Case report: Rapid recovery after intrathecal rituximab administration in refractory anti-NMDA receptor encephalitis: report of two cases.

Background: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is one of the most prevalent etiologies of autoimmune encephalitis. Approximately 25% of anti-NMDAR encephalitis cases prove refractory to both first- and second-line treatments, posing a therapeutic dilemma due to the scarcity of evidence-based data for informed decision-making. Intravenous rituximab is commonly administered as a second-line agent; however, the efficacy of its intrathecal administration has rarely been reported. Case summary: We report two cases of severe anti-NMDAR encephalitis refractory to conventional therapies. These patients presented with acute-onset psychosis progressing to a fulminant picture of encephalitis manifesting with seizures, dyskinesia, and dysautonomia refractory to early initiation of first- and second-line therapeutic agents. Both patients received 25 mg of rituximab administered intrathecally, repeated weekly for a total of four doses, with no reported adverse effects. Improvement began 2-3 days after the first intrathecal administration, leading to a dramatic recovery in clinical status and functional performance. At the last follow-up of 6 months, both patients remain in remission without the need for maintenance immunosuppression. Conclusion: Our cases provide evidence supporting the intrathecal administration of rituximab as a therapeutic option for patients with refractory anti-NMDAR encephalitis. Considering the limited penetration of intravenous rituximab into the central nervous system, a plausible argument can be made favoring intrathecal administration as the preferred route or the simultaneous administration of intravenous and intrathecal rituximab. This proposition warrants thorough investigation in subsequent clinical trials.

The effectiveness of psychological interventions alone, or in combination with phosphodiesterase-5 inhibitors, for the treatment of erectile dysfunction:A systematic review.

Objectives: To highlight the efficacy of various psychological interventions (PI) when used in combination with, or in place of, phosphodiesterase-5 inhibitors (PDE-5i), as compared to the traditional treatment of men with erectile dysfunction (ED) with PDE-5i alone. Methods: A comprehensive literature review for the years 2005-2020 via MEDLINE and PubMed. We included randomised controlled trials that compared the use of either PDE-5i alone, PI alone or a combination of PDE-5i and PI in the treatment of psychogenic ED. All studies included were performed in adults aged 19-55 years and were written in English. Results: A total of 13 articles, with an overall sample of 597 men, were included in this systematic review. The results show that the combination of PI and PDE-5i was more effective than either PI or PDE-5i alone, on erectile function and long-term sexual satisfaction in men with psychogenic ED. Combined interventions were found to be significantly superior to medical treatment in seven studies and to PI alone in one study. In comparing PI to PDE-5i, two studies found PI to be significantly superior to PDE-5i use. In three other studies, PI was found significantly superior to no treatment at all, although some participants in the control group had taken PDE-5i. Conclusions: The combination of PDE-5i with PI shows real promise for the treatment of psychogenic ED. However, no conclusions could be made about what PI is more promising than the other and larger studies are needed to confirm these initial findings. Abbreviations: CBT: cognitive behavioural therapy; CBST: cognitive behavioural sex therapy; COVID-19: coronavirus disease 2019; ED: erectile dysfunction; EDITS: Erectile Dysfunction Inventory of Treatment Satisfaction; GPT, group psychotherapy: IIEF(-EF) (-OS) (-SD): International Index of Erectile Function (erectile functioning) (overall sexual satisfaction) (level of sexual desire); ITP: integrative treatment protocol; MHI: Mental Health Inventory; PDE-5i: phosphodiesterase-5 inhibitors; PI, psychological interventions; QoL: quality of life; RCT: randomised controlled trial; SHIM: Sexual Health Inventory for Men.

Pudendal nerve release for lower urinary tract symptoms in young males.

OBJECTIVES: The aim of this study was to assess the efficacy of laparoscopic transperitoneal pudendal decompression in the improvement of refractory lower urinary tract symptoms (LUTS) in young males presenting with clinical features of pudendal nerve entrapment with no known comorbidities that could explain their LUTS. METHODS: This is a prospective pilot study involving patients suffering from LUTS refractory to standard treatment and clinical features of pudendal nerve entrapment on physical examination. They underwent laparoscopic transperitoneal pudendal decompression. International Prostate Symptom Score (IPSS) and maximal flow (Qmax) on uroflowmetry were evaluated before and 3 months after the procedure. RESULTS: Five male patients aged 34 ± 4 years were recruited. The median IPSS differed significantly before and 3 months after the procedure (18 vs 8, P = .042); likewise, median Qmax differed significantly before and 3 months after the procedure (12 vs 18 mL/s, P = .042). CONCLUSION: Pudendal nerve entrapment syndrome should be considered as a main differential diagnosis for refractory LUTS in young males with no other comorbidities. When clinical features of pudendal nerve entrapment are present, laparoscopic transperitoneal pudendal decompression relieves LUTS in these young males.