Erectile Dysfunction and Depression: A Systematic Review and Meta-Analysis

Hyperuricaemia is an important risk factor of the erectile dysfunction: A systematic review and meta-analysis

Serum uric acid can affect endothelial function, and hyperuricaemia-induced endothelial dysfunction is involved in the pathogenesis of cardiovascular diseases. As endothelial dysfunction is also a main pathogenic mechanism of erectile dysfunction (ED), the present study aims to evaluate the relationship between hyperuricaemia and ED via systemic review and meta-analysis. Five cohort studies and six cross-sectional studies on hyperuricaemia and ED, including a total of 454,510 participants, were recruited. Odds ratio (OR) and the 95% confidence intervals (CI) were adopted to estimate the relationship between hyperuricaemia and ED. Overall risk on effects of urate-lowering therapy (ULT) were analysed. In addition, subgroup analyses on study design, populations, age stratification and the object were conducted. In the patients with hyperuricaemia, the risk of ED was 1.59-fold higher than (pooled OR = 1.59, 95% CI [1.29, 1.97]) the non-hyperuricaemia counterparts. Urate-lowing therapy (ULT) in these hyperuricaemia patients reduced the risk of ED by 27% (OR = 1.27, 95% CI [1.14, 1.41]). After subgroup analysis, the association between hyperuricaemia and ED remained significant apart from the >60 years subgroup. Hyperuricaemia is an important risk factor of ED, while ULT can reduce the risk of ED in hyperuricaemia. This study suggests that hyperuricaemia-associated endothelial dysfunction may also underlie the pathogenesis of ED in these patients.

Erectile Dysfunction is a Modifiable Risk Factor for Major Depressive Disorder: Analysis of a Federated Research Network

BACKGROUND

Erectile dysfunction is one of many conditions associated with depression, but few studies exist to establish the risk of major depressive disorder (MDD) in the large population of men with erectile dysfunction, and it is unclear whether erectile dysfunction (ED) treatment is associated with decreased rates of MDD.

AIM

We determined the risk of major depressive disorder in men with erectile dysfunction and evaluated whether treatment of ED with phosphodiesterase-5 inhibitor or penile prosthesis is associated with a lower risk of developing major depressive disorder.

METHODS

We reviewed a large, retrospective, cohort that utilized electronic health record data collected by the TriNetX Research Network, a global federated database that provides healthcare data for analysis. We performed multiple comparisons: men with ED against men without ED; men with ED treated with phosphodiesterase-5 inhibitors against untreated ED patients, and of men with ED who received penile prosthesis against those who did not. We assessed major depressive disorder (ICD-10-CM F32-F33) as a primary outcome and used propensity score matching to control for ethnicity, race, type 2 diabetes mellitus (E11), essential hypertension (I10), acute myocardial infarction (I21), chronic ischemic heart disease (I25), cerebral infarction (I63), overweight and obesity (E66), personal history of nicotine (Z87.891), hypogonadism (E29.1), and alcohol related disorders (F10).

OUTCOMES

We assessed new diagnosis of major depressive disorder (F32-F33) within a 3-year time window following index event of ED diagnosis, visit to healthcare organization, or ED treatment with phosphodiesterase-5 inhibitor or penile prosthesis as the primary outcome.

RESULTS

ED was associated with major depressive disorder both before and after (OR 2.00, 95% CI 1.94-2.06) controlling for confounding variables through propensity score matching. Men who received ED therapies had lower rates of depression compared to those who did not, whether they were treated with phosphodiesterase-5 inhibitor (0.80, 0.77-0.83) or penile prosthesis (0.73, 0.60-0.89).

STRENGTHS AND LIMITATIONS

Strengths include a large sample size and robust statistical techniques. Limitations include lack of detailed information regarding clinical severity and socioeconomic factors.

CLINICAL IMPLICATIONS

Our findings indicate that clinicians should consider evaluating depressive symptoms among men with erectile dysfunction and counsel them regarding the risk of developing major depressive disorder.

CONCLUSIONS

Erectile dysfunction is associated with major depressive disorder, but treatment is associated with decreased rates of MDD. S Nackeeran, A Havanur, J Ory, et al. Erectile Dysfunction is a Modifiable Risk Factor for Major Depressive Disorder: Analysis of a Federated Research Network. J Sex Med 2021;18:2005-2011.

A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine (ESSM)

INTRODUCTION

Although erectile dysfunction (ED) involves an interaction between physiological and psychological pathways, the psychosocial aspects of ED have received considerably less attention so far.

AIM

To review the available evidence on the psychosocial aspects of ED in order to develop a position statement and clinical practice recommendations on behalf of the European Society of Sexual Medicine (ESSM).

METHOD

A comprehensive, narrative review of the literature was performed.

MAIN OUTCOME MEASURES

Specific statements and recommendations according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence criteria were provided.

RESULTS

A multidisciplinary treatment, in which medical treatment is combined with a psychological approach, is preferred over unimodal treatment. There is increasing evidence that psychological treatments of ED can improve medical treatments, the patient's adherence to treatment, and the quality of the sexual relationship. The main components of psychological treatment of ED involve cognitive and behavioral techniques aimed at reducing anxiety, challenging dysfunctional beliefs, increasing sexual stimulation, disrupting sexual avoidance, and increasing intimacy and communication skills in a relational context. When applicable and possible, it is strongly recommended to include the partner in the assessment and treatment of ED and to actively work on interpartner agreement and shared decision-making regarding possible treatment options. To ensure a better integration of the biopsychosocial model into clinical practice, developing concrete treatment protocols and training programs are desirable.

CONCLUSION

Because the psychosocial approach to ED has been underexposed so far, this position statement provides valuable information for clinicians treating ED. Psychological interventions on ED are based on existing theoretical models that are grounded in empirical evidence. However, the quality of available studies is low, which calls for further research. The sexual medicine field would benefit from pursuing more diversity, inclusivity, and integration when setting up treatments and evaluating their effect. Dewitte M, Bettocchi C, Carvalho J, et al. A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine (ESSM). Sex Med 2021;9:100434.

Tadalafil improves erectile dysfunction and quality of life in men with cirrhosis: a randomized double blind placebo controlled trial

BACKGROUND AND AIMS

Patients with cirrhosis have high prevalence of erectile dysfunction (ED). The aim of this study was to study the efficacy and safety of tadalafil for ED in patients with cirrhosis.

METHODS

140 cirrhotic males with ED were randomized into tadalafil 10 mg daily (n = 70) or placebo (n = 70) for 12 weeks. ED was diagnosed if erectile function (EF) domain score was < 25 in International Index of Erectile Function (IIEF) questionnaire. The erectile function domain consists of six questions concerning erection frequency, erection firmness, frequency of partner penetration, frequency of maintaining erection after penetration, ability to maintain erection to completion of intercourse and confidence in achieving and maintaining erection. Primary outcome was proportion of patients having an increase in > 5 points in EF domain of the IIEF. Generalized Anxiety Disorder 7 (GAD-7) questionnaire was used for screening and severity measuring of GAD. The presence of depression was screened using the Patient Health Questionnaire (PHQ-9) and the assessment of health related quality of life was done using the Short Form (36) Health Survey.

RESULTS

At the end of 12 weeks, more patients in tadalafil group achieved > 5 points increase in the EF domain of the IIEF when compared with the placebo group [44(62.9%) vs. 21(30%), p < 0.001]. At the end of 12 weeks, patients receiving tadalafil had significantly more change in scores on the erectile function domain, orgasmic function domain, intercourse satisfaction domain, overall satisfaction domain, erection vaginal penetration rates and successful intercourse; significantly more decline in the GAD-7 and PHQ-9 scores; significantly more improvement in scores of five of the eight domains of SF-36 (general health perception, vitality score, social functioning, role emotional and mental health) and the mental component summary rates when compared with placebo. The development of side effects and the changes in HVPG were not significantly different between the two groups.

CONCLUSIONS

Tadalafil therapy may enhance erectile function, improve anxiety, depression and quality of life; and is well tolerated by men with cirrhosis (CTP score < 10) and ED. However, further larger and long-term studies are needed to confirm these results and look for rarer side effects of using tadalafil in patients with cirrhosis.

TRIAL REGISTRATION

ClinicalTrials.gov identifier number NCT03566914; first posted date: June 25, 2018.

The connection of 5-alpha reductase inhibitors to the development of depression

Recent literature connects 5-alpha reductase inhibitors (5-ARIs) with neuropsychiatric adverse effects. Several clinical studies have indicated that former 5-ARIs users had a higher incidence of depressive symptoms and neuropsychiatric side effects than non-users. However, the underlying mechanisms involved in the depression in former 5-ARIs patients, a condition known as "post finasteride syndrome (PFS)", are not thoroughly understood. This review aims to summarize and discuss the association between 5-ARIs and depression as well as possible mechanisms. We used PubMed search terms including "depression", "depressive symptoms", "MDD", "anxiety", or "suicidal idea", and "5-alpha reductase inhibitors", "finasteride", "dutasteride", "5-ARIs". All relevant articles from in vivo and clinical studies from 2002 to 2021 were carefully reviewed. Any contradictory findings were included and debated. The potential mechanisms that link 5-ARIs and depression include alteration in neuroactive steroids, dopaminergic dysfunction, reduced hippocampal neurogenesis, increased neuroinflammation, alteration of the HPA axis, and epigenetic modifications. From this review, we hope to provide information for future studies based on animal experiments, and potential therapeutic strategies for depressive patients with PFS.

Attention Bias and Recognition of Sexual Images in Depression

Depression greatly affects sexuality. Theoretical and empirical evidence account for the existence of attention bias to sex-related stimuli. This attention bias might be impaired in depression, resulting in sexual problems. A sample of 13 patients with depression and 13 matched healthy controls were tested using the dot-probe and picture recognition task to measure attention to erotic images. No difference in attention to sex-related stimuli (ω² = 0, p = 0.22) and in memory bias (ω² = 0, p = 0.72) was found between the two groups. Explorative analyses were conducted to identify the sexual content-induced delay effect in the data, assess variability differences, and compare trial-level bias score-based indexes between groups. Across all analyses, there was little evidence for depression affecting sexual-related cognitive processing, and even this might be explained by other means. Our results suggest that restrained attention is probably not the main factor behind sexual problems in depression.

Pornography Addiction: An Exploration of the Association Between Use, Perceived Addiction, Erectile Dysfunction, Premature (Early) Ejaculation, and Sexual Satisfaction in Males Aged 18-44 Years

INTRODUCTION

The way men consume pornography changed over the last decade, with increased numbers of men presenting with self-perceived Internet pornography (IP) addiction and related sexual dysfunction. A lack of consensus and formal recognition in the DSM-5 lead to a variety of definitions of IP addiction. Currently, the majority of evidence linking IP addiction and sexual dysfunction was derived from consumers, case studies, and qualitative research. Where empirical measures were used, researchers found mixed outcomes in sexual response. Inconclusive data appeared to relate to the conflation of IP use and self-perceived IP addiction, and normal variations in sexual response with clinical diagnosis of sexual dysfunction. Thus, further empirical clarification is required to assess the impact of both IP use and self-perceived IP addiction, on men's sexual function.

AIMS

This study has 3 aims: First, to assess if there is an association between IP use alone and erectile dysfunction (ED), premature (early) ejaculation (EE) and sexual satisfaction (SS); Second, to assess whether there is an association between self-perceived IP addiction and ED, EE and SS. Third, to assess whether IP use or self-perceived IP addiction uniquely predicts ED, EE, SS in men.

METHOD

Correlation and regression analysis was conducted on a cross-sectional sample of 942 heterosexual men aged 18-44 years who participated in an online survey sourced from Reddit IP subgroups.

MAIN OUTCOME MEASURES

Cyber-Pornography Use Inventory; International Index Erectile Dysfunction; The Checklist for Early Ejaculation Symptoms; New Sexual Satisfaction Scale; Depression Anxiety Stress Scale-21.

RESULTS

There was no evidence for an association between IP use with ED, EE, or SS. However, there were small to moderate positive correlations between self-perceived IP addiction and ED, EE and sexual dissatisfaction. Further, self-perceived IP addiction uniquely predicted increased ED, EE and individual sexual dissatisfaction. Contrary to expectations, self-perceived IP addiction did not predict sexual dissatisfaction with one's sexual partner.

CONCLUSION

These results suggest that IP use alone does not predict sexual dysfunction. Rather, self-perception of increased IP addiction was related to negative sexual outcomes. Thus, we concluded that subjective interpretation of ones IP use was a contributor to IP related sexual problems in our sample of males who share IP on social media sites. We recommend that clinicians consider self-perceived IP addiction as a possible contributing factor to sexual dysfunction. Whelan G, Brown J. Pornography Addiction: An Exploration of the Association Between Perceived Addiction, Erectile Dysfunction, Premature (Early) Ejaculation, and Sexual Satisfaction in Males Aged 18-44 Years. J Sex Med 2021;18:1582-1591.

Efficacy and safety of low-intensity shockwave therapy plus tadalafil 5 mg once daily in men with type 2 diabetes mellitus and erectile dysfunction: a matched-pair comparison study

Low-intensity extracorporeal shockwave therapy (LiESWT) represents a promising treatment for patients with erectile dysfunction (ED). We investigated the efficacy of LiESWT combined with tadalafil 5 mg once daily in men with type 2 diabetes mellitus (T2DM) and ED and compared LiESWT protocols administering different number of shockwaves. We performed a retrospective matched-pair comparison using data from a prospectively maintained database. Seventy-eight patients who received tadalafil 5 mg once daily for 12 weeks + LiESWT performed with an electrohydraulic source for 3 weeks (Group A) were matched 1:1 to patients who received tadalafil 5 mg once daily alone for 12 weeks (Group B). A subgroup analysis was performed according to the number of shockwaves delivered during each session (1500, 1800, and 2400 in subgroup A1, A2, and A3, respectively). The mean International Index of Erectile Function-5 (IIEF-5) score variations with respect to baseline recorded at 4, 12, and 24 weeks after the end of the treatment were investigated as treatment outcomes. The mean IIEF-5 scores significantly improved in all groups and subgroups at 4-week follow-up without intergroup differences. At 12- and 24-week follow-up, the mean IIEF-5 improvement was significantly higher among patients in the A3 subgroup (+5.0 ± 2.1 [P < 0.001] and +4.7 ± 2.3 [P < 0.001], respectively). The combined approach with tadalafil 5 mg once daily and LiESWT with a protocol involving 2400 shockwaves provides significant advantages in terms of IIEF-5 improvement and durability compared to tadalafil 5 mg once daily alone in patients with T2DM and ED.

Erectile Dysfunction in Men with Chronic Obstructive Pulmonary Disease

Erectile dysfunction (ED) seems to be a widespread sexual issue in men affected by chronic obstructive pulmonary disease (COPD). Multiple causes appear to be involved such as hormonal imbalance, smoking habit, chronic inflammation, endothelial dysfunction, chronic hypoxia, psychiatric disorders (depression and anxiety), and medications. ED can have a significant impact on COPD men and consequently on their quality of life, which is usually already compromised. Given this situation, however, pneumologists usually do not properly care for the sexuality of COPD patients especially because men can be reluctant to talk about their intimate issues. The aim of this narrative review is to briefly summarize the evidence emerging from literature and to provide a wide point of view about sexual dysfunction in COPD men.

Risk of osteoporosis in patients with erectile dysfunction: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Erectile dysfunction (ED) and osteoporosis are both common health problems and have similar risk factors. Recent studies have found that people with ED have a higher risk of osteoporosis.We aimed to systematically assess osteoporosis risk in patients with ED.

METHODS

A systematically research was carried out in Medline via PubMed, Cochrane Library, EMBASE, and Web of Science up to June 4, 2020, to identify articles related to ED and osteoporosis. The 2 researchers independently reviewed the literature, extracted the data, and evaluated the quality of the literature. All analyses were done using RevMan5.3 and Stata14.

RESULTS

A total of 4 studies involving 22,312 participants were included. The meta-analysis results showed that the risk of osteoporosis in the ED group was significantly higher than that in the non-ED group [odds ratio (OR) = 2.66, 95% confidence interval (95% CI) 1.42 to 4.98, P = .002, I2 = 68%]. Interestingly, compared with older participants, the increased risk of osteoporosis in ED patients seemed to be more pronounced in younger participants. Despite the lack of data for meta-analysis, more than half of the literature mentioned this tendency. We found the source of heterogeneity through sensitivity analysis, and there was no significant effect on the results before and after the removal of this literature, indicating that our results were robust. No obvious publication bias was found through Egger method (P = .672).

CONCLUSION

People with ED have a higher risk of osteoporosis, especially among younger males. Because the assessment of osteoporosis is economical and noninvasive, ED patients should be evaluated by bone mineral density or men with osteoporosis should be further assessed for erectile function.

Assessment of Female Sexual Dysfunction and Erectile Dysfunction and Its Association with Lower Urinary Tract Symptoms in Women and Men Over 18 Years Old: Results From the COBaLT Study

BACKGROUND

Female sexual dysfunction and erectile dysfunction (FSD/ED) have been linked with lower urinary tract symptoms (LUTS), from both epidemiological data and basic research studies, but few studies have been conducted in Latin America addressing these issues and most of them do not include the young population.

AIM

To determine the prevalence of FSD/ED and its association with LUTS in Colombia.

METHODS

Sub-analysis of a cross-sectional, population-based study conducted in subjects ≥18 years old to evaluate LUTS/OAB. The estimated sample size was 1,054. ED was defined as ≤21 points in the SHIM and FSD as ≤19 in the FSFI-6. For LUTS/OAB, we used the 2002 ICS and 2010 IUGA/ICS definitions and validated questionnaires. Descriptive and inferential statistics were employed.

OUTCOMES

Prevalence of FSD/ED and association of FSD/ED and LUTS.

RESULTS

We included 1,060 participants; the median age was 40 (IQR 27-54) years. Fifty-seven (11.4%) men and 182 (32.7%) women were sexually inactive. The prevalence of FSD/ED in sexually active participants was 47% (men 52.9%, women 38.9%). The most common FSD/ED symptoms were diminished/absent lubrication in women (42%) and diminished erection maintenance after penetration in men (13%). Individuals with FSD/ED had higher rates of various LUTS. The multivariable logistic regression model found that the city of residence (OR = 0.4, 95% CI 0.2-0.9), diabetes mellitus (DM) (OR = 8.4, 95% CI 1.4-48.7), menopause (OR=3.5, 95% CI 1.9-6.2), urge urinary incontinence (UUI) (OR=1.9, 95% CI 1.1-3.3) and nocturia ≥2 (OR = 2.2, 95% CI 1.2-4.2) were associated with FSD. In men, age 40-59 (OR = 2.3, 95% CI 1.4-3.7) and ≥60 (OR = 5.5, 95% CI 2.4-12.5), the city of residence (OR = 0.2, 95% CI 0.1-0.3), less than a high-school diploma vs higher education (OR = 2.0, 95% CI 1.2-3.2), depression (OR = 4.6, 95% CI 1.8-11.5), UUI (OR = 3.2, 95% CI 1.1-10.2) and feeling of incomplete bladder emptying (OR = 2.1, 95% CI 1.3-3.5) were associated with ED.

CLINICAL IMPLICATIONS

This study underlines the importance of assessing LUTS in women and men of all affected age groups who present with symptoms of FSD/ED and vice versa, which could help achieve a better approach for these patients.

STRENGTHS & LIMITATIONS

This is the first study in Colombia and one of the few in Latin America that addresses both FSD/ED and LUTS in men and women aged 18 years and older. Limitations include being a sub-analysis of a study aiming to determine the prevalence of LUTS/OAB and not FSD/ED.

CONCLUSIONS

Regardless of age, LUTS were observed more frequently in patients with FSD/ED. Various LUTS were associated with FSD/ED. Bravo-Balado A, Trujillo CG, Caicedo JI, et al. Assessment of Female Sexual Dysfunction and Erectile Dysfunction and Its Association with Lower Urinary Tract Symptoms in Women and Men Over 18 Years Old: Results From the COBaLT Study. J Sex Med 2021;18:1065-1074.

Prevalence of erectile dysfunction and associated factors among males visiting family medicine clinics in a Tertiary Care Hospital in Karachi, Pakistan

Background

The burden of erectile dysfunction (ED) among the developed countries is found to be quite high. However, there is a paucity of data among developing countries to know its actual burden and factors associated with it.

Methods

The current study is cross-sectional and was conducted in Family Medicine clinics of Liaquat National Hospital during May 2017-January 2018. A total of 450 males participated in this study with the age range of 24-77 years. More than half of the participants were graduates or above.

Results

On multivariable analysis, age (aOR = 5.47, 95% CI: 2.74-10.89), alcohol use (aOR = 5.23, 95% CI: 1.45-18.84), diabetes (aOR = 6.61, 95% CI: 3.27-13.36), and current smoking (OR = 2.41, 95% CI: 1.35-4.31) were significantly associated with ED. ED risk was significantly lower in those who either attended secondary school (aOR = 0.33, 95% CI: 0.13-0.88) or were at least graduates (aOR = 0.40, 95% CI: 0.17-0.96) than illiterate when model was adjusted for other covariates.

Conclusion

Erectile dysfunction in a Pakistani male population highlights the need for routine screening at the primary care level. There is a possibility that the actual burden is underreported due to cultural stigmatization; hence, further research is warranted to validate the findings.

The efficacy and safety of acupuncture in the treatment of erectile dysfunction: A protocol for systematic review and meta-analysis

BACKGROUND

Erectile dysfunction (ED) can negatively affect men's mental health, interpersonal relationships, and overall well-being. ED has affected >150 million men worldwide, and this number will reach approximately 322 million by 2025. Although PDE5-Is is a landmark in the treatment of erectile dysfunction, it may have side effects such as penile pain, cardiovascular dysfunction, and deafness. Some studies have shown that acupuncture may have a positive effect on the pathophysiology of ED. Therefore, we will select all randomized controlled trials related to evaluate the efficacy and safety of acupuncture treatment of ED.

METHODS

This study will systematically search 7 digital databases including China National Knowledge Infrastructure, Wanfang, VIP, China Biology Medicine, Cochrane Library, PubMed, and Embase for randomized controlled trials without language restrictions. Two researchers will independently read the title, abstract, and full text to screen for studies that can be included in the meta-analysis. If there is any dispute, the third party will be required to reach a consensus.

RESULTS

The purpose of this study is to evaluate the efficacy and safety of acupuncture in the treatment of ED and the difference in the impact of different types of acupuncture on ED.

CONCLUSION

Judge whether acupuncture and moxibustion can help improve the symptoms of ED by evaluating relevant literatures, and make up for the lack of relevant research.

INPLASY REGISTRATION NUMBER

INPLASY 202140040.

Erectile Dysfunction Is the Main Correlate of Depression in Men with Chronic Spinal Cord Injury

Depression is the most prevalent psychological issue after a spinal cord injury (SCI) and is associated with noticeable disability, mortality and health expenditure. As SCI mainly occurs in sexually active men at a young age, and can lead to them suffering from an organic neurogenic erectile dysfunction (ED), we supposed that ED could be a major correlate of depressive status in men with SCI. As documented by a Beck Depression Inventory-II (BDI-II) score ≥14, depression was reported in 17 out of 57 men with a chronic SCI (29.8%). They exhibited a significantly higher prevalence of ED and a more severe bowel and bladder dysfunction when compared to the group without depression. At the multiple logistic regression analysis, depression showed a significant independent association with ED (OR = 19.0, 95% CI: 3.1, 203.3; p = 0.004) and, to a lesser extent, with a severe impairment of bowel and bladder function (OR = 0.84; 95% CI: 0.72, 0.94; p = 0.01). Depression was observed in 43.7% of men with ED and only in 12.0% of those without ED (p = 0.002). In conclusion, healthcare providers should give the right level of importance to the management of ED in men with SCI, as this represents a major independent correlate of depression, which, in turn, might hinder physical rehabilitation and exacerbate physical health issues related to SCI.

Intra-cavernous injection of BOTOX® (50 and 100 Units) for treatment of vasculogenic erectile dysfunction: Randomized controlled trial

BACKGROUND

Erectile dysfunction (ED) is a socioeconomic problem.There are several options for its management including intra-cavernosal injection (ICI).

OBJECTIVE

To compare the safety, efficacy, and durability of ICI of onabotulinum toxin-A (BTX) in different doses (50 and 100 U) against placebo (saline) in the management of vasculogenic ED non-responding to pharmacological therapy (phosphodiesterase type 5 inhibitors or/and ICI of trimix).

MATERIALS AND METHODS

A prospective randomized double-blind placebo-controlled trial was conducted between July 2016 and February 2019. A total of 176 patients were randomly assigned (1:1:1) to one of the treatment sequences: Botox 100 U group (BTX-100; 62 patients), Botox 50 U group (BTX-50; 59 patients), or placebo group (55 patients). All patients were followed up for 6 months.

RESULTS

Significant improvement in all parameters, that is, SHIM score & Erection Hardness Score (EHS), Sexual Encounter Profile (SEP), Global Assessment Score (GAS), and Doppler parameters (p < 0.001) was observed in patients of BTX-100 and BTX-50 groups with maximum improvement at 3rd month of treatment. Around 40% of patients were responders and were able to engage in sexual intercourse. Patients in placebo group did not experience significant improvement (p = 0.264). It was noted that at the 2nd week and 3rd months after treatment, there was no statistically significant difference in the improvement of these parameters in BTX-100 and BTX-50 groups (p > 0.05). In the 6th month, there was a statistically significant difference between the aforementioned groups in favor of BTX-100 (p < 0.01).

CONCLUSIONS

Only one-time ICI of BTX (50 U and 100 U) is effective and safe for the treatment of refractory ED. This agent has a considerable long duration of action, particularly BTX-100U seems to be more durable.

The Quality of Life and Economic Burden of Erectile Dysfunction

Erectile dysfunction (ED) is a common disorder in adult males that results in withdrawal from sexual intimacy, psychosocial problems (ie, poor self-esteem, depression, anxiety), decreased work productivity, and reduction in quality of life for both the men suffering from ED and their female partners. A pragmatic literature review was undertaken using PUBMED to identify original research studies published over the past 20 years that assessed the impact of ED on a male’s quality of life, the impact of ED on a female partner’s quality of life, or the economic impact of ED on employers. Twenty studies were selected for inclusion. This review showed that men with ED have a poorer quality of life than men without ED (n=9 studies). Results from a global burden of illness study showed that men with ED report substantially lower SF-36 Mental and Physical Component Summary scores and SF‐6D scores compared to men without ED (p<0.001). Similarly, the partner is also negatively impacted by ED due to relationship difficulties and decreased sexual satisfaction (n=8 studies). Results from the Female Experience of Men’s Attitudes to Life Events and Sexuality study showed that females were significantly less satisfied and engaged in sexual activity less frequently after their partner developed ED (p<0.001). ED also poses a substantial economic burden on employers (n=3 studies). An observational study in men aged 40–70 showed that men with ED had significantly higher rates of absenteeism (2x) and work productivity impairment compared to men without ED (p<0.001). Overall, this contemporary review demonstrated that ED imposes a substantial quality of life burden on men and their female partners as well as a significant economic burden on their employers. These findings underscore the need for more education and awareness of the burden of ED and greater access to appropriate ED treatments to help alleviate this burden.

Measures of mental, physical, and social wellbeing and their association with death by suicide and self-harm in a cohort of 266,324 persons aged 45 years and over

PURPOSE

The aim of this study was to examine the relation of mental, physical, and social wellbeing measures to death by suicide and self-harm (SH).

METHODS

Using a cohort design, questionnaire data on 266,324 responders aged ≥ 45 years, living in NSW, Australia were linked to hospital and death databases during 2006-2017. Adjusted incidence rate ratios (IRR) were calculated.

RESULTS

Overall, 212 suicides and 723 SH episodes were observed. A dose-response relationship with suicidal behaviour was found for Kessler-10 Psychological Distress Scale; IRRs of 4.5 (95% CI 2.4-8.3) for suicide and 8.3 (95% CI 6.5-10.7) for SH were observed for scores of high versus low distress. Elevated rates were also observed for those reporting poor versus good or excellent health (suicide, IRR: 3.8, 95% CI 2.2-6.9; SH, IRR: 4.5 95% CI 3.4-6.1); being dependent versus not dependent on help with daily tasks (suicide, IRR: 2.4 95% CI 1.5-3.7; SH, IRR: 2.6 95% CI 2.0-3.3); being a current smoker (suicide, IRR: 1.8, 95% CI 1.1-2.9; SH, IRR: 2.9 95% CI 2.3-3.5) having versus not having male erectile problems (SH, IRR: 1.9 95% CI 1.4-2.5). Participants with ≥ 5 people versus one person to depend on had reduced suicidal behaviour (suicide, IRR: 0.5 95% CI 0.3-0.7, SH, IRR: 0.5 95% CI 0.4-0.6).

CONCLUSIONS

An active social network was linked to lower rates of suicide and self-harm. Adverse health, dependence on help, psychological distress were associated with higher rates of suicide and self-harm, while erectile problems were linked to an elevated rate of self-harm.

Sexual Health Implications of COVID-19 Pandemic

INTRODUCTION

A novel coronavirus (COVID-19) reached pandemic levels by March 11th, 2020, with a destructive impact across socioeconomic domains and all facets of global health, but little is known of its impact on sexual health.

OBJECTIVE

To review current knowledge on sexual health-related containment measures during pandemics, specifically COVID-19, and focus on 2 main areas: intimacy and relational dynamics and clinical effects on sexual health.

METHODS

We carried out a literature search encompassing sexual health and pandemic issues using Entrez-PubMed and Google Scholar. We reviewed the implications of the COVID-19 pandemic on sexual health regarding transmission and safe sex practices, pregnancy, dating and intimacy amid the pandemic, benefits of sex, and impact on sexual dysfunctions.

RESULTS

Coronavirus transmission occurs via inhalation and touching infected surfaces. Currently, there is no evidence it is sexually transmitted, but there are sexual behaviors that pose a higher risk of infectivity due to asymptomatic carriers. Nonmonogamy plays a key role in transmission hubs. New dating possibilities and intimacy issues are highlighted. Sexual activity has a positive impact on the immune response, psychological health, and cognitive function and could mitigate psychosocial stressors. COVID-19 pandemic affects indirectly the sexual function with implications on overall health.

CONCLUSION

Increased awareness of health-care providers on sexual health implications related to the COVID-19 pandemic is needed. Telemedicine has an imperative role in allowing continued support at times of lockdown and preventing worsening of the sexual, mental, and physical health after the pandemic. This is a broad overview addressing sexual issues related to the COVID-19 pandemic. As this is an unprecedented global situation, little is known on sexuality related to pandemics. Original research is needed on the topic to increase the understanding of the impact the current pandemic may have on sexual health and function. Pennanen-Iire C, Prereira-Lourenço M, Padoa A, et al. Sexual Health Implications of COVID-19 Pandemic. Sex Med Rev 2021;9:3-14.

Prevalence and factors associated with erectile dysfunction among adult men in Moshi municipal, Tanzania: community-based study

Background

Erectile dysfunction (ED) has a negative impact on ones’ relationships with poor quality of life as inevitable result. The effects of ED maybe worse in developing countries setting like Tanzania because men’s sexual health has been forgotten. Men’s sexual and reproductive health needs are not in the national reproductive health strategic. This study aimed to determine the prevalence and factors associated with erectile dysfunction among adult men in Moshi municipality, northern Tanzania.

Results

The mean age of the 381 men was 39.6 (SD ±16.8) years. The overall prevalence of ED on this study was 29.7%. The severity of ED among study participants was; 13.4% (51), 9.7% (37), 3.7% (14), 2.9% (11) had mild, mild to moderate, moderate and severe erectile dysfunction respectively. Age 40–54 years (Adjusted OR 5.0, 95% CI 2.5–9.9), > 55 years (aOR 11.7, 95% CI 5.8–23.7) and hypertension (aOR 2.6, 95% CI 1.1–6.4) were independent predictors of ED respectively.

Conclusion

The prevalence of ED is high among men in Moshi municipal as 1 out of 3 men have ED. Age and hypertension were independent predictors of ED. These results point to the need of community awareness and education programs to raise awareness among men about existence of ED problem, its consequence and where they can get advice and care in this setting. Further, health providers taking care of hypertensive and men with DM should be equipped with knowledge and skills on early detection for ED and how to counsel and where to refer patients for help.

Metabolic syndrome is not associated with erectile dysfunction in apparently healthy men

AIMS

To investigate whether metabolic syndrome (MetS) is associated with erectile dysfunction (ED) among apparently healthy men when depressive symptoms and serum testosterone levels are taken into account.

METHODS

A study population of 549 men at risk for cardiovascular disease or type 2 diabetes was drawn from the participants of a population survey, the Harmonica Project. MetS was diagnosed with the United States National Cholesterol Education Program Third Adult Treatment Panel (ATPIII) 2005 definition, the International Diabetes Federation (IDF) 2005 definition and the Harmonization 2009 definition. ED was evaluated by the International Index of Erectile Function (IIEF-5) questionnaire. Depressive symptoms were assessed with Beck's Depression Inventory (BDI).

RESULTS

Of the 549 men (mean age 58.4 ± 6.7 years), 56.5 % reported ED. The prevalence of MetS was 48.6%, 35.5%, and 50.6% according to the IDF, the ATPIII, and the Harmonization criteria, respectively. We found no difference in the prevalence of ED between men with or without MetS. In a multivariate analysis, age, presence of depressive symptoms and lower education were significant predictors of ED.

CONCLUSIONS

The prevalence of ED is quite high even in apparently healthy men. Depressive symptoms are a critical component to consider in men suffering from ED.

Association between erectile dysfunction and fibromyalgia in male patients: A Taiwanese nationwide population-based cohort study

OBJECTIVES

To investigate the association between erectile dysfunction and fibromyalgia, and to clarify related comorbidities and treatment modalities.

METHODS

This retrospective cohort study was carried out using 1 million records in the National Health Insurance Research Database. From 2001 to 2012, a total of 53 678 male patients newly diagnosed with fibromyalgia were recruited as the fibromyalgia cohort, and the same number of the non-fibromyalgia cohort was enrolled and matched with propensity score with age, income, comorbidities, and prescribed medications. All records were followed up until the end of 2013. The Cox proportional hazards model was carried out to assess the risk of erectile dysfunction among fibromyalgia patients.

RESULTS

The incidence rates of erectile dysfunction were 36.86 and 21.15 (per 10 000 person-years) in the fibromyalgia and non-fibromyalgia cohorts, respectively, and a significantly increased risk of erectile dysfunction in fibromyalgia patients was noted (adjusted hazard ratio 1.69, 95% confidence interval 1.55-1.85, P < 0.001). The Cox proportional hazards regression analysis showed increased risk of erectile dysfunction in the fibromyalgia cohort regardless of treatment prescriptions of tramadol, antidepressants, gabapentin and non-steroidal anti-inflammatory drugs.

CONCLUSIONS

Fibromyalgia was found to be an independent risk factor for the incidence of erectile dysfunction.

Cognitive Behavioral Sex Therapy: An Emerging Treatment Option for Nonorganic Erectile Dysfunction in Young Men: A Feasibility Pilot Study

Introduction

An increasing number of young men have been found to develop nonorganic erectile dysfunction (NOED) in recent years. The NOED has been shown to respond better to cognitive behavior sex therapy (CBST) in a few past studies.

Aim

The present research aims to establish the efficacy of CBST as a promising treatment option in young men suffering from NOED by administering a feasibility pilot trial.

Methods

28 young men (M = 31 years) out of a total of 39 men (7 excluded, 4 quit treatment) diagnosed with NOED from sexual health clinics in Pakistan were recruited to receive CBST treatment (n = 13) on average twice a week for a period of 50 minutes per session for a period of 4, 6, 8, and 12 weeks for the mild, mild to moderate, moderate, and severe forms of NOED, respectively, and sildenafil citrate group (n = 15) receiving sildenafil citrate 50 mg on demand. The trial design was sequential random assignment clinical trial.

Main Outcome Measures

International Index of Erectile Functoning-5 and Depression Anxiety Stress Scale-21 were used before treatment, after treatment, and in follow-up as the main outcome measures.

Results

The repeated measures analysis of covariance established a nonsignificant difference between CBST and sildenafil citrate 50 mg in NOED scores improvement, NOED severity reduction, and reduction in depression scores at posttreatment assessment. There were significant differences among different CBST modalities in improving NOED scores, reduction in NOED severity, and depression scores. There was significant difference in CBST and sildenafil citrate 50 mg in anxiety reduction at posttreatment assessment. The covariates age, age groups, and NOED duration did not significantly impact the treatment outcome for both treatment groups except age which impacted the interaction of treatment and anxiety scores.

Conclusion

The CBST is an emerging and promising treatment choice in younger men suffering from NOED.

Bilal A, Abbasi NuH. Cognitive Behavioral Sex Therapy: An Emerging Treatment Option for Nonorganic Erectile Dysfunction in Young Men: A Feasibility Pilot Study. J Sex Med 2020;8:396–407.

Effect of daily tadalafil on reported outcomes in patients with erectile dysfunction and depressive symptoms: STROBE, a case-control study

Erectile dysfunction (ED) and depression are closely related. We sought to determine ED and depression were improved by tadalafil, a phosphodiesterase type 5 (PDE5) inhibitor, at 5 mg daily, in this case-control study.Participants were men aged 20 to 65 years with ED for >3 months, International Index of Erectile Function-5 (IIEF) score <21 points, and Zung Self-Rating Depression Scale (SDS) survey result >50 points who were willing to participate.On first visit (V1) and after 1 (V2) and 2 months (V3), clinical features were examined using IIEF-5 for diagnosing and evaluating ED, SDS for evaluating depression, and International Prostate Symptom Score and Quality of Life (IPSS/QoL) survey for examining lower urinary tract symptoms (LUTS). Tadalafil 5 mg was administered daily for 2 months.A total of 60 participants were an average age of 58.68 ± 6.71 years. Patient overall average IIEF was 8.76 ± 5.98, showing mild ED symptoms, and total average IPSS 13.74 ± 7.55 showed moderate LUTS. Average overall SDS index was 58.93 ± 9.21, indicating moderate-to-severe findings. Average change in IIEF among all patients revealed significant improvement from V1 to V2 (-2.69 ± 1.22, P = .03) and V1 to V3 (-4.38 ± 1.20, P < 0.01). IPSS also significantly improved from V1 to V3 (3.48 ± 1.37, P = .01), as did SDS index (V1, V2: 4.69 ± 1.89, P = 0.02), (V1, V3: 5.43 ± 1.89, P < .01). Patients with severe IIEF scores (group 1, n = 27) experienced significantly greater improvement in IIEF from V1 to V2 and V1 and V3, compared to those with mild-to-moderate IIEF scores. Both groups improved in SDS index from V1 to V2 and V1 to V3, with the greatest improvement between V1 and V3 for group 1 and V1 and V2 for group 2.Daily tadalafil 5 mg could be helpful for ED patients with depressive symptoms and improved LUTS and quality of life.

Hypoactive sexual desire disorder (HSDD) is not "female erectile dysfunction (ED)": challenges with the characterization of HSDD in women based on a systematic literature review

Objective: Hypoactive sexual desire disorder (HSDD) in women has been viewed inaccurately by some in the medical and payer community as analogous to erectile dysfunction (ED) in men. This literature review aims to highlight the distinctions between HSDD and ED.Methods: Two systematic literature searches were conducted on the epidemiology, symptomatology and biopsychosocial outcomes of HSDD and ED. Studies published since 2007 were considered for HSDD; studies published since 2012 were considered for ED.Results: HSDD in women is primarily a central nervous system condition related to neuroendocrine factors, whereby neural pathways that regulate sexual excitation and/or inhibition appear to be involved. A combination of organic and psychogenic factors often contributes to ED. HSDD and ED are associated with similar psychological and interpersonal consequences, but affect different phases of the sexual response model (desire versus arousal) and have different pathophysiologies, therefore requiring different treatment and outcome paradigms. ED is measured by objective, physiological responses (erection and sexual function), but quantitative assessments for HSDD are more difficult because loss of desire with associated distress has to be assessed. Outcome measures used to assess ED, such as the number of satisfying sexual events, are far less informative as an endpoint for randomized clinical trials of treatments for HSDD.Conclusions: HSDD and ED are distinct conditions affecting different phases of the sexual response model, and thus require clear and unique clinical characterization and adequate communication between the health care professional and patient for appropriate diagnosis, management and treatment.

Increased risk of prostatitis in male patients with depression

Objectives: To investigate whether male patients with depression are at an increased risk of prostatitis.Methods: We used a universal insurance claims database in Taiwan from 2000 to 2010 to identify patients with newly diagnosed depression (n = 13,019) (depression cohort) and those without depression (n = 53,026) (comparison cohort). Both cohorts were matched by age and index year of depression incidence. Hazard ratios of prostatitis were calculated by multivariable Cox proportional hazard models.Results: The incidence of prostatitis demonstrated a 2-fold increase in the depression cohort in comparison with that observed in the non-depression cohort, with an adjusted hazard ratio of 1.70 after adjustment for age, occupation, urbanisation level, potential comorbidity and medication. Furthermore, patients with depression, relative to the non-depression cohort, were 1.85-fold more likely to develop acute prostatitis, 1.76-fold more likely to develop chronic prostatitis and 1.63-fold more likely to develop unspecific prostatitis. Major associations still existed; even those stratified by age, occupation, urbanisation level and comorbidity all showed greater increased risks of prostatitis in the depression cohort than in the non-depression cohort.Conclusions: Depression can be an independent factor associated with the increased risk of prostatitis for men. The incidence of chronic prostatitis is greater than that of acute prostatitis. Close surveillance for UTI and depression treatment and lifestyle intervention should be considered for men with high risk for prostatitis. The mechanism associated with the development of prostatitis in men with depression requires further study. In addition, the mechanism of prostatitis may need comprehensive investigation.

Pharmacology and perspectives in erectile dysfunction in man

Penile erection is a perfect example of microcirculation modulated by psychological factors and hormonal status. It is the result of a complex neurovascular process that involves the integrative synchronized action of vascular endothelium; smooth muscle; and psychological, neuronal, and hormonal systems. Therefore, the fine coordination of these events is essential to maintain penile flaccidity or allow erection; an alteration of these events leads to erectile dysfunction (ED). ED is defined as the consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual activity. A great boost to this research field was given by commercialization of phosphodiesterase-5 (PDE5) inhibitors. Indeed, following the discovery of sildenafil, research on the mechanisms underlying penile erection has had an enormous boost, and many preclinical and clinical papers have been published in the last 10 years. This review is structured to provide an overview of the mediators and peripheral mechanism(s) involved in penile function in men, the drugs used in therapy, and the future prospective in the management of ED. Indeed, 30% of patients affected by ED are classified as "nonresponders," and there is still an unmet need for therapeutic alternatives. A flowchart suggesting the guidelines for ED evaluation and the ED pharmacological treatment is also provided.

Erectile dysfunction and associated risk factors in male patients with ischemic stroke: A cross-sectional study

Patients with ischemic stroke (IS) often suffered from the problem of erectile dysfunction (ED) and psychological disease. However, they are often ignored because these symptoms are more obvious in the convalescent stage of stroke, which affects the quality of sexual life of patients. This study aimed to investigate the incidence of ED, sexual quality of life, and mental state of patients after stroke, as well as analyze the relevant risk factors affecting their psychological status.A total of 361 IS patients were enrolled. The international erectile function index-5 scale was used to diagnose ED. Accordingly, the patients were divided into ED group and non-ED group. Magnetic resonance imaging was used to evaluate the brain lesions of patients. We assessed neurological deficits by the National Institutes of Health Stroke Scale score and patient health questionnaire-9 (PHQ-9) and general anxiety disorder-7 (GAD-7) were used to evaluate the depression and anxiety. The differences between the ED group and the non-ED group clinical factors were compared.The response rate was 88.6% (n = 320), and more than two-thirds of patients reported ED (77.8%). Patients with ED had higher PHQ-9 (8.40 ± 4.18 vs 4.94 ± 3.73, P < .01) and GAD-7 (6.73 ± 3.56 vs 4.51 ± 3.35, P < .01) scores, were more likely to have the frontal lobe (75.1% vs 49.3%, P < .01) and lateral ventricle (69.8% vs 53.5%, P = .01) lesions, with hypertension (75.1% vs 46.5%, P < .01) and hyperlipidemia (48.2% vs 25.4%), and on antihypertensive (67.9% vs 35.25, P < .01) and hypolipidemic drug (43.4% vs 16.9%, P < .01). Multivariate logistic regression analysis showed that antihypertensive drug (odds ratio [OR]: 2.50, 95% confidence interval [CI]: 1.02-6.10, P = .04), depression (OR: 1.18, 95% CI: 1.06-1.32, P < .01) and anxiety (OR: 1.13, 95% CI: 1.01-1.27, P = .04) might be the independent risk factors for ED group.ED is more common in male IS patients. Antihypertensive drug, depression and anxiety are the main factors affecting ED.

A prospective study of erectile dysfunction in men after pelvic surgical procedures and its association with non-modifiable risk factors

Objective

A pelvic surgery can cause erectile dysfunction. The purpose of this study was to evaluate erectile function at various times after pelvic surgery in male patients; to search the non-modifiable risk factors associated with the presence and intensity of sexuality in these patients. This prospective study used the erectile dysfunction IIEF scale.

Results

The study population comprised of 106 male patients who had undergone minor pelvic surgery at least 9 months before and during the 2010–2016 period in the 4th Surgical Clinic. A control group of healthy males (N = 106) who underwent no pelvic surgery matched for age was also used for reference values. The main age of the participants was 66.16 ± 13.07 years old. A history of colectomy was present in 36.8%, 18.9% had undergone sigmoidectomy, and 33% inguinal hernia repair. The percentage of severe erectile function increased from 38.7% before surgery to 48.1% (25% increase) after surgery, at the end of the follow-up period (p < 0.05). In the multivariate analysis model, age emerged as an independent predictor of erectile function (p < 0.001). Age was the most important determinant of the IIEF score, which was aggravated by 25% from the first to the last assessment of patients.

An open-label, single-arm pilot study to evaluate the efficacy of daily low dose tadalafil on depression in patients with erectile dysfunction

Background

Many studies have reported not only that depression and antidepressant medications can cause erectile dysfunction (ED), but also that having ED may increase the risk of depression. We investigated the effect of a daily low dose of a phosphodiesterase (PDE) type 5 inhibitor (tadalafil, 5 mg) on depression and levels of brain-derived neurotrophic factor (BDNF) in patients with ED.

Methods

Ten male patients with at least a 3-month history of ED [International Index of Erectile Function (IIEF)-5 score ≤21] and depression [the Korean version of the Patient Health Questionnaire (PHQ)-9 score ≥5] were analyzed in this study. The subjects were prescribed a low dose of a PDE5 inhibitor (tadalafil 5 mg) once daily for 8 weeks. The survey questionnaires were performed using the PHQ-15 and the PHQ-9 before and after administration of 8 weeks of tadalafil. Blood samples used for measuring serum BDNF levels were taken and measured at baseline and after 8 weeks of treatment.

Results

The mean changes in the PHQ-9 and PHQ-15 scores were 3.60±3.27 and 2.00±2.98, respectively. Analyses of the mean changes in the PHQ-9 scores revealed that the depressive symptoms of the subjects were significantly improved after administration of eight weeks of tadalafil (P<0.05). And, there was also a statistically significant increase in the PHQ-15 scores (P<0.05). Serum levels of BDNF were higher after tadalafil treatment compared to before treatment; however, this difference was not statistically significant.

Conclusions

The results of this prospective, clinical study suggest that daily low dose tadalafil may have a potential role in the treatment of depression in patients with ED.

Acceptance and Commitment Therapy to Increase Adherence to Penile Injection Therapy-Based Rehabilitation After Radical Prostatectomy: Pilot Randomized Controlled Trial

INTRODUCTION

Despite the importance of using penile injections as part of a penile rehabilitation program, men have difficulty complying with these programs.

AIM

To test a novel psychological intervention based on Acceptance and Commitment Therapy for erectile dysfunction (ACT-ED) to help men utilize penile injections.

METHODS

This pilot randomized controlled trial (RCT) recruited men who were beginning a standard care (SC) structured penile rehabilitation program following radical prostatectomy. The SC program instructed patients to use penile injections 2 to 3 times per week. Participants were randomized to SC+ACT-ED or SC+enhanced monitoring (EM). Over 4 months, patients in the SC+ACT-ED group received SC plus 4 ACT sessions and 3 ACT phone calls; those in the EM group received SC plus 7 phone calls from an experienced sexual medicine nurse practitioner. Participants were assessed at study entry and at 4 and 8 months. For this pilot study, the goal was to determine initial efficacy (ie, effect sizes, where d = 0.2 is small, d = 0.5 is medium, and d = 0.8 is large).

MAIN OUTCOME MEASURE

Primary outcomes were feasibility and use of penile injections. Secondary outcomes were ED treatment satisfaction (ie, Erectile Dysfunction Inventory of Treatment Satisfaction, or EDITS), sexual Self-Esteem and Relationship (SEAR) quality, sexual bother (SB), and prostate cancer treatment regret.

RESULTS

The 53 participants were randomized (ACT, n = 26; EM, n = 27). The study acceptance rate was 61%. At 4 months, the ACT-ED group utilized more penile injections per week (1.7) compared to the EM group (0.9) (d = 1.25; P = .001) and was more adherent to penile rehabilitation compared to the EM group (ACT, 44%; EM, 10%; relative risk [RR], 4.4; P = .02). These gains were maintained at 8 months for injections per week (ACT, 1.2; EM, 0.7; d = 1.08; P = .03) and approached significance for adherence (ACT, 18%; EM, 0%; P = .10). At 4 months, ACT-ED, compared to EM, reported moderate effects for greater satisfaction with ED treatment (d = 0.41; P = .22), greater sexual self-esteem (d = 0.54; P = .07) and sexual confidence (d = 0.48; P = .07), lower sexual bother (d = 0.43; P = .17), and lower prostate cancer treatment regret (d = 0.74; P = .02). At 8 months, moderate effects in favor of ACT-ED were maintained for greater sexual self-esteem (d = 0.40; P = .19) and less treatment regret (d = 0.47; P = .16).

CLINICAL IMPLICATIONS

ACT concepts may help men utilize penile injections and cope with the effects of ED.

STRENGTHS AND LIMITATIONS

Strengths include use of an innovative intervention utilizing ACT concepts and pilot RCT. Limitations include the pilot nature of the study (eg, small samples size, lack of statistical power).

CONCLUSION

ACT-ED is feasible and significantly increases the use of penile injections. ACT-ED also shows promise (moderate effects) for increasing satisfaction with penile injections and sexual self-esteem while decreasing sexual bother and prostate cancer treatment regret. Nelson CJ, Saracino RM, Napolitano S, et al. Acceptance and Commitment Therapy to Increase Adherence to Penile Injection Therapy-Based Rehabilitation After Radical Prostatectomy: Pilot Randomized Controlled Trial. J Sex Med 2019; 19:1398-1408.

National Health and Wellness Survey exploratory cluster analysis of males 40-70 years old focused on erectile dysfunction and associated risk factors across the USA, Italy, Brazil and China

OBJECTIVES

Prior studies of erectile dysfunction (ED) tend to narrowly focus on relationships with specific comorbidities, rather than evaluating a more comprehensive array of risk factors and assessing naturalistic patterns among them. This study identifies natural clusters of male characteristics from a general population sample per country, quantifies ED dynamics in these profiles and compares profiles across the US, Italy, Brazil and China samples.

METHODS

National Health and Wellness Survey 2015 and 2016 patient-reported data on men aged 40-70 years (USA n = 15,652; Italy n = 2,521; Brazil n = 2,822; China n = 5,553) were analysed. Hierarchical agglomerative clustering identified clusters where predictors included demographics, health characteristics/behaviours, ED risk factors and provider visits in the past 6 months. Multinomial logistic regression assessed the independent utility of variables in predicting cluster membership, compared with the healthiest control cluster per country.

RESULTS

Different natural clusters were found across countries, with four clusters for the USA, Italy and China and three clusters for Brazil. Age, income, employment, health behaviours and ED risk factors predicted different cluster membership across countries. In the USA, Italy and Brazil, younger clusters were predicted by ED, unhealthy behaviours and ED risk factors. Unique cluster profiles were identified in China, with ED and ED risk factors (aside from hypertension) not predicting cluster membership, while socio-demographics and health behaviours were strongly predictive.

CONCLUSIONS

Natural cluster profiles revealed notable ED rates among adult males of age 40-70 in four different countries. Clusters were mainly predicted by unhealthy behaviours, ED risk factors and ED, regardless of level or presence of positive health characteristics and behaviours. This analysis identified meaningful subgroups of men with heightened ED risk factors, which can help healthcare providers to better recognise specific populations with the greatest need for intervention.

Gout is associated with elevated risk of erectile dysfunction: a systematic review and meta-analysis

Previous studies investigating the risk of erectile dysfunction (ED) among patients with gout have produced inconsistent evidence. Therefore, the aim of this meta-analysis was to investigate the relationship between gout and the risk of ED. The Embase, Medline, Scopus, Web of Science and Cochrane Library databases were searched for all studies assessing the risk of ED in patients with gout. Relative risks (RR) and corresponding 95% confidence intervals (CI) were adopted to estimate the association between gout and the risk of ED. Sensitivity analyses were applied to evaluate the robustness of results. Overall, 355,761 participants were included from 8 studies (3 cross-sectional and 5 cohort studies). Of these, 85,067 were patients with gout. Synthesis results showed patients with gout had a 1.2-fold higher risk of ED than individual without gout (RR 1.20, 95% CI 1.10-1.31, P < 0.001). The results of sensitivity analysis are consistent with the trend of synthesis results. The present meta-analysis revealed that the risk of ED in patients with gout was dramatically increased when compared with the general population, which suggests that clinicians should assess erectile function when treating an individual who suffers from gout.

Physical activity as an adjunct treatment for erectile dysfunction

Increasing data are available to suggest that physical activity and lifestyle modification in general can benefit erectile function, with effect sizes comparable with established treatment options such as testosterone therapy and phosphodiesterase type 5 inhibitors. Despite this evidence, primary-care physicians are rarely afforded critical information on the underlying mechanisms through which physical activity works as a treatment, severely hampering treatment credibility for both physician and patient. Physical activity is associated with psychological and metabolic adaptations that are compatible with the adaptations required for the treatment of erectile dysfunction (ED). These adaptations include increased expression and activity of nitric oxide synthase, strengthened endothelial function, acute rises in testosterone, decreased stress and anxiety, and improved body image. Use of physical activity as a first-line treatment option for ED is limited, and explicit physical activity guidelines for the treatment of ED are required. Such guidelines should include not only a suggested exercise programme but also guidelines for physician-patient communication that might enhance patient receptivity and therapy continuation. An understanding of how physical activity affects erectile function, as well as its effectiveness in treating ED compared with other established treatments, can benefit urologists and primary-care physicians searching for noninvasive treatment options for men presenting with poor erectile function.

Simvastatin and the Rho-kinase inhibitor Y-27632 prevent myofibroblast transformation in Peyronie's disease-derived fibroblasts via inhibition of YAP/TAZ nuclear translocation

OBJECTIVES

To uncover the anti-myofibroblast (MFB) properties of Rho-kinase inhibitor (compound Y-27632) and simvastatin in an in vitro model of Peyronie's disease (PD), a sexually debilitating disease caused by an irreversible fibrotic plaque in the penile tunica albuginea (TA).

MATERIALS AND METHODS

Primary human fibroblasts (FBs) were isolated from surgically obtained TA tissue from patients with PD. To induce MFB status, cells were stimulated with 3 ng/mL transforming growth factor-β1 (TGF-β1). Increasing doses of Y-27632 and simvastatin were added. Real-time quantitative PCR was used to assess mRNA expression of α-smooth muscle actin (α-SMA), collagen III, elastin and connective tissue growth factor (CTGF) after 72 h. Western blot analysis was used to quantify α-SMA protein contents, and immunofluorescence (IF) was used to visualize MFB differentiation by staining for α-SMA after 72 h. A resazurin-based assay was used to assess cell viability to ensure the anti-MFB effect of the drugs. A mechanistic study was performed using IF staining for YAP/TAZ nuclear translocation.

RESULTS

After 72 h of stimulation with TGF-β1, a six- to 10-fold upregulation of α-SMA could be observed. When treated with Y-27632 or simvastatin, the α-SMA, collagen III, elastin and CTGF mRNA expression was impeded. Additionally, TGF-β1 stimulation showed a twofold increase in α-SMA protein expression, which was reversed to non-stimulated levels after treatment with Y-27632 and simvastatin. Using IF, stimulated cells were identified as MFB (α-SMA+, Vim+) as opposed to the non-stimulated, Y-27632- and simvastatin-treated cells (α-SMA-, Vim+). The resazurin-based assay confirmed that the cell viability was not compromised by the administered drugs. On stimulation with TGF-β1, nuclear translocation of YAP/TAZ could be observed, which was prevented by adding the aforementioned compounds.

CONCLUSION

Transformation of FBs into the contractile and extracellular matrix-producing MFBs occurs after TGF-β1 stimulation. In our experiments, Rho-kinase inhibition and simvastatin treatment were shown to prevent this in TGF-β1-stimulated cells on an RNA and protein level through the inhibition of YAP/TAZ nuclear translocation. Y-27632 and simvastatin could become a novel treatment option in the early treatment of PD.