Endocrine evaluation of erectile dysfunction

Efficacy and safety of PDE5 inhibitors in middle-aged and old patients with and without hypogonadism

PURPOSE

Although several reviews have evaluated the use of PDE5 inhibitors (PDE5i) for treating erectile dysfunction (ED), their specific use in middle-aged and old patients has not been fully evaluated. Given that elderly patients with ED often have a complex combination of systemic and sexual health risk factors, the safety and efficacy of PDE5i in such a context are hereby reviewed.

MATERIALS AND METHODS

A thorough examination of existing literature has been conducted on PubMed.

RESULTS

PDE5i has good safety and efficacy, but the situation is more complex for patients with hypogonadism than those with normal testosterone levels, with reduced responsiveness to PDE5i. In this case, combination therapy with testosterone is recommended, safe and effective.

CONCLUSIONS

Eliminating or reducing reversible risk factors and controlling or slowing the development of irreversible factors is an important foundation for using PDE5i to treat ED in all patients, especially middle-aged and elderly ones.

Testosterone and aging male, a perspective from a developing country

PURPOSE

Hypogonadism is associated with a wide range of physical and psychological symptoms that can affect the overall health of men. However, in a developing country, there are several imposing challenges in the diagnosis and treatment of hypogonadism, including a lack of awareness and understanding of the condition among healthcare providers and patients, limited resources and the high cost of treatment. This review aimed to examine the potential benefits and risks of testosterone replacement therapy (TRT) and provides a perspective of a developing country on the topic.

MATERIALS AND METHODS

A comprehensive literature review was conducted to gather relevant information on the impact of testosterone deficiency on ageing males and the effectiveness of TRT for treating hypogonadism. Published peer-reviewed articles were analyzed to evaluate the benefits and risks of TRT. Additionally, the unique challenges faced in the diagnosis and treatment of hypogonadism in a developing country were considered.

RESULTS

Testosterone replacement therapy has been shown to be an effective treatment for hypogonadism, particularly in symptomatic men with low testosterone levels. It offers potential benefits such as improvements in symptoms and overall quality of life. However, there are associated risks and side effects that need to be considered. In a developing country, challenges such as limited awareness and understanding of hypogonadism, resource constraints, and high treatment costs pose additional barriers to accessing TRT and comprehensive care.

CONCLUSION

In conclusion, TRT holds promise as a treatment for hypogonadism, but its implementation and accessibility face significant challenges in a developing country. Addressing these challenges, including raising awareness, allocating resources, and finding cost-effective solutions, is crucial for ensuring that men with hypogonadism in such settings receive appropriate diagnosis and treatment. Further research and efforts are needed to improve the management of hypogonadism in developing countries and optimize the potential benefits of TRT for affected individuals.

Effect of Angiotensin 1-7 Peptide Agonist AVE 0991 on Diabetic Endothelial Dysfunction in an Experimental Animal Model: A Possible Tool to Treat Diabetic Erectile Dysfunction

Background The renin-angiotensin system and its metabolites are crucial in the pathogenesis and progression of complications of diabetes. Aim In this study, we aimed to evaluate the effect of angiotensin 1-7 non-peptide agonist AVE 0991 (576 ug/kg/day i.p.) on diabetic endothelial dysfunction. Materials and methods In this experimental animal study, we investigated the effects of angiotensin 1-7 non-peptide agonist AVE 0991 (576 ug/kg/day i.p.) treatment in male Wistar rats. Diabetes was created via injecting streptozotocin (55 mg/kg/i.p., single dose). Following the cavernous tissue submaximal phenylephrine contraction, relaxation responses were obtained by applying electrical field stimulation (0.5 ms, 40 V) for 15 seconds at 2, 4, 8, 16, 32, and 64 Hz, with two-minute intervals, respectively. To evaluate the effect of nitric oxide, the responses were compared by incubating with 100 mM N(gamma)-nitro-L-arginine methyl ester (L-NAME) for 20 minutes. Additionally, Y-27632 and sodium nitroprusside responses were evaluated in tissues contracted with submaximal doses of phenylephrine. Results Following a submaximal contraction of phenylephrine in the aorta rings, relaxation responses obtained with acetylcholine, sodium nitroprusside, and Y-27632 were impaired in diabetic rats; however, significant results were obtained with treatment. Although there was no significance between the groups in the electrical field stimulation responses, there was a significant dose-dependent difference in the treatment group in this parameter after L-NAME, sodium nitroprusside, and Y-27632 relaxation. Conclusions We determined that treatment with a non-peptide receptor antagonist of angiotensin 1-7, an enzyme detected in the aortic and cavernosum endothelium, may be a promising alternative for treating the complications of diabetes.

Association between COVID-19 and sexual health: an umbrella review

PURPOSE

We conducted this umbrella review to review the current evidence on the relationship between COVID-19 and sexual health in both men and women.

METHODS

We conducted searches in Pubmed, Embase, and the Cochrane dataset for meta-analyses that met our pre-set inclusion criteria. We included studies with detailed information investigating the link between COVID-19 and sexual health in men/women. We did not limit the language.

RESULTS

The results of the included studies frequently relied on the Female Sexual Function Index to assess sexual health in women. For men, the International Index of Male Function and hospital diagnoses were commonly used to assess sexual health. Currently, there is conflicting evidence regarding the impact of COVID-19 on sexual health. However, since most studies were observational in nature, additional study designs are necessary to draw definitive conclusions across different contexts.

CONCLUSION

Our findings highlight the importance of sexual health among COVID-19 patients and people affected due to COVID-19. Further critical studies should investigate the mechanism underlying the association between COVID-19 and sexual health.

Effects of Growth Hormone on Adult Human Gonads: Action on Reproduction and Sexual Function

Growth hormone (GH), which is commonly considered to be a promoter of growth and development, has direct and indirect effects on adult gonads that influence reproduction and sexual function of humans and nonhumans. GH receptors are expressed in adult gonads in some species including humans. For males, GH can improve the sensitivity of gonadotropins, contribute to testicular steroidogenesis, influence spermatogenesis possibly, and regulate erectile function. For females, GH can modulate ovarian steroidogenesis and ovarian angiogenesis, promote the development of ovarian cells, enhance the metabolism and proliferation of endometrial cells, and ameliorate female sexual function. Insulin-like growth factor-1 (IGF-1) is the main mediator of GH. In vivo, a number of the physiological effects of GH are mediated by GH-induced hepatic IGF-1 and local IGF-1. In this review, we highlight the roles of GH and IGF-1 in adult human gonads, clarify potential mechanisms, and explore the efficacy and the risk of GH supplementation in associated deficiency and assisted reproductive technologies. Besides, the effects of excess GH on adult human gonads are discussed as well.

Application of dual-energy CT angiography in diagnosis of arterial erectile dysfunction: new scanning technology, new scanning area

OBJECTIVES

To explore the value of dual-energy computed tomography (DE-CT) angiography in diagnosis of arteriogenic erectile dysfunction (ED) patients and feasibility of new scanning area that excludes the testis.

MATERIALS AND METHODS

Ninety-three patients suspected of suffering arterial ED and 40 health volunteers underwent penile duplex Doppler ultrasound and DE-CT angiography (DE-CTA). The scanning range of DE-CTA covered whole arterial system of pelvis and testis was excluded. Two blinded investigators independently evaluated the arterial system that supplies the penis.

RESULTS

Finally, 1596 segments were evaluated and 470 segments were judged to be abnormal. The distribution was: 2 (0.4%) in common iliac artery, 7 (1.5%) in internal iliac artery, 82 (17.5%) in internal pudendal artery, 89 (18.9%) in penile artery, 120 (25.5%) in dorsal artery, and 170 (36.2%) in cavernosal artery. The specificity, sensitivity, positive predictive value, and negative predictive value of DE-CTA in diagnostic were 86.02%, 87.50%, 94.12%, and 72.92%. Besides, the new scan area allowed for effective evaluation of the arteries while excluding the testis.

CONCLUSION

DE-CTA can provide unbiased, safe evaluation of the vascular status of the penile bed in patients with ED.

Impact of COVID 19 on erectile function

Purpose: COVID-19, a novel infection, presented with several complications, including socioeconomical and reproductive health challenges such as erectile dysfunction (ED). The present review summarizes the available shreds of evidence on the impact of COVID-19 on ED.Materials and methods: All published peer-reviewed articles from the onset of the COVID-19 outbreak to date, relating to ED, were reviewed. Results: Available pieces of evidence that ED is a consequence of COVID-19 are convincing. COVID-19 and ED share common risk factors such as disruption of vascular integrity, cardiovascular disease (CVD), cytokine storm, diabetes, obesity, and chronic kidney disease (CKD). COVID-19 also induces impaired pulmonary haemodynamics, increased ang II, testicular damage and low serum testosterone, and reduced arginine-dependent NO bioavailability that promotes reactive oxygen species (ROS) generation and endothelial dysfunction, resulting in ED. In addition, COVID-19 triggers psychological/mental stress and suppresses testosterone-dependent dopamine concentration, which contributes to incident ED.Conclusions: In conclusion, COVID-19 exerts a detrimental effect on male reproductive function, including erectile function. This involves a cascade of events from multiple pathways. As the pandemic dwindles, identifying the long-term effects of COVID-19-induced ED, and proffering adequate and effective measures in militating against COVID-19-induced ED remains pertinent.

Erectile dysfunction as a marker of endocrine and glycemic disorders

PURPOSE

The aim of this study was to evaluate in a population of patients with erectile dysfunction (ED): (a) the prevalence of a previously unknown endocrine/glycemic disorders; (b) the correlation between ED severity and endocrine/glycemic disorders.

METHODS

1332 patients referred for ED from 2013 to 2020 were included. The ED diagnosis was made using the International-Erectile-Function-Index-5 questionnaire. ED severity was considered according to presence/absence of spontaneous erections, maintenance/achievement deficiency. All patients were subjected to search for sociodemographic and clinical characteristics: age, ethnicity, marital status, previous use of PDE5i, previous prostatectomy, diabetes mellitus (DM), prediabetes, endocrine dysfunctions.

RESULTS

The mean ± SD age was 54.3 ± 13.7 years. The 19.1% (255/1332) of patients were already in treatment for prediabetes/diabetes or endocrine dysfunctions. Among the remaining 1077, the prevalence of previously unknown endocrine and glycemic disorders was 30% (323/1077). Among them, 190/323 subjects (58.8%) were affected by hypogonadism, with high estradiol level observed in 8/190 (4.2%). The prevalence of new glycemic alterations was 17.3% (56/323) [specifically, 32/56 (57.1%) DM, and 24/56 (42.9%) prediabetes]. A thyroid dysfunction was observed in 40/323 subjects (12.3%) and hyperprolactinemia in 37/323 (11.5%). Patients with new diagnosis of DM showed more severe form of ED compared to the total group {difficulty in the achievement of erection: 46/56 [82.2%, vs 265/1332 (19.9%), p < 0.05]; absence of spontaneous erection 23/56 [41.1%, vs 321/1332 (24.1%), p < 0.05]}.

CONCLUSION

ED is an early marker of endocrine/glycemic disorder, and a previously unknown dysfunction was found in more than a quarter of patients. A newly diagnosed DM is associated with ED severity, especially in elderly man and in presence of hypertension.

Assessment of a New Formulation of Sildenafil on Common Practice: An Observational Study

Erectile dysfunction (ED) has a significant impact on the quality of life of patients. Xybilun® (IBSA Pharma SAS, France) is a new formulation of sildenafil in an orodispersible film (ODF). This study aims to assess the response rate (RR), satisfaction with, and safety of sildenafil-ODF in daily practice in France. Patients aged ≥18 years with ED were included in four groups: Group 1 mild, Group 2 moderate, Group 3 severe ED, according to the International Index for Erectile Function (IIEF)-6 subscore, never treated with phosphodiesterase inhibitors (PDE)5-I; Group 4, patients previously treated with another PDE5-I. Patients were evaluated at baseline (V1), one (V2), and three (V3) months. The RR and satisfaction were assessed using the IIEF-6 subscore questionnaire, a 5-point Likert scale, and a Global Assessment Question (GAQ). The primary endpoint for Groups 1 to 3 was the RR according to Rosen criteria at V3 compared to V1. For Group 4, the primary endpoint was the RR, defined as the satisfaction compared with previous treatment. Secondary endpoints were the RR at V2 compared to V1, the evolution of IIEF-6 and IIEF-15 scores, dose adjustment, satisfaction, convenience, and safety. One hundred and five patients were enrolled, 83 analysed. The RR at V3 was 100% (Group 1); 75% (Group 2); 65.2% (Group 3); and 84.2% (Group 4). The overall RR was 78.3%. Secondary parameters confirmed the satisfaction with sildenafil-ODF, with 81.6% of patients very satisfied at V3. No Serious Adverse Events (SAEs) were observed. In conclusion, sildenafil-ODF seems beneficial for patients irrespective of the severity of the ED. This study confirms in the context of daily clinical practice the satisfaction of patients with sildenafil-ODF. Data suggest that the availability of the intermediate dose of 75 mg could add greater flexibility to the therapy.

Pharmacological strategies for sexual recovery in men undergoing antipsychotic treatment

INTRODUCTION

: First- and second-generation antipsychotics are highly accountable for causing a plethora of medical side effects, ranging from metabolic imbalances to sexual dysfunction (SD), that frequently undermine patient-doctor relationships. Nevertheless, to date antipsychotics are one of the best treatment options for dealing with numerous either acute or chronic conditions like agitation, suicidality, depression, dementia, and of course psychosis. For these reasons, clinicians need to handle them wisely to preserve patients' sexual health, avoid poor therapeutic adherence and prevent high rates of therapy drop-out.

AREAS COVERED

: This article reviews the literature on pharmacologic approaches for management strategies in men who are administered with antipsychotics and developed SD. The etiology of antipsychotic-induced SD is also discussed.

EXPERT OPINION

: Clinicians must consider sexual life as a major health domain. To do so, a first step would be to measure and monitor sexual function by means of psychometric tools. Secondly, primary prevention should be conducted when choosing antipsychotics, i.e., picking sex-sparing compounds like aripiprazole or brexpiprazole. Thirdly, if sexolytic compounds cannot be dismissed, such as first-generation antipsychotics, risperidone, paliperidone, or amisulpride, then aripiprazole 5-20 mg/day adjunctive therapy has proven to be most effective in normalizing prolactin levels and consequently treating antipsychotic-induced SD.

Relationship between hyperuricemia with deposition and sexual dysfunction in males and females

PURPOSE

The association between gout, the most common crystal arthropathy, and sexual dysfunctions has often been investigated by studies in the last decades. Despite the presence of shared risk factors and comorbidities and the possible effects on sexual health of long-term gout complications, awareness of this association is severely lacking and the pathogenetic mechanisms have only partially been identified. In the present review, we aimed to investigate the current evidence regarding the potential mechanisms linking sexual dysfunctions and gout.

METHODS

A comprehensive literature search within PubMed was performed to provide a summary of currently available evidence regarding the association between gout and sexual dysfunctions.

RESULTS

Gout and sexual dysfunctions share several risk factors, including diabesity, chronic kidney disease, hypertension, metabolic syndrome, and peripheral vascular disease. Gout flares triggered by intense inflammatory responses feature severe pain and disability, resulting in worse sexual function, and some, but not all, treatments can also impair sexual health. Long-term gout complications can result in persistent pain and disability due to joint deformity, fractures, or nerve compression, with negative bearing on sexual function. The presence of low-grade inflammation impairs both sex steroids synthesis and endothelial function, further advancing sexual dysfunctions. The psychological burden of gout is another issue negatively affecting sexual health.

CONCLUSIONS

According to currently available evidence, several biological and psychological mechanisms link sexual dysfunctions and gout. Addressing risk factors and providing adequate treatment could potentially have beneficial effects on both conditions. Appropriate clinical evaluation and multidisciplinary approach are recommended to improve patient care.

Dyadic Satisfaction and Shared Affectivity Are Associated with Psycho-Sexual Functioning in Elderly Men and Women

Objectives The quality of sexual life of elderly people represents an understudied topic of sexual medicine and of psycho-sexology. Hence, we aimed to evaluate the association of specific psycho-relational variables, such as intimacy, increased affective gestures towards a partner (AGtP), daily shared activities, and dyadic satisfaction, with the psychosexual wellbeing of elderly people, expressed in terms of sexual satisfaction. Methods: A cohort of elderly people was selected from a sample of a broader study evaluating the role of sexual activity in protecting the emotional wellbeing of a population subjected to quarantine due to the COVID-19 pandemic. Specifically, the presence of sexual dysfunctions, the emotional wellbeing (i.e., absence of anxiety and/or depression), and the quality of the partners’ relationships were studied. For the study’s purpose, the Sexual Health Inventory for Males (SHIM), the Female Sexual Function Index (FSFI), the Orgasmometer and the Orgasmometer-F, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire (PHQ-9), and the Dyadic Adjustment Scale were adopted. Results: A group of 124 elderly subjects (≥60) was selected for the study’s purposes. Among these, 84% were males (120/124), and 16% were females (20/124). All the subjects declared to be in a stable relationship and to be sexually active during the first lockdown period. Gender differences were found for the Dyadic Satisfaction subscale (males: 37.04 ± 6.57; females: 32.85 ± 10.04; p < 0.05) and the Orgasmometer (males: 7.64 ± 1.30; females: 6.60 ± 2.46; p < 0.01). Linear regression analysis showed the association between higher Orgasmometer scores and: (i) the absence of sexual dysfunctions (β = −1.213; SE = 0.271; p < 0.0001), (ii) higher dyadic satisfaction (β = 0.042; SE = 0.019; p < 0.05), and (iii) reduced shared activities with partner (β = −0.463; SE = 0.143; p < 0.01) and increased affective gestures towards partner (DAS measured AGtP) (β = 0.595; SE = 0.065; p < 0.0001). Post hoc analysis of ANCOVA with the Bonferroni correction method showed a significant difference in the Orgasmometer scores between subjects with and without sexual dysfunction (mean difference: 2.102; SE = 0.340; pBonf < 0.001), with healthy subjects reporting higher scores compared to dysfunctional ones. Conclusions: It is reasonable to suppose that, beyond the presence of sexual dysfunctions, the sexual health of elderly people may benefit from the quality of the relationship, and, specifically, from the presence of affective gestures towards the partner and the dyadic satisfaction. To the contrary, the quantity of time spent together, sharing specific activities, may be considered a factor worsening relational and sexual health. These data should be considered during the evaluation of sexual health among elderly people.

Sexual Dysfunction in Men and Women with Diabetes: A Reflection of their Complications?

BACKGROUND

Diabetes mellitus (DM), one of the worldwide leading causes of death, is associated with a plethora of micro- and macro-vascular complications which should be carefully investigated and, in case, treated in order to improve quality of life and reduce the risk of premature mortality.

OBJECTIVE

The study aimed to investigate and report current evidence with regard to the association between sexual dysfunction and diabetes.

METHODS

A detailed analysis of current literature has been performed on PubMed and Scholar in order to retrieve the most relevant findings pertaining to the study topic.

RESULTS

Female and male sexual dysfunction often occurs in diabetes; while cardiovascular complications are clearly involved, psychosexological factors, endocrine complications, and endothelial dysfunction all contribute to the pathogenesis of sexual dysfunctions. Psychological symptoms are seldom investigated, yet they should not be overlooked by the clinician; in fact, an interplay between sexual dysfunctions and depressive symptoms has been reported, and beneficial effects in both conditions might be obtained by adequate psychological support. Sexual dysfunctions can also act as early biomarkers of cardiovascular disease, a phenomenon frequently reported in men, in which erectile dysfunction predicts the development of coronary artery disease. Additionally, drug therapies can act in both directions, with treatments for diabetes possibly improving male sexual function and exerting beneficial effects for cardiovascular health being reported for pro-erectile drugs.

CONCLUSION

Sexual dysfunctions often occur in men and women with diabetes. Investigating micro- and macro-vascular complications might not be enough to prevent the development or worsening of any sexual dysfunction; endocrine and psychological assessments are therefore needed to provide the best chances for adequate treatment.

The Sexual Long COVID (SLC): Erectile Dysfunction as a Biomarker of Systemic Complications for COVID-19 Long Haulers

Introduction

Long term complications of COVID-19, the disease caused by the SARS-CoV-2, involve many organ systems, dramatically worsening the quality of life, and finally contributing to impaired physical functioning. Despite the presence of well-identified pathogenetic mechanisms, the effect of “Long COVID” on sexual health has been only marginally addressed.

Objectives

To provide coverage of the current literature on long COVID, its epidemiology, pathophysiology, and relevance for erectile function. Methods. Comprehensive review of literature pertaining to the epidemiology and pathophysiology of long COVID, and its relevance for erectile function.

Results

Symptoms of long COVID are highly prevalent and involve almost all systems of the human body, with a plethora of clinical manifestations which range from minor nuisances to life-threatening conditions. “Brain fog” and fatigue are the most common complaints, although other neuropsychiatric complications, including sensory dysfunctions, anxiety, depression, and cerebrovascular events have also been reported. The respiratory and cardiovascular systems are also affected, with dyspnea, pulmonary fibrosis, endothelial dysfunction, and myocarditis occurring in some COVID long haulers. A subset of patients might develop endocrine manifestations, including onset of diabetes, thyroid dysfunction, and hypogonadism. Overall, long COVID features many complications which can impair erectile function by multiple pathogenetic mechanisms, and which could require tailored treatment: (i) careful investigation and management from the sexual medicine expert are therefore much needed, (ii) and future research on this topic is warranted.

Conclusion

in COVID-19 long haulers, several complications can adversely affect erectile function which, upon future tailored studies, could be used as biomarker for the severity of the long COVID disease and for its follow-up.

Sansone A, Mollaioli D, Limoncin E et al. The Sexual Long COVID (SLC): Erectile Dysfunction as a Biomarker of Systemic Complications for COVID-19 Long Haulers. Sex Med Rev 2022;10:271–285.

Predictive factors of erectile dysfunction in Egyptian individuals after contracting COVID-19: A prospective case-control study

This study aimed to screen healthy individuals who contracted COVID-19 for erectile dysfunction (ED) and to determine the potential risk factors that can predict ED in these individuals. One hundred and seven cases versus 90 controls agreed to participate in the study. Two structured interviews with 1 month interval were conducted. All participants were evaluated by the validated Arabic version of the international index of erectile function (IIEF-5) and assessment of the psychological state by Hamilton depression rating scale (HDRS). Interestingly, the study had demonstrated a significant difference in mean testosterone level between cases and controls (3.91 ± 2.31, 5.04 ± 2.22, p < 0.001 respectively). Additionally, the study had demonstrated a significant difference in mean IIEF-5 score between cases and controls (22.63 ± 2.79, 23.54 ± 1.26, p < 0.041 respectively). Moreover, there were significant differences in mean anxiety and stress scores of the cases before and after COVID-19 (4.95 ± 4.03, 6.19 ± 3.55, p = 0.022, 12.75 ± 9.98, 15.30 ± 7.42, p = 0.024 respectively). A multiple logistic regression model for predicting ED occurrence post-COVID-19 had revealed that smoking, baseline IIEF-5 score and COVID-19 severity (p = 0.022, p = 0.017, p = 0.021, p = 0.009, p = 0.008 respectively) were the only significant independent variables.

Serum concentrations of dihydrotestosterone are associated with symptoms of hypogonadism in biochemically eugonadal men

PURPOSE

Symptoms of hypogonadism are often reported by subjects with normal serum testosterone (T) levels. We aimed to assess the association between clinical symptoms in andrological outpatients and sex steroids levels.

METHODS

This is a retrospective cross-sectional cohort study in an Academic clinic and research unit. International Index of Erectile Function (IIEF, EF domain) and Aging Males Symptoms scale (AMS) questionnaires were completed by 635 and 574 men, respectively (mean age: 47.3 ± 13.9 and 47.4 ± 13.8 years, p = 0.829), free of interfering medications with complaints possibly related to hypogonadism.

RESULTS

Serum total/free T as well as dihydro-T (DHT) was associated with IIEF-EF and AMS scores in the overall population using univariate analyses. Multivariate approaches revealed DHT concentrations in subjects with normal T levels (n = 416, Total T > 12 nmol/L) to be significant predictors of AMS scores. A 0.1 nmol/l serum DHT increase within the eugonadal range was associated with a 4.67% decrease in odds of having worse symptoms (p = 0.011). In men with biochemical hypogonadism (Total T < 12 nmol/L), total and free T rather than DHT were associated with AMS results. This association was not found for IIEF-EF scores. Indirect effects of age and BMI were seen for relations with hormone concentrations but not questionnaire scores.

CONCLUSION

DHT can be associated with symptoms of hypogonadism in biochemically eugonadal men. Serum DHT measurement might be helpful once the diagnosis of hypogonadism has been ruled out but should not be routinely included in the primary diagnostic process.

The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine

INTRODUCTION

The "lost penis syndrome" (LPS) is a term often used in non-clinical settings to describe the subjective perception of the loss of cutaneous and proprioceptive feelings of the male organ during vaginal penetration. Although deserving clinical attention, this syndrome did not receive any consideration in the medical literature. Notwithstanding, it represents a relatively unexceptional condition among patients in sexual medicine clinics, and it is often reported together with other sexual dysfunctions, especially delayed ejaculation, anejaculation, male anorgasmia and inability to maintain a full erection.

OBJECTIVES

To draft a new conceptual characterization of the LPS, defined as a lack of penile somesthetic sensations during sexual penetration due to various causes and leading to several sexual consequences in both partners.

METHODS

Based on an extensive literature review and physiological assumptions, the mechanisms contributing to friction during penovaginal intercourse, and their correlation to LPS, have been explored, as well as other nonanatomical factors possibly contributing to the loss of penile sensations.

RESULTS

Efficient penile erection and sensitivity, optimal vaginal lubrication and trophism contribute to penovaginal friction. Whenever one of these processes does not occur, loss of penile sensation defined as LPS can occur. Sociocultural, psychopathological and age-related (ie, couplepause) factors are also implicated in the etiology. Four types of LPS emerged from the literature review: anatomical and/or functional, behavioral, psychopathological and iatrogenic. According to the subtype, a wide variety of treatments can be employed, including PDE5i, testosterone replacement therapy and vaginal cosmetic surgery, as well as targeted therapy for concomitant sexual comorbidity.

CONCLUSION

We held up the mirror on LPS as a clinically existing multifactorial entity and provided medical features and hypotheses contributing to or causing the occurrence of LPS. In the light of a sociocultural and scientific perspective, we proposed a description and categorization of this syndrome hypothesizing its usefulness in daily clinical practice. Colonnello E, Limoncin E, Ciocca G, et al. The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine. Sex Med Rev 2021;XX:XXX-XXX.

Facing Counterfeit Medications in Sexual Medicine. A Systematic Scoping Review on Social Strategies and Technological Solutions

Introduction

The counterfeit phenomenon is a largely under-reported issue, with potentially large burden for healthcare. The market for counterfeit drugs used in sexual medicine, most notably type 5 phosphodiesterase inhibitors (PDE5i), is rapidly growing.

Aims

To report the health risks associated with the use of counterfeit medications, the reasons driving their use, and the strategies enacted to contain this phenomenon.

Methods

A systematic scoping review of the literature regarding counterfeit PDE5i was carried between January and June 2021, then updated in August 2021.

Main Outcome Measure

We primarily aimed to clarify the main drivers for counterfeit PDE5i use, the health risks associated, and the currently available strategies to fight counterfeiters.

Results

One hundred thirty-one records were considered for the present scoping review. Production of fake PDE5i is highly lucrative and the lacking awareness of the potential health risks makes it a largely exploitable market by counterfeiters. Adulteration with other drugs, microbial contamination and unreliable dosages make counterfeit medications a cause of worry also outside of the sexual medicine scope. Several laboratory techniques have been devised to identify and quantify the presence of other compounds in counterfeit medications. Strategies aimed at improving awareness, providing antitampering packaging and producing non-falsifiable products, such as the orodispersible formulations, are also described.

Clinical implications

Improving our understanding of the PDE5i counterfeit phenomenon can be helpful to promote awareness of this issue and to improve patient care.

Strengths & Limitations

Despite the systematic approach, few clinical studies were retrieved, and data concerning the prevalence of counterfeit PDE5i use is not available on a global scale.

Conclusion

The counterfeit phenomenon is a steadily growing issue, with PDE5i being the most counterfeited medication with potentially large harmful effects on unaware consumers.

Sansone A, Cuzin B, and Jannini EA. Facing Counterfeit Medications in Sexual Medicine. A Systematic Scoping Review on Social Strategies and Technological Solutions. Sex Med 2021;9:100437.

Environmental Factors-Induced Oxidative Stress: Hormonal and Molecular Pathway Disruptions in Hypogonadism and Erectile Dysfunction

Hypogonadism is an endocrine disorder characterized by inadequate serum testosterone production by the Leydig cells of the testis. It is triggered by alterations in the hypothalamic–pituitary–gonadal axis. Erectile dysfunction (ED) is another common disorder in men that involves an alteration in erectile response–organic, relational, or psychological. The incidence of hypogonadism and ED is common in men aged over 40 years. Hypogonadism (including late-onset hypogonadism) and ED may be linked to several environmental factors-induced oxidative stresses. The factors mainly include exposure to pesticides, radiation, air pollution, heavy metals and other endocrine-disrupting chemicals. These environmental risk factors may induce oxidative stress and lead to hormonal dysfunctions. To better understand the subject, the study used many keywords, including “hypogonadism”, “late-onset hypogonadism”, “testosterone”, “erectile dysfunction”, “reactive oxygen species”, “oxidative stress”, and “environmental pollution” in major online databases, such as SCOPUS and PUBMED to extract relevant scientific information. Based on these parameters, this review summarizes a comprehensive insight into the important environmental issues that may have a direct or indirect association with hypogonadism and ED in men. The study concludes that environmental factors-induced oxidative stress may cause infertility in men. The hypothesis and outcomes were reviewed critically, and the mechanistic approaches are applied through oxidant-sensitive pathways. This study also provides reccomendations on future therapeutic interventions and protective measures against such adverse environmental factors-induced hypogonadism and ED.

Erectile Dysfunction Is Associated With Excessive Growth Hormone Levels in Male Patients With Acromegaly

Objective

To determine the risk factors for erectile dysfunction (ED) in male patients with acromegaly and to prospectively investigate the short-term changes of erectile function after surgery or medical treatment.

Methods

Sixty-three male patients were subjected to nocturnal penile tumescence and rigidity (NPTR) test for the evaluation of erectile function. The measurement of serum nitric oxide (NO) was also performed. Twenty-seven patients were re-evaluated by NPTR after surgery or long-term somatostatin analogues (SSA) treatment.

Results

Twenty-two patients (34.9%) had ED. Patients with ED showed higher random GH (17.89 [10.97-44.19] μg/L vs 11.63 [4.31-28.80] μg/L, p = 0.020) and GH nadir (GHn) (10.80 [6.69-38.30] μg/L vs 8.76 [3.62-18.19] μg/L, p = 0.044) during oral glucose tolerance test (OGTT). The NO levels of ED patients were lower than non-ED patients (9.15 [5.58-22.48] μmol/L vs 16.50 [12.33-31.78] μmol/L, p = 0.012). After treatment, patients who present improvement in erectile function showed lower post-GHn (0.07 [0.03-0.12] ng/ml vs 1.32 [0.09-3.60] ng/ml, p = 0.048) and post-IGF-1 index (1.03 ± 0.38 vs 1.66 ± 0.95, p = 0.049). The multivariate analysis indicated post-GHn was still associated with the improvement of erectile function after correction of other covariates (OR: 0.059, 95% CI: 0.003-1.043, p = 0.053).

Conclusions

Excessive GH is related to ED in male patients with acromegaly. GH normalization after treatment is beneficial for short-term erectile function recovery.

Association between Psychopathological Dimensions and Sexual Functioning/Sexual Arousal in Young Adults

Psychological-psychiatric factors have a different effect on sexual functioning in men and women. This research aimed to examine the association between psychopathological dimensions and dimensions of sexual functioning in Spanish young adults in two studies. Study 1 examined sexual functioning and psychopathological dimensions in 700 women and 516 men. Study 2 conducted an experimental laboratory task to evaluate subjective sexual arousal and genital sensations when watching visual sexual stimuli in a subsample of participants from Study 1 (143 women and 123 men). As a result, the first study showed that depression and anxiety-related symptoms had a negative effect, both in men and women, and having a partner had a positive influence on the dimensions of sexual functioning. The second study showed that anxiety symptoms were positively associated with subjective sexual arousal in both men and women, and anxiety was associated with the assessment of genital sensations in men. The differences between the results of anxiety may be explained because sexual arousal was evaluated in general terms in Study 1, whereas it was evaluated as a state in Study 2. These findings confirm that the presence of psychopathological symptoms contributes to sexual functioning, as well as the necessity of strengthening mental illness prevention programs that include sexual health components.

"Mask up to keep it up": Preliminary evidence of the association between erectile dysfunction and COVID-19

Background

Erectile dysfunction (ED), as the hallmark of endothelial dysfunction, could be a short‐ or long‐term complication of COVID‐19. Additionally, being ED a clinical marker and predictor of non‐communicable chronic diseases, particularly cardiovascular, subjects with ED could potentially have a higher risk of contracting COVID‐19.

Objectives

To investigate the prevalence of ED among subjects with a reported diagnosis of COVID‐19 and to measure the association of COVID‐19 and ED.

Materials and methods

We reviewed data from the Sex@COVID online survey (performed between April 7 and May 4, 2020, in Italy) to retrieve a sample of Italian male sexually active subjects with reported SARS‐CoV‐2 infection. A matching sample of COVID‐19‐negative male sexually active subjects was also retrieved using propensity score matching in a 3:1 ratio. The survey used different standardized psychometric tools to measure effects of lockdown and social distancing on the intrapsychic, relational, and sexual health of Italian subjects.

Results

One hundred subjects were included in the analysis (25 COVID‐positive; 75 COVID‐negative). The prevalence of ED, measured with the Sexual Health Inventory for Men, was significantly higher in the COVID+ group (28% vs. 9.33%; p = 0.027). Logistic regression models confirmed a significant effect of COVID‐19 on the development of ED, independently of other variables affecting erectile function, such as psychological status, age, and BMI [OR 5.66, 95% CI: 1.50–24.01]. Likewise, subjects with ED were more likely to have COVID‐19, once corrected for age and BMI [OR 5.27, 95% CI: 1.49–20.09].

Discussion and conclusion

On top of well‐described pathophysiological mechanisms, there is preliminary evidence in a real‐life population of ED as a risk factor of developing COVID‐19 and possibly occurring as a consequence of COVID‐19. Universal vaccination against the COVID‐19 and the personal protective equipment could possibly have the added benefit of preventing sexual dysfunctions.

Addressing male sexual and reproductive health in the wake of COVID-19 outbreak

PURPOSE

The COVID-19 pandemic, caused by the SARS-CoV-2, represents an unprecedented challenge for healthcare. COVID-19 features a state of hyperinflammation resulting in a "cytokine storm", which leads to severe complications, such as the development of micro-thrombosis and disseminated intravascular coagulation (DIC). Despite isolation measures, the number of affected patients is growing daily: as of June 12th, over 7.5 million cases have been confirmed worldwide, with more than 420,000 global deaths. Over 3.5 million patients have recovered from COVID-19; although this number is increasing by the day, great attention should be directed towards the possible long-term outcomes of the disease. Despite being a trivial matter for patients in intensive care units (ICUs), erectile dysfunction (ED) is a likely consequence of COVID-19 for survivors, and considering the high transmissibility of the infection and the higher contagion rates among elderly men, a worrying phenomenon for a large part of affected patients.

METHODS

A literature research on the possible mechanisms involved in the development of ED in COVID-19 survivors was performed.

RESULTS

Endothelial dysfunction, subclinical hypogonadism, psychological distress and impaired pulmonary hemodynamics all contribute to the potential onset of ED. Additionally, COVID-19 might exacerbate cardiovascular conditions; therefore, further increasing the risk of ED. Testicular function in COVID-19 patients requires careful investigation for the unclear association with testosterone deficiency and the possible consequences for reproductive health. Treatment with phosphodiesterase-5 (PDE5) inhibitors might be beneficial for both COVID-19 and ED.

CONCLUSION

COVID-19 survivors might develop sexual and reproductive health issues. Andrological assessment and tailored treatments should be considered in the follow-up.

Sexual Dysfunction: A Neglected and Overlooked Issue in Adult GH Deficiency: The Management of AGHD Study

Context

Although sexuality influences well-being and quality of life (QoL), studies on sexual dysfunction (SD) in adult growth hormone deficiency (AGHD) patients are lacking.

Objective

To investigate the prevalence of SD in AGHD patients grouped according to recombinant human growth hormone (r-hGH) therapy.

Design

Prospective, cross-over, 24 months, monocentric study.

Setting

Real-life clinical setting in a tertiary, endocrinological center.

Patients

83 AGHD patients (31 women, 52 men, mean age 56.3 ± 14.7 years) were enrolled according to stringent criteria.

Intervention(s)

Patients already on long-term r-hGH therapy (Group 1, n = 32) vs untreated (Group 2, n = 51).

Main outcome measure(s)

Serum hormones, QoL Satisfaction in Hypopituitarism (QLS-H) and QoL Assessment of GHD in Adults (QoL-AGHDA) questionnaires for QoL, Index for Erectile Function-15 (IIEF-15) in men, and Female Sexual Function Index (FSFI) in women for SD.

Results

The overall prevalence of SD was 71.2% (60% men, 89% women). All IIEF-15 scores were lower (P = 0.001) and erectile dysfunction was more prevalent in Group 2 (75%) than Group 1 (35%). IGF-1 was correlated to scores of all IIEF-15 domains, particularly with that of erectile function (EF) (R²=0.123, P = 0.019). EF domain score correlated with QLS-H (P < 0.005) and QoL-AGHDA (P = 0.001). Despite the high prevalence of female SD also in untreated AGHD women, FSFI scores did not correlate with IGF-1 levels and QoL scores.

Conclusions

SD is highly prevalent in AGHD patients, especially in those untreated. SD represents an overlooked and neglected issue in AGHD, regardless the contribution of sexual life on QoL. The evaluation of sexual function should be integrated in the global assessment of AGHD patients.

The impact of menopause on sexual function in women and their spouses

Background

The purpose of this study is to evaluate the impact of menopause on sexual function in women and their spouses.

Methods

This is a cross-sectional study that was conducted from January 2018 to May 2019 in Rasht (North of Iran). The participants included 215 menopausal women and their spouses. Data were collected using the demographic questionnaire, the Female Sexual Function Index (FSFI) questionnaire, and the International Index of Erectile Function (IIEF) questionnaire.

Results

On the basis of the FSFI and IIEF scores, 36.28% (78/215) women reported female sexual dysfunction (FSD) and 17.2% (37/215) men reported erectile dysfunction (ED) with 8.37% (N = 18) being mild, 5.58% (N = 12) mild to moderate, and 3.25% (N = 7) moderate ED. After adjusting differences in the female age distribution, the total score and scores of the IIEF subscales were also not significantly lower in the spouses of women with FSD than women without FSD.

Conclusion

Although, significant correlations between male erectile function and menopausal female sexual function have not identified; but, low scores of the subscales of FSFI in female participants mostly impaired sexual satisfaction and overall satisfaction in their spouses.

Erectile Dysfunction in Young Men: Testosterone, Androgenic Polymorphisms, and Comorbidity With Premature Ejaculation Symptoms

BACKGROUND

The association between erectile dysfunction (ED), free testosterone (T), and androgenic genetic polymorphisms is still unclear. As most studies in the field have focused on older (>40 y.o.) men, data from young men is scarce. In addition, the clinically observed comorbidity between ED and premature ejaculation (PE) has not been explained.

AIM

The aim of the present study was 3-fold: to assess in a sample of young men (1) the association between ED and T; (2) the role of androgenic genetic polymorphisms in the aforementioned association; and (3) comorbidity between ED and PE symptoms.

METHODS

Statistical analyses were performed on a population-based sample of 2,302 Finnish men, (M_age = 26.8 years). Hormone samples were available from 317 men, and genotype information was available from a minimum of 1,144 men depending on genetic locus. For twin analyses, the sample contained 533 male individuals from opposite-sex fraternal twin pairs, 491 identical male individuals (110 complete pairs), 493 male individuals from male fraternal twin pairs (92 complete pairs), and 658 siblings of twins.

OUTCOMES

The main outcome measure includes association between levels of salivary T and ED, main effects of the androgen-related genetic polymorphisms on ED scores. Bivariate twin models of PE and ED were fitted to elucidate possible shared etiology.

RESULTS

We found no significant association between T levels and ED and no significant main effects of the androgenic genetic polymorphisms on ED. We found no evidence suggesting that any of the genetic polymorphisms would moderate the association between T and ED symptoms. We found shared unique environmental influences between PE and ED (r_E = .28).

CLINICAL TRANSLATION

Obtained data suggest that ED has T-independent causes and that any comorbidity between PE and ED is not explained by a set of genes affecting both phenotypes.

STRENGTHS & LIMITATIONS

First, the sample size for both parts of the study was relatively small, which may make some statistical analyses underpowered. Furthermore, as the sample was a population-based sample of relatively young men, the number of clinically relevant ED cases was low. Second, some concerns about T derived from saliva exist because saliva sampling comes with increased risks of error particularly because saliva samples are more vulnerable to contamination.

CONCLUSION

We found no significant association between free T levels, androgenic genetic polymorphisms, and ED in the younger age cohort. Twin analysis suggested a common nonshared environmental component in PE and ED. Zhuravleva1 ZD, Johansson A, Jern P. Erectile Dysfunction in Young Men: Testosterone, Androgenic Polymorphisms, and Comorbidity With Premature Ejaculation Symptoms. J Sex Med 2021;18:265-274.

Comparison of hormone profile and systemic inflammation in patients presenting with sexual dysfunction: Which is important?

INTRODUCTION

Erectile dysfunction (ED) is the inability to achieve or maintain erection sufficient for satisfactory sexual performance. Although the definition is well known, there are controversial issues about the effects of hormones and inflammation on ED.

OBJECTIVES

We aimed to compare the clinical value of the hormonal and inflammation parameters in sexual dysfunction.

MATERIALS AND METHODS

A total of 152 patients diagnosed with erectile dysfunction between September 2018 and March 2019 and 101 healthy males were included in this prospective study as case group and control group, respectively. The 152 patients were divided into three groups based on their total International Index of Erectile Function (IIEF) scores: (I) severe ED, (II) mild-moderate ED and (III) mild ED. All groups were compared in terms of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and total testosterone (TT), estradiol, prolactin, testosterone-to-estradiol ratio and 25 (OH) vitamin D.

RESULTS

Patient and control groups differed significantly in term of NLR, PLR, prolactin and vitamin D (p<0.001, p=0.004, p=0.002, p<0.001, p<0.001, respectively). NLR was more significant in determining the severity of ED (p<0.001). It was observed that libido score (the total score of IIEF items #11 and #12) was negatively associated with prolactin and NLR (p<0.001, p=0.023, respectively), was positively associated with vitamin D and TT (p<0.001, p=0.02, respectively), and was lower in severe ED patients.

CONCLUSIONS

Although more clinical studies are needed, we think that our findings may be useful on these controversial issues of ED.

Relationship between penile erection and the ratio of estradiol to testosterone: A retrospective study

Previous studies have found that the ratio of estradiol to testosterone (E2/T ratio) has a negative effect on sexual function, but the relationship between the E2/T ratio and erection of the penis is not clarified. We conducted a retrospective study of 183 patients with erectile dysfunction and 52 healthy men to investigate the relationship between penis base erection and tip erection. All participants underwent nocturnal penile tumescence tests and medical history checks and had relevant biochemical and endocrine indicators measured. The ratio of estradiol to testosterone was calculated. The relationship between E2/T ratio and erectile time of penile tip and penile base was determined by univariate analysis, multivariate analysis and stratification analysis. After adjusting for mixed factors, the results showed that the E2/T ratio had a more significant negative effect on the base of the penis compared with the tip of the penis (Hazard ratio: -4.34 95% CI: -6.52, -2.16 p = .0001). Moreover, when the effective erection time was ≥10 min, the negative effect of E2/T on penile root erection was more obvious (HR ratio: -4.46 95% CI: -6.50, -2.43 p < .0001). In summary, our study demonstrated a negative relationship between E2/T ratio and penile erection, particularly at the root of the penis.

Monitoring testosterone replacement therapy with transdermal gel: when and how?

PURPOSE

Testosterone replacement therapy (TRT) is recommended for the treatment of most cases of male hypogonadism. Transdermal testosterone (T) gels are commonly used in clinical practice; however, there is little evidence concerning how to monitor dosage to bring and maintain serum T levels in the normal physiologic range.

METHODS

We examined 30 hypogonadal patients undergoing treatment with 40 mg/day transdermal 2% testosterone gel. After a week from treatment onset, all patients underwent a total of four measurements to assess serum total T, bioavailable T and free T at + 2 h (samples A and A') and + 23 h (samples B and B').

RESULTS

No significant difference was found concerning total, free and bioavailable T between the two samples taken at the same time points (A vs A' and B vs B'). A repeated-measures mixed effects regression model showed significantly lower serum levels of total, free and bioavailable T at + 23 h compared to + 2 h (total T, β = - 3.050 ± 0.704, p < 0.001; free T, β = - 85.187 ± 22.746, p < 0.001; bioavailable T, β = - 1.519 ± 0.497, p = 0.003) without a significant between-sample variability. Serum T > 3.5 ng/ml at + 2 h was reached in 21/30 patients (70%), but only 11 (36.7%) still had adequate serum T at + 23 h.

CONCLUSION

Assessment of TRT with transdermal gels at its peak and at its minimum could be useful in providing a finely tailored treatment for hypogonadal men, both preventing supra-physiological levels and maintaining adequate concentrations through the day.

The Sentiment Analysis of Tweets as a New Tool to Measure Public Perception of Male Erectile and Ejaculatory Dysfunctions

INTRODUCTION

Twitter is a social network based on "tweets," short messages of up to 280 characters. Social media has been investigated in health care research to ascertain positive or negative feelings associated with several conditions but never in sexual medicine.

AIM

To assess perceptions related to erectile dysfunction (ED) and premature ejaculation (PE) among Twitter users.

METHODS

Data collection was performed on a daily basis between May 24-October 9, 2018 (138 days) via an automated script. Data collection was then performed after data cleaning. The statistical software R and the rtweet packages were used in both phases.

RESULTS

We collected 11,000 unique tweets for PE and 30,546 unique tweets for ED. After data cleaning, we analyzed 7,020 tweets on PE and 22,648 tweets on ED by analyzing the most recurring words and the clusters describing word associations. The most popular words for ED were "Treatment," "Health," and "Viagra," whereas "Sex," "Sexual," and "Cure" were the top 3 for PE. Word clusters suggest the presence of some recurring themes, such as medical terms being grouped together. Additionally, tweets reflect the general feelings triggered by specific events, such as pieces of news pertaining to sexual dysfunctions.

CLINICAL IMPLICATIONS

Tweets on sexual dysfunctions are posted every day, with more tweets on ED than on PE. Treatment is among the chief topics discussed for both conditions, although health concerns differ between PE and DE tweets.

STRENGTH AND LIMITATIONS

This is the first analysis conducted on Tweets in the field of andrology and sexual medicine. A significant number of tweets were collected and analyzed. However, quantitative assessment of the sentiment was not feasible.

CONCLUSION

Sexual dysfunctions are openly discussed on social media, and Twitter analysis could help understand the needs and interests of the general population on these themes. Sansone A, Cignarelli A, Ciocca G, et al. The Sentiment Analysis of Tweets as a New Tool to Measure Public Perception of Male Erectile and Ejaculatory Dysfunctions. Sex Med 2019;7:464-471.

Diagnostic and Therapeutic Workup of Erectile Dysfunction: Results From a Delphi Consensus of Andrology Experts

INTRODUCTION

Erectile dysfunction is a highly prevalent condition. Existing guidelines provide recommendations for diagnosis and treatment, but they are often disregarded in clinical practice in favor of a "patient-tailored" approach.

OBJECTIVES

We planned a Delphi consensus method to bridge the gap between evidence-based medicine and the real-life approach in daily practice.

MATERIALS AND METHODS

The Advisory Board prepared 15 statements on debated topics in andrology, each including 4-6 items designed as a 5-point Likert scale. After a validation phase, the questionnaire was sent by e-mail to a panel of experts for a first round of voting; members of the panel were later invited to a second round of voting, preceded by discussion of the "hot topics" identified in the first round.

RESULTS

The first round of the Delphi consensus involved 101 experts; 71 (70%) also took part in the second round of voting. The Advisory Board deemed 22 items to be worthy of debate, and these underwent the second round of voting. "Real-life" results from the survey proved quite different from evidence-based recommendations.

CONCLUSION

Although guidelines suggest the best approach for a "standard" patient, real-life settings require flexibility. Diagnostic and therapeutic approaches should be tailored to the patients' needs. Phosphodiesterase type 5 inhibitors are recognized as the first-line therapy in both settings, including the newly introduced sildenafil orodispersible film. Indications from the panel might help close the gap between recommendations from guidelines and real-life practice in relation to the diagnosis and treatment of erectile dysfunction. Isidori AM, Giammusso B, Corona G, et al. Diagnostic and Therapeutic Workup of Erectile Dysfunction: Results From a Delphi Consensus of Andrology Experts. Sex Med 2019;7:292-302.

Sexual dysfunction and hyperprolactinemia in schizophrenia before and after six weeks of D2/3 receptor blockade - An exploratory study

Sexual side-effects along with antipsychotic treatment may be linked to hyperprolactinemia and dopamine D₂ receptor blockade. High prevalence of sexual dysfunction in un-medicated patients challenges the notion of sexual dysfunction as merely a side-effect of antipsychotic medication. Sexual dysfunction was assessed in fifty-six initially antipsychotic-naïve patients with schizophrenia using the UKU (Udvalget for Kliniske Undersøgelser) questionnaire. Serum-prolactin was obtained before and after six weeks of D_2/3 receptor blockade with amisulpride. At baseline 68% of patients reported one or more items of sexual dysfunction (males > females,), but the cumulative load of sexual dysfunction was similar in males and females. After 6 weeks treatment with amisulpride (mean dose 279 mg/day), 65% of patients reported one or more items of sexual dysfunctions (females > males). There was a significant sex*time interaction on mean sexual dysfunction load. All patients developed hyperprolactinaemia, and a significant effect of time and sex was found on s-prolactin (females > males). The results support that patients with schizophrenia report high levels of sexual dysfunction before antipsychotic exposure. After treatment, sexual side-effects were more frequent in females, coinciding with pronounced serum-prolactin increases. These findings suggest sex differences in sexual dysfunction before and after antipsychotic treatment.

Investigating the basis of sexual dysfunction during late-onset hypogonadism

Late-onset hypogonadism (LOH) is the term used to describe the decline in serum testosterone levels associated with increasing age in men above 40 years. A number of symptoms are attributed to LOH, but the most common association is that of sexual dysfunction. LOH has recently come under greater scrutiny with the widespread use of testosterone therapy, and concerns regarding the efficacy and safety of testosterone replacement therapy have been raised. In particular, the cardiovascular safety and the beneficial effects of testosterone replacement therapy on general health have been questioned. This review will give an overview of the current evidence for the relationship of LOH and male sexual dysfunction.

Sport, doping and male fertility

It is universally accepted that lifestyle interventions are the first step towards a good overall, reproductive and sexual health. Cessation of unhealthy habits, such as tobacco, alcohol and drug use, poor nutrition and sedentary behavior, is suggested in order to preserve/improve fertility in humans. However, the possible risks of physical exercise per se or sports on male fertility are less known. Being "fit" does not only improve the sense of well-being, but also has beneficial effects on general health: in fact physical exercise is by all means a low-cost, high-efficacy method for preventing or treating several conditions, ranging from purely physical (diabetes and obesity) to psychological (depression and anxiety), highly influencing male reproduction. If male sexual and reproductive health could be positively affected by a proper physical activity, inadequate bouts of strength - both excessive intensity and duration of exercise training - are more likely to have detrimental effects. In addition, the illicit use of prohibited drugs (i.e. doping) has reached pandemic proportions, and their actions, unfortunately very often underestimated by both amateur and professional athletes, are known to disrupt at different levels and throughout various mechanisms the male hypothalamic-pituitary-gonadal axis, resulting in hypogonadism and infertility.

Klinefelter syndrome, insulin resistance, metabolic syndrome, and diabetes: review of literature and clinical perspectives

PURPOSE

Klinefelter syndrome (KS), the most frequent chromosomic abnormality in males, is associated with hypergonadotropic hypogonadism and an increased risk of cardiovascular diseases (CVD). The mechanisms involved in increasing risk of cardiovascular morbidity and mortality are not completely understood. This review summarises the current understandings of the complex relationship between KS, metabolic syndrome and cardiovascular risk in order to plan future studies and improve current strategies to reduce mortality in this high-risk population.

METHODS

We searched PubMed, Web of Science, and Scopus for manuscripts published prior to November 2017 using key words "Klinefelter syndrome" AND "insulin resistance" OR "metabolic syndrome" OR "diabetes mellitus" OR "cardiovascular disease" OR "testosterone". Manuscripts were collated, studied and carried forward for discussion where appropriate.

RESULTS

Insulin resistance, metabolic syndrome, and type 2 diabetes are more frequently diagnosed in KS than in the general population; however, the contribution of hypogonadism to metabolic derangement is highly controversial. Whether this dangerous combination of risk factors fully explains the CVD burden of KS patients remains unclear. In addition, testosterone replacement therapy only exerts a marginal action on the CVD system.

CONCLUSION

Since fat accumulation and distribution seem to play a relevant role in triggering metabolic abnormalities, an early diagnosis and a tailored intervention strategy with drugs aimed at targeting excessive visceral fat deposition appear necessary in patients with KS.

Coffee Intake and Incidence of Erectile Dysfunction

Coffee intake is suggested to have a positive impact on chronic diseases, yet its role in urological diseases such as erectile dysfunction (ED) remains unclear. We investigated the association of coffee intake with incidence of ED by conducting the Health Professionals Follow-Up Study, a prospective analysis of 21,403 men aged 40-75 years old. Total, regular, and decaffeinated coffee intakes were self-reported on food frequency questionnaires. ED was assessed by mean values of questionnaires in 2000, 2004 and 2008. Multivariable adjusted Cox proportional hazards models were used to compute hazard ratios for patients with incident ED (n = 7,298). No significant differences were identified for patients with incident ED after comparing highest (≥4 cups/day) with lowest (0 cups/day) categories of total (hazard ratio (HR) = 1.00, 95% confidence interval (CI): 0.90, 1.11) and regular coffee intakes (HR = 1.00, 95% CI: 0.89, 1.13). When comparing the highest category with lowest category of decaffeinated coffee intake, we found a 37% increased risk of ED (HR = 1.37, 95% CI: 1.08, 1.73), with a significant trend (P trend = 0.02). Stratified analyses also showed an association among current smokers (P trend = 0.005). Overall, long-term coffee intake was not associated with risk of ED in a prospective cohort study.

Sexual well-being and diurnal cortisol after prostate cancer treatment

Sexual dysfunction and psychological distress are common after prostate cancer. Research has not examined the role of neuroendocrine markers of stress (e.g. cortisol). This study examines whether sexual functioning or sexual bother is associated with diurnal cortisol. Men treated for prostate cancer completed the University of California-Los Angeles Prostate Cancer Index and provided saliva samples four times daily for cortisol assessment. Higher sexual bother, but not sexual functioning, was associated with steeper cortisol slope. Better sexual functioning, and not sexual bother, was significantly associated with the cortisol awakening response. Assessment of stress and stress-reducing interventions might be warranted in sexual rehabilitation after prostate cancer.

Serum Homocysteine Levels in Men with and without Erectile Dysfunction: A Systematic Review and Meta-Analysis

OBJECTIVES

Elevated levels of serum homocysteine (Hcy) have been associated with cardiovascular diseases and endothelial dysfunction, conditions closely associated with erectile dysfunction (ED). This meta-analysis was aimed to assess serum Hcy levels in subjects with ED compared to controls in order to clarify the role of Hcy in the pathogenesis of ED.

METHODS

Medline, Embase, and the Cochrane Library were searched for publications investigating the possible association between ED and Hcy. Results were restricted by language, but no time restriction was applied. Standardized mean difference (SMD) was obtained by random effect models.

RESULTS

A total of 9 studies were included in the analysis with a total of 1320 subjects (489 subjects with ED; 831 subjects without ED). Pooled estimate was in favor of increased Hcy in subjects with ED with a SMD of 1.00, 95% CI 0.65-1.35, p < 0.0001. Subgroup analysis based on prevalence of diabetes showed significantly higher SMD in subjects without diabetes (1.34 (95% CI 1.08-1.60)) compared to subjects with diabetes (0.68 (95% CI 0.39-0.97), p < 0.0025 versus subgroup w/o diabetes).

CONCLUSIONS

Results from our meta-analysis suggest that increased levels of serum Hcy are more often observed in subjects with ED; however, increase in Hcy is less evident in diabetic compared to nondiabetic subjects. This study is registered with Prospero registration number CRD42018087558.

Endogenous and exogenous testosterone and prostate cancer: decreased-, increased- or null-risk?

For more than 70 years, the contention that high levels of testosterone or that the use of testosterone therapy (TTh) increases the development and progression of prostate cancer (PCa) has been widely accepted and practiced. Yet, the increasing and emerging evidence on testosterone research seems to challenge that contention. To review literature on the associations of endogenous and exogenous testosterone with decreased-, increased-, or null-risk of PCa, and to further evaluate only those studies that reported magnitude of associations from multivariable modeling as it minimizes confounding effects. We conducted a literature search to identify studies that investigated the association of endogenous total testosterone [continuous (per 1 unit increment and 5 nmol/L increment) and categorical (high vs. low)] and use of TTh with PCa events [1990-2016]. Emphasis was given to studies/analyses that reported magnitude of associations [odds ratio (OR), relative risk (RR) and hazard ratios (HRs)] from multivariable analyses to determine risk of PCa and their statistical significance. Most identified studies/analyses included observational and randomized placebo-controlled trials. This review was organized in three parts: (I) association of endogenous total testosterone (per 1 unit increment and 5 nmol/L increment) with PCa; (II) relationship of endogenous total testosterone (categorical high vs. low) with PCa; and (III) association of use of TTh with PCa in meta-analyses of randomized placebo-controlled trials. The first part included 31 observational studies [20 prospective (per 5 nmol/L increment) and 11 prospective and retrospective cohort studies (per 1 unit increment)]. None of the 20 prospective studies found a significant association between total testosterone (5 nmol/L increment) and increased- or decreased-risk of PCa. Two out of the 11 studies/analyses showed a significant decreased-risk of PCa for total testosterone per 1 unit increment, but also two other studies showed a significant increased-risk of PCa. Remaining studies reported null-risks values. Second part: eight of out of 25 studies reported an increased-risk of PCa for men with high levels of testosterone compared to low, but only four were statistically significant. However, 17 studies showed a decreased-risk of PCa after comparing high vs. low levels of testosterone, but 11 studies/analyses were statistically significant. Third part: two meta-analyses of randomized placebo-controlled trials (n=8 and n=11, each) that investigated use of TTh with PCa reported not significant decreased-risks of PCa. The contention that high levels of testosterone or that the use of TTh increases the risk of PCa doesn't seem to be supported from the literature. Yet, we still need a study with the adequate power, follow-up data, epidemiological, pathological and clinical data that can support the safety and beneficial effects of high levels of endogenous testosterone or use of TTh in the natural history of PCa and in men's health.

Relationship Between Use of Videogames and Sexual Health in Adult Males

BACKGROUND

Videogame use is increasingly prevalent in people of all ages, and despite the wide amount of scientific evidence proving a role for electronic entertainment in human health, there is no evidence about the relation between use of videogames and sexual health.

AIM

To investigate the association between use of videogames and male sexual health.

METHODS

We administered the two validated questionnaires, the Premature Ejaculation Diagnostic Tool (PEDT) and the International Index of Erectile Function (IIEF-15), to men 18 to 50 years old recruited through social networks and specific websites. In addition to the questionnaires, volunteers were asked to provide information on their gaming habit and lifestyle.

OUTCOMES

An extended version of the IIEF-15 and PEDT, including data about gaming habits and relevant lifestyles.

RESULTS

From June 18, 2014 through July 31, 2014, 599 men 18 to 50 years old completed the questionnaires. One hundred ninety-nine men reported no sexual activity during the previous 4 weeks; four records were rejected because of inherent errors. The remaining 396 questionnaires were analyzed, with 287 "gamers" (playing >1 hour/day on average) and 109 "non-gamers" providing all the required information. We found a lower prevalence of premature ejaculation in gamers compared with non-gamers (mean PEDT score = 3.57 ± 3.38 vs 4.52 ± 3.7, P < .05, respectively). Analysis of the IIEF-15 showed no significant differences between gamers and non-gamers in the domains of erectile function, orgasmic function, and overall satisfaction. Median scores for the sexual desire domain were higher for non-gamers (median score [interquartile range] 9 [8-9] vs 9 [8-10], respectively; P = .0227).

CLINICAL IMPLICATIONS

These results support the correlation between videogame use and male sexual health. Compared with non-gamers, men playing videogames for more than 1 hour/day were less likely to have premature ejaculation but more likely to have decreased sexual desire.

STRENGTHS AND LIMITATIONS

This is the first study aimed to assess male sexual health in gamers. We identified an association between PEDT and IIEF scores and videogame use; however, these findings require validation through interventional studies. Furthermore, volunteers were recruited through social networks, thus increasing the risk of recruitment bias.

CONCLUSION

To our knowledge, this is the first observational study investigating the link between electronic entertainment and male sexuality, specifically for ejaculatory response and sexual desire. Sansone A, Sansone M, Proietti M, et al. Relationship Between Use of Videogames and Sexual Health in Adult Males. J Sex Med 2017;14:898-903.

Gynecomastia and hormones

Gynecomastia-the enlargement of male breast tissue in men-is a common finding, frequently observed in newborns, adolescents, and old men. Physiological gynecomastia, occurring in almost 25 % of cases, is benign and self-limited; on the other hand, several conditions and drugs may induce proliferation of male breast tissue. True gynecomastia is a common feature often related to estrogen excess and/or androgen deficiency as a consequence of different endocrine disorders. Biochemical evaluation should be performed once physiological or iatrogenic gynecomastia has been ruled out. Non-endocrine illnesses, including liver failure and chronic kidney disease, are another cause of gynecomastia which should be considered. Treating the underlying disease or discontinuing medications might resolve gynecomastia, although the psychosocial burden of this condition might require different and careful consideration.

Testosterone Replacement Therapy: The Emperor's New Clothes

The mean age of the world population has steadily increased in the last decades, as a result of increased life expectancy and reduced birth rate. Global aging has led to a greater worldwide cost for healthcare: hormonal alterations contribute to the pathogenesis of several conditions and might cause a significant reduction in the perceived sense of well-being. Menopause is archetypal of hormonal alterations occurring during aging: in males, sex hormones do not decrease abruptly, yet testosterone levels decrease steadily and continuously during aging, ultimately resulting in late-onset hypogonadism. Treatment of this condition might mitigate most symptoms; however, testosterone replacement therapy (TRT) should be prescribed only in selected patients and it should not be considered as an antiaging treatment. In recent years, different authors have questioned health risks associated with testosterone treatment; while position statements from many scientific societies seem to be reassuring, the Food and Drug Administration has issued a warning in regard to the possible side effects of this therapy. We aim to review recent controversies and discoveries in regard to TRT.

Association of Urinary Phthalate Metabolites With Erectile Dysfunction in Racial and Ethnic Groups in the National Health and Nutrition Examination Survey 2001-2004

Phthalates are endocrine-disrupting compounds detectable in more than 75% of the U.S. population with differential distributions across racial and ethnic groups, and they have been linked with reduced levels of serum testosterone. This study aims to investigate the associations of phthalate metabolites with erectile dysfunction (ED) and to determine whether these associations vary by race/ethnicity among men in the United States. Analyzed data for 12 phthalate metabolites from 3,746 men (≥20 years old), who participated in the National Health and Nutrition Examination Survey 2001-2004 cross-sectional study, were included. Metabolites included MBP, MCHP, MEP, MEHP, MiNP, MBzP, MMP, MCPP, MEHHP, MEOHP, MiBP, and MECPP. Racial/ethnic groups included non-Hispanic Blacks ( n = 770), non-Hispanic Whites ( n = 2,147), and Mexican Americans ( n = 829). ED was assessed by a single question during a self-paced, computer-assisted self-interview. In racial/ethnic stratified analyses, there were higher MBP and MBzP concentrations that had a strong-dose response association with lower prevalence odds of ED among Mexican Americans, p_trend < .01, and p_trend = .03, respectively. Similarly, a significant inverse association between MEHHP and likelihood of ED among non-Hispanic Black men ( p_trend < .04) was observed. Furthermore, significant inverse associations between higher concentrations of phthalates and ED were identified only in minority populations. Further investigations, particularly prospective studies, are warranted to determine the role of phthalates on the biological mechanism(s) associated with ED. A focus may be placed on testosterone levels which are suggested to be affected by phthalates, and also low levels of testosterone are suggested to increase the risk of ED.

Erectile dysfunction

Erectile dysfunction is a multidimensional but common male sexual dysfunction that involves an alteration in any of the components of the erectile response, including organic, relational and psychological. Roles for nonendocrine (neurogenic, vasculogenic and iatrogenic) and endocrine pathways have been proposed. Owing to its strong association with metabolic syndrome and cardiovascular disease, cardiac assessment may be warranted in men with symptoms of erectile dysfunction. Minimally invasive interventions to relieve the symptoms of erectile dysfunction include lifestyle modifications, oral drugs, injected vasodilator agents and vacuum erection devices. Surgical therapies are reserved for the subset of patients who have contraindications to these nonsurgical interventions, those who experience adverse effects from (or are refractory to) medical therapy and those who also have penile fibrosis or penile vascular insufficiency. Erectile dysfunction can have deleterious effects on a man's quality of life; most patients have symptoms of depression and anxiety related to sexual performance. These symptoms, in turn, affect his partner's sexual experience and the couple's quality of life. This Primer highlights numerous aspects of erectile dysfunction, summarizes new treatment targets and ongoing preclinical studies that evaluate new pharmacotherapies, and covers the topic of regenerative medicine, which represents the future of sexual medicine.

Erectile dysfunction and its management in patients with diabetes mellitus

Diabetes can be described as a syndrome of multiple closely related conditions induced by a chronic state of hyperglycaemia resulting from defective insulin secretion, insulin action or both. Chronic complications associated with diabetes (including neuropathy, vascular disease, nephropathy and retinopathy) are common, and of these, erectile dysfunction (ED) deserves special attention. ED and its correlation with cardiovascular disease require careful evaluation and appropriate treatment. PDE5 inhibitors (PDE5is) are an important tool for the treatment of ED, with new drugs coming onto the market since the late 90s. This review offers an overview of PDE5is and their use in treating ED in diabetes. We underline the differences between different types of PDE5i, focusing on available doses, duration of action, T ½, side effects and selectivity profiles in relation to patients with diabetes. We also discuss the link between diabetes and ED in presence of various associated cofactors (obesity, hypertension and its pharmacological treatments, atherosclerosis, hyperhomocysteinaemia, neuropathy, nephropathy, hypogonadism and depression). Finally a number of past and ongoing clinical trials on the use of PDE5is in patients with diabetes are presented to offer an overview of the appropriate treatment of ED in this condition.

Hormonal correlations of premature ejaculation

Premature ejaculation is the most frequent male sexual dysfunction, significantly impairing quality of life of both the patient and the partner and affecting up to one-third of men of every age. In the last years, our knowledge about this topic has greatly increased, and studies on the causes and treatments related to ejaculatory disorders have shed a light on previously uncharted territory. Public interest on sexual dysfunctions has likewise increased in the general population: the time lapse between the first symptoms of sexual dysfunction and the seeking of medical advice has been significantly reduced, whereas demand for a treatment has markedly increased. A role of endocrine regulation has been established in all the aspects of male reproduction; however, the endocrine control of ejaculation is not fully understood. Sex steroid, pituitary, and thyroid hormones have all been advocated as potential candidates in the regulation of the ejaculatory process, but exact mechanisms are not clear yet and further studies are required in order to identify potential targets for treatment.