[Recommendations for the treatment of premature ejaculation]. / Recommandations pour le traitement de l'éjaculation prématurée.

OBJECTIVES: The Post-University Interdisciplinary Association of Sexology (AIUS) has brought together a panel of experts to develop French recommendations for the management of premature ejaculation. METHODS: Systematic review of the literature between 01/1995 and 02/2022. Use of the clinical practice guidelines (CPR) method. RESULTS: We recommend giving all patients with PE psychosexological counseling, and whenever possible combining pharmacotherapies and sexually-focused cognitive-behavioral therapies, involving the partner in the treatment process. Other sexological approaches could be useful. We recommend the use of dapoxetine as first-line, on-demand oral therapy for primary and acquired PE. We recommend the use of lidocaine 150mg/mL/prilocaine 50mg/mL spray as local treatment for primary PE. We suggest the combination of dapoxetine and lidocaine/prilocaine in patients insufficiently improved by monotherapy. In patients who have not responded to treatments with marketing authorisation, we suggest using an off-label SSRI, preferably paroxetine, in the absence of a contraindication. We recommend treating ED before PE in patients with both symptoms. We do not recommend using α-1 blockers or tramadol in patients with PE. We do not recommend routine posthectomy or penile frenulum surgery for PE. CONCLUSION: These recommendations should contribute to improving the management of PE.

[Practical recommendations for the management of testosterone deficiency]. / Recommandations pratiques pour la prise en charge du déficit en testostérone.

OBJECTIVES: The Francophone Society of Sexual Medicine (SFMS) and the Andrology and Sexual Medicine Committee (CAMS) of the French Association of Urology (AFU) have brought together a panel of experts to develop French recommendations for the management of testosterone deficiency (TD). METHODS: Systematic review of the literature between 01/2000 and 07/2019. Use of the method of recommendations for clinical practice (RPC) and the AGREE II grid. RESULTS: TD is defined as the association of clinical signs and symptoms suggestive of TD with a decrease in testosterone levels or serum androgen activity. Diagnosis requires a T lower than the reference values in young men on 2 successive assays. Sexual disorders are often at the forefront, and concern the whole male sexual function (desire, arousal, pleasure and orgasm). The most evocative symptoms are: decrease in sexual desire, disappearance of nocturnal erections, fatigue, loss of muscle strength. Overweight, depressed mood, anxiety, irritability and malaise are also frequently found. TD is more common in cases of metabolic, cardiovascular, chronic, andrological diseases, and in cases of corticosteroid, opioid, antipsychotic, anticonvulsant, antiretroviral, or cancer treatment. Since SHBG is frequently abnormal, we recommend that free or bioavailable T is preferred over total T. The treatment of TD requires a prior clinical (DRE, breast examination) and biological (PSA, CBC) assessment. Contraindications to T treatment are: progressive prostate or breast cancer, severe heart failure or recent cardiovascular event, polycytemia, complicated BPH, paternity project. It is possible in cases of sleep apnea syndrome, psychiatric history, stable heart disease, prostate cancer under active surveillance and after one year of complete remission of a low or intermediate risk localized prostate cancer treated in a curative manner. It includes long-term testosterone supplementation and life-style counseling. Treatment is monitored at 3, 6, 12 months and annually thereafter. It is clinical (annual DRE) and biological (total T, PSA, CBC), the most frequent side effect being polyglobulia. CONCLUSION: These recommendations should help improve the management of TD.

[Medical optimisation of sperm retrieval in non obstructive azoospermia]. / Optimisation médicale du recueil de spermatozoïdes dans les azoospermies non obstructives.

Medical optimisation of sperm retrieval in non-obstructive azoospermia is reviewed. Gonadotropin treatment of hypogonadotropic hypogonadism allows obtaining sperms in the ejaculate in about 90% of cases provided the duration of treatment was long enough. TESE is indicated in case of persistent azoospermia at 2 years of continuous treatment. Some publications reported a possible effect of hormonal treatments (FSH, hCG, anti-estrogens, aromatase inhibitors) in primary spermatogenic failure, but mainly in cases selected for their favourable histology and normal hormonal levels. The effect on unselected cases remains doubtful. Conversely, the effect of the treatment of varicoceles is significant. Other medical treatments or advises need further investigations.

[Cosmetic surgery of the female genitalia]. / Chirurgie cosmétique de l'appareil génital féminin.

INTRODUCTION: This review studies rationale and outcome of vulvovaginal aesthetic surgery. METHOD: Medline search of the existing literature utilizing terms labiaplasty, clitoral hood reduction, hymenoplasty, vaginoplasty, perineoplasty, female genital surgery, sexual satisfaction/body image, and anterior/posterior colporrhaphy; references from bibliographies of papers found through the literature search and in the author's reading of available literature until January 2012. Clinicians who receive requests from patients for such procedures should discuss with the patient the reason for request and perform an evaluation for any physical signs or symptoms that may indicate the need for surgical intervention. RESULTS: A physical psychological and sexological evaluation is mandatory before a procedure of female cosmetic genital surgery. Perineoplasties in wide vagina sensations should be proposed after careful evaluation of patients, by trained surgeons, in part of a multidisciplinary approach especially sexologic, after attempt of conservative treatments (pelvic floor rehabilitation). Patients should be informed of results and complications. Female genital mutilation repair with surgery is possible and improve majority of patients. Improvement mechanism is complex and clinical trials are ongoing. Asking for this surgery, is more often result of a deep reflexion for patient who integrate his own story and those of her family. She should be listened to, respected and managed in a reference center. Sexotherapy should be systematically proposed. Concerning hymenoplasty, the procedure is considered as "legally" by medical doctors. Several techniques are available, few described, and there is no evidence-based publication. Labioplasty is a procedure whose patient expectations should be properly evaluated by surgeon and benefits risks should be informed. A preliminary discussion around "normality" and a psychotherapy should be tried, in order to not treat a dysmorphobia by surgery. Vaginal "rejuvenation" and G spot ampliation principles and techniques are very controversial and there is no evidence-based study. CONCLUSION: Cosmetic surgery of the female genitalia covers a variety of techniques corresponding to extremely diverse situations. It requires careful and multidisciplinary evaluation as well as clear and honest information of patients. Reconstructive surgery of female genital mutilation and sexual crimes does not pose a real problem in term of indication or justification.

Assessing erectile neurogenic dysfunction from heart rate variability through a Generalized Linear Mixed Model framework.

BACKGROUND: The low (LF) vs. high (HF) frequency energy ratio, computed from the spectral decomposition of heart beat intervals, has become a major tool in cardiac autonomic system control and sympatho-vagal balance studies. The (statistical) distributions of response variables designed from ratios of two quantities, such as the LF/HF ratio, are likely to non-normal, hence preventing e.g., from a relevant use of the t-test. Even using a non-parametric formulation, the solution may be not appropriate as the test statistics do not account for correlation and heteroskedasticity, such as those that can be observed when several measures are taken from the same patient. OBJECTIVES: The analyses for such type of data require the application of statistical models which do not assume a priori independence. In this spirit, the present contribution proposes the use of the Generalized Linear Mixed Models (GLMMs) framework to assess differences between groups of measures performed over classes of patients. METHODS: Statistical linear mixed models allow the inclusion of at least one random effect, besides the error term, which induces correlation between observations from the same subject. Moreover, by using GLMM, practitioners could assume any probability distribution, within the exponential family, for the data, and naturally model heteroskedasticity. Here, the sympatho-vagal balance expressed as LF/HF ratio of patients suffering neurogenic erectile dysfunction under three different body positions was analyzed in a case-control protocol by means of a GLMM under gamma and Gaussian distributed responses assumptions. RESULTS: The gamma GLMM model was compared with the normal linear mixed model (LMM) approach conducted using raw and log transformed data. Both raw GLMM gamma and log transformed LMM allow better inference for factor effects, including correlations between observations from the same patient under different body position compared to the raw LMM. The gamma GLMM provides a more natural distribution assumption of a response expressed as a ratio. CONCLUSIONS: A gamma distribution assumption intrinsically models quadratic relationships between the expected value and the variance of the data avoiding prior data transformation. SAS and R source code are available on request.

[Prevalence of erectile dysfunction in patients consulting urological clinics: the ENJEU survey (one day national survey on prevalence of male sexual dysfunction among men consulting urologists)]. / Prévalence de la dysfonction érectile chez les patients consultant en urologie : l'enquête ENJEU (Enquête nationale de type 1 Jour sur la prévalence de la dysfonction Erectile chez des patients consultant en urologie).

OBJECTIVE: The objective of this survey was to describe medical reasons disclosed by men over 18 years old when visiting an urologist, to estimate the prevalence of male sexual dysfunction (MSD) including erectile dysfunction (ED) and to describe treatment options for ED. METHODS: This survey was performed, with Urology French Association (AFU) partnership, in 150 urological clinics, sample representative of urologists in France regarding age, geographical distribution and practice. The survey was proposed to all adults' men consulting a participating urologist the defined day (Tuesday the 19th of June 2007 or an imminent day). A total of 1848 (92.5%) patients agreed to participate; analysis was performed on 1740 patients. Information related to urological disorders, sexual dysfunctions, their treatment and their impact on the patient's life were gathered by a patient auto-questionnaire. Erectile dysfunction was assessed through the single question of John B. McKinlay. RESULTS: Among patients (mean age 63+/-14 years), 68% (IC95%=[65.2%; 70.7%]) had ED (44% severe); 25% were treated (of which 2/3 with IPDE5 alone or in association). Male sexual dysfunction was the first reason for visiting urologists (14%) following prostatic diseases (62%). About 60% of the patients had already talked about their ED to a physician, who was an urologist in 44.6% of cases. The perspective of living the rest of their life with this trouble was "unacceptable" for 21.1% of patients with ED and "fairly acceptable" for 34.4%. CONCLUSIONS: This first survey in French urologists' community emphasizes the high prevalence male sexual dysfunctions for inpatients visiting their urologists. Despite declared urologists' interest for male sexual dysfunction, the discrepancy between the high prevalence of ED and the low rate of patients consulting for this condition probably explains the low rate of patients using treatments.

[Sexual dysfunction after radical prostatectomy]. / Dysfonctions sexuelles après prostatectomie totale.

Erectile dysfunction is not the only sexual dysfunction that impact quality of life of patients following radical prostatectomy for prostate cancer. Patients must be informed about these consequences and also about the prevention and treatment modalities that could be proposed after surgery. Preoperative erectile function and couple motivation are predictive of the quality of the sexual relationship after radical prostatectomy. A preoperative erectile dysfunction must be investigated as well as if it was the main symptom (evaluation of comorbidities, cardiovascular and psychological risk factors). The quality of the preservation of the neurovascular bundles is the other main determinant that must be decided according to cancer characteristics and performed according to a mastered surgical technic.

[Dual kidney transplant: the E. Herriot Hospital Lyon experience]. / Bitransplantation rénale : expérience du protocole lyonnais de l'hôpital E.-Herriot.

INTRODUCTION: In the current context of a high incidence end-stage kidney disease and a shortage of organs for kidney transplantation, the increasing use of transplants considered to be "borderline" represents a potential source of transplants. Over the last 10 years, some centers have developed a transplantation strategy, which consists of transplanting two borderline kidneys that cannot be proposed separately in a single recipient. The authors report their experience of dual kidney transplant. MATERIALS AND METHODS: Since 2001, 15 dual kidney transplants have been performed in a single centre according to a local protocol based on the correspondence between the weight of the donor kidney and the recipient's weight, weighted by the number of fibrotic glomeruli observed on the initial biopsy. In this study, the authors analyze the postoperative complications and functional results observed in patients transplanted according to this protocol. RESULTS: Dual kidney transplants represented less than 5% of all transplants performed during the study period concerned, which remained lower than the objectives initially announced by the ABM. The surgical technique was left to the surgeon's discretion. The mean follow-up was 26.3 months. Fourteen of the 15 recipients were alive with a functional graft. Surgical complications were globally more frequent when kidneys were transplanted on the same side (versus transplanted on both sides). Mean serum creatinine was 119.4 mol/l at six months (creatinine clearance according to MDRD formula: 57.3 ml/min per 1.73 m2), 118.8 mol/l at 12 months (creatinine clearance: 55.8) and 132.4 mol/l at 24 months (creatinine clearance: 44.2). One year post-transplant, mean renal function measured by inulin clearance was 55.5 ml/min per 1.73 m2. Four of the 15 patients had experienced an episode of acute rejection and three patients experienced delayed return of transplant function. CONCLUSION: In view of the results obtained, the authors consider that dual kidney transplant could be a reasonable and effective option for selected patients. Positioning of the transplants in each iliac fossa limited the surgical complication rate.

[Investigation, treatment and monitoring of late-onset hypogonadism in males: the official guidelines of the International Society for the Study of the Study of the Aging Male (ISSAM) with comments]. / Diagnostic, traitement et surveillance de l'hypogonadisme de survenue tardive chez l'homme: recommandations officielles de l'International Society for the Study of the Aging Male (ISSAM) et commentaires.

There is increasing interest in the subject of hormone changes in the aging male, which is likely to become particularly important with the expected growth in the population of men over 50. The main concerns at present are androgen decline in the aging male (ADAM), or partial androgen deficiency of the aging male (PADAM), commonly known as the andropause. Although there have been advances in our knowledge of androgen deficiency in the aging male, it is still incomplete, sometimes confusing, and some aspects of androgen replacement therapy remain controversial. The International Society for the Study of the Aging Male (ISSAM) therefore felt it was a good time to review the current situation by publishing a series of practical and official guidelines concerning the diagnosis, treatment and monitoring of late-onset hypogonadism in males. The aim of this study is to present the French translation of these recent international guidelines, and to comment on them.

A dose-escalation study to assess the efficacy and safety of sildenafil citrate in men with erectile dysfunction.

OBJECTIVE: To assess the efficacy and safety of sildenafil citrate (Viagra, Pfizer Inc., USA) in a double-blind, placebo-controlled, dose-escalation study over a period of 26 weeks in men with erectile dysfunction of a broad spectrum of aetiology. PATIENTS AND METHODS: In all, 315 patients from five countries were randomized to receive treatment with placebo (156 men) or sildenafil (159 men). Significant concomitant medical conditions were hypertension (20%), a history of pelvic surgery (19%), diabetes mellitus (15%), and ischaemic heart disease (10%). Patients randomized to treatment received a starting dose of 25 mg of sildenafil or matching placebo, which could be increased to 50 mg and then to 100 mg of sildenafil, based on efficacy and tolerability. Assessments of efficacy comprised the 15-item International Index of Erectile Function (IIEF), including question three (ability to achieve an erection) and question four (ability to maintain an erection), a partner questionnaire, an overall efficacy question, and event-log data. RESULTS: After 12 weeks of treatment, 26%, 32% and 42% of patients were taking 25, 50 and 100 mg of sildenafil, respectively. A similar distribution of doses was reported after 26 weeks of treatment. Treatment with sildenafil significantly improved the patients' abilities to achieve and maintain an erection compared with treatment with placebo (P < 0.001). Scores for four of the five sexual function domains of the IIEF (erectile function, orgasmic function, intercourse satisfaction and overall satisfaction) also improved significantly (P < 0.001). There was a significant improvement in the mean score for the erectile function domain, regardless of the aetiology of erectile dysfunction (P < 0.001). After 12 weeks and 26 weeks of treatment, 82% and 79% of patients receiving sildenafil reported improved erections, compared with 24% and 23% of patients receiving placebo, respectively (P < 0.001). Treatment-related adverse events were mild to moderate and occurred in 27% of patients receiving sildenafil, compared with 8% of patients receiving placebo. CONCLUSION: Sildenafil is an effective and well-tolerated treatment for men with erectile dysfunction of a broad spectrum of aetiology.

L'operation de nesbit dans le traitement de la coudure de verge : a propos de 39 cas

Objectifs L'evaluation des resultats a long terme de l'operation de Nesbit dans le traitement de la coudure de verge. Patients et Methodes Trente-neuf cas de coudure de verge (20 coudures congenitales et 19 coudures secondaires a la maladie de Lapeyronie) ont ete operes dans le service d'urologie de l'Hopital Edouard Herriot de Lyon sur une periode de 10 ans. L'operation de Nesbit a ete pratique dans 74des cas; et dans les autres cas; une variante de celle-ci. Le principe de l'operation de Nesbit est simple. Il consiste a exciser une pastille ovalaire d'albuginee et de corps caverneux au sommet de l'angle de la coudure. Resultats Le redressement de la verge a ete obtenu et maintenu des la premiere intervention dans 97des cas apres 6 mois. La correction est toujours stable a 10 ans. Un seul cas de raccourcissement important de la verge (2 cm) a ete note. Conclusion L'operation de Nesbit est une intervention fiable; bien codifiee actuellement. Elle donne entre les mains entrainees d'excellents resultats

Cardiac pacemakers. When clinical evaluation lags behind technological progress.

OBJECTIVE: The rise in the number of implantations of cardiac pacemakers is of some concern to decision makers in the health sector. We assessed the intrinsic and relative clinical efficacy of cardiac pacemakers in current clinical indications to find out whether scientific or clinical arguments might justify differences in market prices. METHODS: We retrieved papers on cardiac pacing (January 1993-April 1998) from five databases (MEDLINE, HealthSTAR, EMBASE, Cochrane Library, and PASCAL). The citations in these papers were used to seek further articles. We selected the articles that met the criteria of evidence-based medicine (EBM) (randomized and nonrandomized controlled trials) and classified them according to clinical indication and type of evaluation (either of the intrinsic efficacy of a pacemaker versus a control or of the relative efficacy of different pacing modes). RESULTS: A total of 542 references were retrieved, but under 10% met our EBM criteria. Very few were comparative studies versus controls; most were recent and tended to use endpoints other than survival. Clinical efficacy was not proven on the basis of EBM criteria, even in common indications (e.g., sick sinus syndrome). Studies comparing different pacing modes were rarely randomized and did not provide consistent evidence for the superiority of any pacing mode in a given indication. CONCLUSIONS: Knowledge of the natural history of the diseases for which cardiac pacing is indicated is scarce. There is an approximately 20-year gap between technological progress and clinical evaluation that cannot be easily bridged because of methodologic difficulties and ethical issues. Current guidelines on pacemaker use either rely on expert opinion or highlight present inadequacies and make recommendations for future work. Available clinical efficacy data do not justify the wide differences in the price of cardiac pacemakers.

[Pseudotumor amylosis of the bladder. Apropos of a case]. / Amylose pseudo-tumorale de la vessie. A propos d'une observation.

A 57 year-old patient with localized pseudo-tumoral amyloidosis of bladder is described. There was no past medical history. Hematuria was the main symptom. The treatment consisted in transurethral resection. Two recurrences occurred at 4 and at 6 years which were also treated by resections. Clinical and biological evaluation was normal. Localized pseudo-tumoral amyloidosis of the urinary tract is a rare affection of good prognosis. Lesions present as pseudo-tumoral masses which can be biopsied without any risk of hematuria. Investigations are required to eliminate a generalized amyloidosis or a malignant lymphoproliferation. Treatment should be as conservative as possible.

[The woman and the new methods of treatment of male sexual impotence]. / La femme face aux nouvelles méthodes de traitement de l'impuissance sexuelle masculine.

New treatments for male impotence are now available, mainly sildenafil (oral) and prostaglandin 1 (intraurethral). These new treatments, which will be easier to use for men, raise problems of acceptability by women. Schematically, women adopt certain behaviours in relation to male sexuality, which can be characterized as "castrating", "infantile", "not interested", or "narcissistically wounded". New treatments, which will certainly be better accepted by patients and their partners, must not mask the ubiquitous participation of a psychogenic component in all forms of male impotence, including so-called "organic" impotence. The management of male impotence can therefore only be conceived in a context of a "couple project" after having defined the contribution of medicine and the patient's personal investment in finding a solution to his problem. The blind prescription and use of a drug wrongly considered to be a "male youth pill" could lead to major and probably harmful sociological changes in the context of the ever-evolving male-female relationships and in a context of ageing of the population.