent predictors of abnormal PDU studies. CLINICAL IMPLICATIONS: False diagnoses of venous leak during PDU with ICI could be a result of an increased adrenergic discharge during the examination. Routine AVSS may be helpful to avoid error in diagnosis. STRENGTH & LIMITATIONS: The study has randomized the use of AVSS in different session orders. Only one previously published study has used this strategy to control the accommodation effect in repeat studies, a common source of bias in the PDU literature. The main limitation is the absence of a rigidity assessment and a redosing protocol. CONCLUSION: Adding AVSS during PDU improves ICI response and may help clinicians evaluate penile hemodynamics more accurately. Carneiro F, Nascimento B, Miranda EP, et al. Audiovisual Sexual Stimulation Improves Diagnostic Accuracy of Penile Doppler Ultrasound in Patients With Erectile Dysfunction. J Sex Med 2020;17:249-256.

Testosterone Recovery Profiles After Cessation of Androgen Deprivation Therapy for Prostate Cancer.

INTRODUCTION: Androgen deprivation therapy (ADT) is frequently used in the treatment of prostate cancer worldwide. Variable testosterone (T) recovery profiles after ADT cessation have been cited. AIM: To evaluate T recovery after cessation of ADT. METHODS: We reviewed our institutional prospectively maintained database of patients with prostate cancer who received ADT. Serum early morning total T (TT) levels, collected at baseline and periodically after ADT cessation, were analyzed. Patient age, baseline T level, duration of ADT, and presence of diabetes and sleep apnea were selected as potential predictors of T recovery. 3 metrics of T recovery after 24 months of ADT cessation were analyzed: return to non-castrate level (TT > 50 ng/dL), return to normal (T > 300 ng/dL), and return back to baseline level (BTB). Multivariable time-to-event analysis (Cox proportional hazards), χ2 test, logistic regression model, and Kaplan-Meier curve were performed to define impact of the above predictors on time and chance of T recovery. MAIN OUTCOME MEASURES: Time and chance of T recovery to non-castrate level (TT > 50 ng/dL), return to normal (T > 300 ng/dL), and return BTB. RESULTS: 307 men with a mean age of 65 ± 8 years were included. Mean duration of ADT was 17 ± 25 months, and median follow-up was 31 ± 35 months. Mean TT values were 379 ng/dL at baseline and 321 ng/dL at >24 months. At 24 months after cessation of ADT, 8% of men remained at castrate level, 76% returned to TT >300 ng/dL, and 51% had returned BTB. Lower baseline T levels (TT < 400 ng/dL) and ADT duration >6 months were associated with a lower likelihood of recovery to normal TT at 24 months. Age >65 years and receiving ADT for >6 months were significantly associated with a slower T recovery. CLINICAL IMPLICATIONS: T recovery after ADT is not certain and may take longer than expected. Considering the range of side effects of low T, we believe that these findings must be discussed with patients before initiating such therapies. STRENGTHS & LIMITATIONS: Our strengths consisted of a relatively large database, long follow-up, and clinically meaningful endpoints. Limitations included the retrospective design of the study. CONCLUSION: T recovery rates after ADT cessation vary according to patient age, ADT duration, and baseline T levels. Approximately one-quarter of patients failed to normalize their TT level, and one-tenth of men remained at castrate levels 24 months after ADT cessation. Nascimento B, Miranda EP, Jenkins LC, et al. Testosterone Recovery Profiles After Cessation of Androgen Deprivation Therapy for Prostate Cancer. J Sex Med 2019;16:872-879.

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

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

Lower urinary tract symptoms and sexual dysfunction in men with multiple sclerosis.

OBJECTIVES: To assess the prevalence and interrelationship between lower urinary tract symptoms and sexual dysfunction in men with multiple sclerosis (MS). METHODS: In a cross-sectional study, we evaluated 41 men (mean age 41.1±9.9 years) with MS from February 2011 to March 2013, who were invited to participate irrespective of the presence of lower urinary tract symptoms or sexual dysfunction. Neurological impairment was assessed with the Expanded Disability Status Scale; lower urinary tract symptoms were evaluated with the International Continence Society male short-form questionnaire, and sexual dysfunction was evaluated with the International Index of Erectile Function. All patients underwent transabdominal urinary tract sonography and urine culture. RESULTS: The mean disease duration was 10.5±7.3 years. Neurological evaluation showed a median Expanded Disability Status Scale score of 3 [2-6]. The median International Continence Society male short-form questionnaire score was 17 [10-25]. The median International Index of Erectile Function score was 29 [15-46]. Twenty-nine patients (74.4%) had sexual dysfunction as defined by an International Index of Erectile Function score <45. Voiding dysfunction and sexual dysfunction increased with the degree of neurological impairment (r=0.02 [0.02 to 0.36] p=0.03 and r=-0.41 [-0.65 to -0.11] p=0.008, respectively). Lower urinary tract symptoms and sexual dysfunction also displayed a significant correlation (r=-0.31 [-0.56 to -0.01] p=0.04). CONCLUSIONS: Most male patients with MS have lower urinary tract symptoms and sexual dysfunction. The severity of the neurological disease is a predictive factor for the occurrence of voiding and sexual dysfunctions.