The management of sexual dysfunction resulting from radiotherapy and androgen deprivation therapy to treat prostate cancer: A comparison of uro-oncology practice according to disease stage.

OBJECTIVES: To establish current uro-oncology practice in the management of sexual dysfunction (SD) following radiotherapy (RT) and/or androgen deprivation therapy (ADT) to treat prostate cancer. To identify differences in approach to the management of SD according to disease stage. SUBJECTS AND METHODS: A 14-question mixed methods survey was designed to assess the current UK practice. Closed- and open-ended questions were used to quantify results while allowing participants to expand on answers. The survey was distributed to members of the British Uro-Oncology Group at the 2019 annual meeting. RESULTS: Surveys were completed by 63 uro-oncologists attending the annual meeting of the British Uro-Oncology Group (response rate 66%). The major issue highlighted was a difference in approach to managing SD according to disease stage. More than half of the participants (56%) said 'advanced stage of disease' was a barrier to discussing SD. Clinicians were less likely to discuss SD, take baseline assessments, refer to a specialist clinic or offer rehabilitation when dealing with patients with advanced disease. Only a minority said that the management of SD was primarily their responsibility (11%). Nearly all clinicians (92%) had access to SD clinics; however, the majority of clinicians did not routinely refer patients. CONCLUSIONS: This study shows that men with advanced prostate cancer need better support in managing SD. Patients receiving long-term ADT are less likely to be offered any kind of help or intervention. Specific guidance on managing SD in this cohort may result in improvements in sexual function, emotional well-being, quality of life, mental health and confidence.

Prescription switching: Rationales and risks.

BACKGROUND: Therapeutic drug switching is commonplace across a broad range of indications and, within a drug class, is often facilitated by the availability of multiple drugs considered equivalent. Such treatment changes are often considered to improve outcomes via better efficacy or fewer side effects, or to be more cost-effective. Drug switching can be both appropriate and beneficial for several reasons; however, switching can also be associated with negative consequences. AIM: To consider the impact of switching in two situations: the use of statins as a well-studied example of within-class drug switching, and gonadotropin-releasing hormone (GnRH)-targeting drug switching as an example of cross-class switching. RESULTS: With the example of statins, within-class switching may be justified to reduce side effects, although the decision to switch is often also driven by the lower cost of generic formulations. With the example of GnRH agonists/antagonists, switching often occurs without the realisation that these drugs belong to different classes, with potential clinical implications. CONCLUSION: Lessons emerging from these examples will help inform healthcare practitioners who may be considering switching drug prescriptions.

Overactive bladder symptoms and voiding dysfunction in neurologically normal women.

AIMS: To understand mechanisms underlying overactive bladder (OAB) and voiding dysfunction (VD) in neurologically normal women. METHODS: Review of MEDLINE from (1982) to (2011) using defined search terms, and manual analysis. Only articles published in English were included. RESULTS: One in five women report moderate to severe lower urinary tract symptoms (LUTS). Whilst VD is more common in men, women report a higher rate of storage symptoms or post-micturition symptoms. Post-void residual (PVR) volume measurements are vital in the assessment of women with LUTS and patients with VD without stress incontinence (SUI) are likely to have an elevated PVR (82%). Bladder outlet obstruction (BOO) also causes VD in women and can be alleviated by surgery or alpha-blocker therapy, although OAB symptoms typically remain. Surgical repair for SUI can result in temporary VD in the minority of patients, highlighting the complex interplay that is emerging in the urethral bladder functioning complex in women. CONCLUSIONS: Women with impaired bladder emptying present with a wide range of LUTS, and PVR measurement is essential for diagnosis. OAB and VD can clearly coexist and accurate diagnosis of underlying pathophysiology is required. Recommendations for clinical practice and research are provided including: investigation of VD in women with OAB; evaluation of PVR values to determine appropriate therapy and identification of BOO. There is clearly a need for further research into the impact of alpha-blockers in women with VD as well as an evaluation of PVR changes in women with OAB before and after antimuscarinic therapy.

Overactive bladder: Is there a link to the metabolic syndrome in men?

It is becoming increasingly clear that a variety of metabolic, cardiovascular, and endocrine factors contribute to male pelvic health. In particular, a growing body of evidence suggests a relationship between lower urinary tract symptoms, benign prostatic hyperplasia, overactive bladder, erectile dysfunction, and the metabolic syndrome. This article explores these relationships, focusing on the role of the autonomic nervous system and hyperinsulinemia, together with their implications for urological practice.

The pharmacist's role in improving the treatment of erectile dysfunction and its underlying causes.

Erectile dysfunction (ED), which worldwide is likely to affect in excess of 300 million men by 2025, is often either untreated or insufficiently treated. It can be a prelude to other serious illnesses and may be a cause or consequence of depression in affected individuals. Among men younger than 60 years of age, ED can be a robust early-stage indicator of vascular disease and type 2 diabetes. Untreated or inadequately treated ED can also be a sign of poor communication between health professionals and service users of all ages. Improved treatment of ED could cost-effectively prevent premature deaths and avoidable morbidity. The extension of community pharmacy‒based health care would enable more men living with ED to safely access effective medications, along with appropriate diagnostic services and support for beneficial lifestyle changes such as smoking cessation in conveniently accessible settings. The task of introducing improved methods of affordably addressing problems linked to ED exemplifies the strategic challenges now facing health care systems globally. Promoting professionally supported self-care in pharmacies has the potential to meet the needs of aging populations in progressively more effective ways.

Cardiovascular Safety of Phosphodiesterase Type 5 Inhibitors After Nearly 2 Decades on the Market.

BACKGROUND: The phosphodiesterase-5 (PDE5) inhibitors that have been available for nearly 20 years are highly effective in treating erectile dysfunction and have been consistently shown to be safe when used according to package insert instructions. AIM: To review the cardiovascular (CV) safety of PDE5 inhibitors used to treat erectile dysfunction. METHODS: PubMed, the Derwent Drug File, and Embase were searched to identify papers published from 1990-2016 presenting CV safety data for PDE5 inhibitors. OUTCOMES: This narrative review focuses mainly on papers published in the last 10 years with CV safety data for sildenafil, tadalafil, or vardenafil. RESULTS: Similar to earlier studies, newer studies demonstrate that PDE5 inhibitors do not show an increased incidence of serious CV adverse events such as cardiac death or myocardial infarction. There are drug-drug interactions with PDE5 inhibitors that for the most part are now commonly known, and PDE5 inhibitors are generally safe to use with other commonly used drugs including antihypertensive agents. CONCLUSION: PDE5 inhibitors are a class of drugs that when used appropriately demonstrate a favorable CV safety profile and present some encouraging signals for new CV indications, which will require additional study. Kloner RA, Goldstein I, Kirby MG, et al. Cardiovascular Safety of Phosphodiesterase Type 5 Inhibitors After Nearly 2 Decades on the Market. Sex Med Rev 2018;6:583-594.

A New Perspective on the Nitrate-Phosphodiesterase Type 5 Inhibitor Interaction.

BACKGROUND: Nitrates and nitrate-containing compounds are vasodilators used for the treatment of angina and heart failure. Phosphodiesterase type 5 inhibitors used for the treatment of erectile dysfunction are also vasodilators, and when taken together with nitrates, synergistic effects that enhance hypotensive effects may occur. Phosphodiesterase type 5 inhibitors are therefore contraindicated in patients taking organic nitrates. METHODS AND RESULTS: A literature review was performed to provide a historical overview of different phosphodiesterase type 5 inhibitors and nitrates and their interaction. The pharmacologic characteristics of phosphodiesterase type 5 inhibitors and nitrates are reviewed, and clinical recommendations for treating cardiovascular disease in men taking phosphodiesterase type 5 inhibitors are discussed. Pharmacologic and adverse drug reactions between nitrates and phosphodiesterase type 5 inhibitors are dependent on many variables. Organic nitrates remain an absolute contraindication in men treated with phosphodiesterase type 5 inhibitors. In general, nitrates may be taken 24 hours after the last dose of short-acting phosphodiesterase type 5 inhibitors and 48 hours after the last dose of long-acting phosphodiesterase type 5 inhibitors. CONCLUSIONS: This literature review determined that the use of phosphodiesterase type 5 inhibitors with nitrates is a contraindication, with the duration between the last dose of phosphodiesterase inhibitor and nitrate use generally varying between short- and long-acting phosphodiesterase type 5 formulations. Patients receiving nitrates who wish to use phosphodiesterase type 5 inhibitors should be educated regarding the interaction and should be evaluated to determine whether nitrate treatment can be discontinued. Further research is needed to determine how soon phosphodiesterase type 5 inhibitors can be restarted after a patient has taken a nitrate and the effect of high and low phosphodiesterase type 5 inhibitor doses on the interaction effect.

Diabetes and the urologist: a growing problem.

The incidence of diabetes continues to increase dramatically; this incidence is predominantly of the type-2 form which clusters together with other comorbidities of hypertension and lipid abnormalities, to form the metabolic syndrome. These conditions will have an increasing impact on urological practice, with erectile dysfunction, hypogonadism, voiding difficulties and urinary tract infections all more common in these patients. These symptoms might be the initial presentation of previously undiagnosed diabetes and it is important to recognise this condition early to avoid later complications including end-stage renal failure.