Potential for Long-Term Benefit of Cognitive Behavioral Therapy as an Adjunct Treatment for Men with Erectile Dysfunction

Impact of cognitive behavioral therapy on premature ejaculation patients: A prospective, randomized controlled trial protocol

BACKGROUND

Premature ejaculation (PE) is one of the most common male sexual dysfunctions, with a prevalence of about 4%-39% in the Chinese population. Studies have shown that a variety of biological factors can lead to premature ejaculation, such as central nervous system disorders, hypersensitivity of the penis head, and psychological factors. Based on clinical experience, psychological counseling and education of patients and partners should be ranked as the first priority when treating PE. Cognitive behavioral therapy (CBT) addresses emotional, behavioral, and cognitive disorders by altering beliefs and actions. It has also been demonstrated to be clinically useful in treating a number of diseases. The purpose of this trial is to evaluate the efficacy of a mobile-based CBT intervention on patients with PE compared to conventional routine treatment.

METHODS

This study is a prospective randomized controlled trial that will be conducted from May 2023 to Dec 2024 at ten hospitals, primarily including the First Affiliated Hospital of Sun Yat-sen University with an 8-week follow-up. The clinical trial central randomization system will be used to create and implement the specific randomization method. Baseline data of both groups will be measured and collected. The premature ejaculation diagnostic tool (PEDT) and the female sexual distress scale-revised for premature ejaculation (FSDS-R-PE) will be collected on the first day, 28±2 days, and 56±2 days during the intervention period, and the intravaginal ejaculatory latency time (IELT) will be measured in both groups. The Shapiro-Wilk test will be used for normality testing. Pearson correlation analysis will be used for correlation analysis. Differences between groups will be compared using analysis of variance or exact probability calculations.

DISCUSSION

This study will investigate the effect of a mobile-based CBT intervention on patients with PE.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2300070581).

Heart Failure and Erectile Dysfunction: a Review of the Current Evidence and Clinical Implications

PURPOSE OF REVIEW

Heart failure (HF) and erectile dysfunction (ED) are two common conditions that affect millions of men worldwide and impair their quality of life. ED is a frequent complication of HF, as well as a possible predictor of cardiovascular events and mortality. ED deserves more attention from clinicians and researchers.

RECENT FINDINGS

The pathophysiology of ED in HF involves multiple factors, such as endothelial dysfunction, reduced cardiac output, neurohormonal activation, autonomic imbalance, oxidative stress, inflammation, and drug side effects. The diagnosis of ED in HF patients should be based on validated questionnaires or objective tests, as part of the routine cardiovascular risk assessment. The therapeutic management of ED in HF patients should be individualized and multidisciplinary, considering the patient's preferences, expectations, comorbidities, and potential drug interactions. The first-line pharmacological treatment for ED in HF patients with mild to moderate symptoms (NYHA class I-II) is phosphodiesterase type 5 inhibitors (PDE5Is), which improve both sexual function and cardiopulmonary parameters. PDE5Is are contraindicated in patients who use nitrates or nitric oxide donors for angina relief, and these patients should be advised to avoid sexual activity or to use alternative treatments for ED. Non-pharmacological treatments for ED, such as psychotherapy or couples therapy, should also be considered if there are significant psychosocial factors affecting the patient's sexual function or relationship. This review aims to summarize the most recent evidence regarding the prevalence of ED, the pathophysiology of this condition with an exhaustive analysis of factors involved in ED development in HF patients, a thorough discussion on diagnosis and management of ED in HF patients, providing practical recommendations for clinicians.

Efficacy of online cognitive behavioral therapy for nonorganic erectile dysfunction in reproductive-age males during the COVID-19 pandemic: a randomized wait list-controlled trial

BACKGROUND

Previous research has documented the impact of the COVID-19 pandemic on male sexual and mental health. However, no prior study has evaluated the efficacy of online cognitive behavioral therapy (CBT) during the COVID-19 pandemic for treating nonorganic erectile dysfunction (ED) by improving negative emotions and self-esteem.

AIM

To test the efficacy of online CBT for nonorganic ED during the COVID-19 pandemic in Shanghai, China.

METHODS

A randomized controlled trial was conducted during the COVID-19 pandemic. Paired t-tests and 1-way analysis of variance were used to analyze and compare erectile functioning, self-esteem, and emotional state between and within groups.

OUTCOMES

The main outcome measures included scores on the 5-item International Index of Erectile Function, Rosenberg Self-esteem Scale, 9-item Patient Health Questionnaire, and 7-item Generalized Anxiety Disorder scale to evaluate erectile functioning, self-esteem, depression, and anxiety, respectively.

RESULTS

In the CBT group, erectile functioning, intercourse satisfaction, orgasmic functioning, sexual desire, and overall satisfaction were significantly improved at posttreatment as compared with pretreatment (P < .05). After treatment, group differences in emotional state and self-esteem were observed between the CBT group and the control group. Results revealed that the CBT group had significantly better scores than the control group at posttreatment on the Rosenberg Self-esteem Scale (mean ± SD, 30.43 ± 6.51 vs 22.67 ± 10.74), Patient Health Questionnaire (7.07 ± 2.74 vs 11.07 ± 4.41), and Generalized Anxiety Disorder scale (8.36 ± 1.97 vs 11.13 ± 3.94; P < .05).

CLINICAL IMPLICATIONS

This study represents an important advance in understanding of the efficacy of online CBT for treating nonorganic ED in reproductive-age males during the COVID-19 pandemic.

STRENGTHS AND LIMITATIONS

The study participants, treatment modality, and COVID-19 pandemic background of this study are innovative and therefore strengths. However, our study has several limitations-namely, its sample size and use of self-report data to measure erectile functioning due to the pandemic. Further studies should incorporate sexual functioning-monitoring instruments as well as self-report data to measure erectile function.

CONCLUSION

Online CBT clearly improved the emotional state and self-esteem of patients with ED during the COVID-19 pandemic.

The Italian Society of Andrology and Sexual Medicine (SIAMS), along with ten other Italian Scientific Societies, guidelines on the diagnosis and management of erectile dysfunction

PURPOSE

Erectile dysfunction (ED) is one of the most prevalent male sexual dysfunctions. ED has been in the past mistakenly considered a purely psycho-sexological symptom by patients and doctors. However, an ever-growing body of evidence supporting the role of several organic factors in the pathophysiological mechanisms underlying ED has been recognized.

METHODS

The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving several other National Societies to provide an updated guideline on the diagnosis and management of ED. Derived recommendations were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Several evidence-based statements were released providing the necessary up-to-date guidance in the context of ED with organic and psychosexual comorbidities. Many of them were related to incorrect lifestyle habits suggesting how to associate pharmacotherapies and counseling, in a couple-centered approach. Having the oral therapy with phosphodiesterase type 5 inhibitors as the gold standard along with several other medical and surgical therapies, new therapeutic or controversial options were also discussed.

CONCLUSIONS

These are the first guidelines based on a multidisciplinary approach that involves the most important Societies related to the field of sexual medicine. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving couple sexual satisfaction and overall general health.

Conservative Non-surgical Options for Erectile Dysfunction

PURPOSE OF REVIEW

This study aimed to review recent evidence on conservative non-surgical options for erectile dysfunction (ED) in men. A narrative review of the literature was performed. A comprehensive search in the MEDLINE, Embase, and Cochrane databases was done. Papers in English language, published from May 2017 until May 2022, were included. Papers reporting basic research or animal research were excluded, as long as reviews or meta-analyses. Congress reports, clinical cases, or clinical trials protocols with no results were also excluded.

RECENT FINDINGS

We found a multitude of different treatment modalities for ED. We must take into account the type of patient, their comorbidities, the origin of their ED, and its severity in order to reproduce effective results using these therapies. Some of the treatments show good results with a good level of evidence (new IPDE5 formulations, intracavernous injections, shock wave therapy, hormonal theraphy, psycho-sexual theraphy). However, others (some new molecules, stem cell theraphy, platelet-rich plasma injections, oxygenation-based therapy, nutraceuticals), although some of them present promising results, require randomized studies with a larger number of patients and a longer follow-up time to be able to establish firm recommendations. Regarding the conservative treatment of erectile dysfunction, in recent years, some therapies have been consolidated as effective and safe for certain types of patients. On the other hand, other treatment modalities, although promising, still lack the evidence and the necessary follow-up to be recommended in daily practice.

Chronic prostatitis/chronic pelvic pain syndrome-related pain symptoms and their impact on sexual functioning

INTRODUCTION

The present study sought to examine a new model to evaluate the mechanistic pathways between pain and sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), incorporating cognitive and emotional factors.

METHODS

Men with a self-reported diagnosis of CP/CPPS (n=94, 24-69 years, Mage=44.22, standard deviation 11.25) were recruited through social media, support groups, and urology clinics and completed an online questionnaire of demographic, pain, cognitive, psychological, and sexual variables. Descriptive statistics, correlation analysis, and serial mediation analyses assessed variable associations.

RESULTS

Almost half of participants reported mild to severe erectile dysfunction (47.4%). Sexual dysfunction was associated with greater pain symptom severity and pain catastrophizing, as well as depressive symptoms (p<0.01 for all). While pain did not independently predict levels of sexual dysfunction, the addition of pain catastrophizing and depressive symptoms into the pathway explained the association between increased pain symptoms and decreased sexual functioning (p<0.01).

CONCLUSIONS

Beyond generally poor sexual functioning in the current sample, it appears as if cognitive and emotional factors play a role in the association between pain symptoms and sexual functioning in these men with CP/CPPS. The findings of how pain catastrophizing and depression impact the association of pain severity and decreased sexual functioning is important for improving patient care.

Randomized Placebo Controlled Trial of Sildenafil Citrate, Cognitive Behavior Sex Therapy and Integrated Treatment in Men Diagnosed With Non Organic Erectile Dysfunction

Introduction

The integrated treatment combining phosphodiesterase-type 5 inhibitors (PDE5i) and Cognitive Behavior Sex Therapy (CBST) has been shown to yield promising results in the treatment of Non Organic Erectile Dysfunction (NOED) in young men.

Aim

The current study aimed to establish the efficacy of integrated treatment combining Sildenafil Citrate (SC) 50mg and CBST as a treatment of choice in young Pakistani men with NOED.

Methods

One hundred thirty-seven young men were recruited to participate in the study out of 164 men referred from sexual health clinics in Pakistan. They were randomized sequentially into 4 treatment groups namely SC = 35, CBST = 34, integrated treatment = 35, and placebo = 33. 7, 4, 6, and 4 men were dropped out of each treatment group respectively. The data of 116 men were analyzed. The on demand SC 50 mg, twice weekly 50 minutes sessions and home assignments, a combination of SC and 50 minutes sessions, and placebo were administered to firsst, second, third, and fourth group respectively for a period of 12 weeks. The follow-up assessment was done after 12 weeks of post-treatment for all groups.

Main Outcome Measures

The Urdu standardized versions of International Index of Erectile Functoning-5 (IIEF-5) and Depression Anxiety Stress Scale-21 (DASS-21) were the main outcome measures.

Results

The mixed repeated measures analysis of co-variance yielded significant impact of both CBST and integrated treatment groups in improving IIEF-5 scores at post treatment as compared to placebo. The CBST group experienced reduction in depression scores at post treatment as compared to both SC and integrated treatment. Only the integrated treatment brought reduction in anxiety scores at post treatment as compared to SC. The covariates age and NOED duration did not significantly impact the treatment outcome for all treatment groups.

Clinical Implications

The efficacy of integrated treatment approach for improving symptoms of NOED and associated depression and anxiety is strong clinical implication of the study.

Strengths & Limitations

The effectiveness of integrated treatment approach in the improvement of NOED symptoms and associated depression and anxiety scores is the main strength of the study. The improvement in depression scores is the added strength of CBST component of integrated treatment approach. The study should have included other PDE5i to compare their effects with the CBST or placebo groups.

Conclusion

The study concludes that the CBST and integrated treatments are treatment of choice for NOED and associated depression and anxiety in young men.

Bilal A, Abbasi NH. Randomized Placebo Controlled Trial of Sildenafil Citrate, Cognitive Behavior Sex Therapy and Integrated Treatment in Men Diagnosed With Non Organic Erectile Dysfunction. Sex Med 2022;10:100464.

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.

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

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

Possible Role for Imagery-Based Therapy in Managing PTSD in Pakistani Women Experiencing Domestic Abuse: A Pilot Study Using Eidetic Therapy

Domestic abuse of women is a serious problem worldwide that has economic, physical, and psychological consequences, yet in many countries and cultures, victims often have little access to psychological support. Using a pre-post design, we investigated the effects of psychological intervention using an imagery-based therapy in women showing post-traumatic stress disorder (PTSD) resulting from spousal domestic abuse. Forty women, referred from outpatient clinics in Pakistan and meeting inclusion criteria, underwent individual trauma counseling for 10–12 weeks using the principles of Eidetic Therapy, an imagery-based therapy that circumvents heavy reliance on verbal skills and narratives. Women showed significant reductions in PTSD by the end of treatment. Predictors of treatment gains included type of abuse, PTSD level at the outset of therapy, and years in the relationship. Neither economic resources or literacy, nor abuser or victim characteristics, predicted the amount of improvement. In conclusion, therapy was associated with a reduction in PTSD symptoms regardless of literacy level of participants. This reduction in PTSD was notable because, unlike many situations involving spousal abuse, these women were generally not in a position to leave their relationship, and hence the women might have experienced continued exposure to abuse. Context/cultural-based explanations for these findings are presented and discussed.

Practical Approaches to Treat ED in PDE5i Nonresponders

Erectile dysfunction (ED) is a common sexual disorder in adult males and one of the most important factors affecting their quality of life and that of their partners. Although PDE5 inhibitors (PDE5is) are the first choice for improving erectile function, there is a substantial proportion of ED patients, termed PDE5i nonresponders, who do not respond to PDE5is. Because of the lack of effective therapies, these patients always have serious social and psychological problems due to ED, which should be addressed. Here, we review the available literature about ED and PDE5is and propose several strategies for mitigating ED in PDE5i nonresponders.

Global perspectives on the three criteria for premature ejaculation: An observational study of ejaculatory latency, ejaculatory control and bother/distress

Criteria for premature ejaculation (PE) were established using Western-based samples, yet these criteria are applied worldwide for its diagnosis. This study (a) determined whether men from various world regions differ/agree on their views of ejaculation latency (ELT) and their perceptions of ejaculatory control and bother/distress, the three criteria for PE, and (b) compared PE and non-PE men across worldwide regions on these measures. 1,065 participants were recruited via social media to respond to a survey about men's typical, ideal and PE ELTs, about their own ELT, and about perceptions of ejaculatory control and bother/distress related to PE. Responses from men from four worldwide regions were compared to a reference group of North American/European men, and PE men were compared with non-PE men across three world regions. Results showed that most world region groups showed similarity in ELT estimations. The Sub-Saharan group focused more heavily on the importance of ejaculatory control. Both ELT and ejaculatory control differed between PE and non-PE groups in all regions assessed. In conclusion, perceived ELTs and ejaculatory control show substantial consistency across world regions despite geo-cultural variations and traditions. Such findings argue for the universality of the concepts of ELT, control and bother/distress related to PE.

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.

Meta-analytic Evidence for Neural Dysactivity Underlying Sexual Dysfunction

INTRODUCTION

About 30-40% of the population report sexual dysfunction. Although it is well known that the brain controls sexual behavior, little is known about the neural basis of sexual dysfunction.

AIM

To assess convergence of altered brain activity associated with sexual dysfunction across available functional imaging studies.

METHODS

We used activation likelihood estimation meta-analysis to quantify interstudy concordance across 14 functional imaging studies reporting 179 foci from 40 individual analyses involving 191 subjects with sexual dysfunction and 123 controls.

MAIN OUTCOME MEASURE

Activation likelihood estimation scores were used to assess convergence of findings.

RESULTS

Consistently decreased brain activity associated with sexual dysfunction was identified in the dorsal anterior cingulate cortex, ventral striatum, dorsal midbrain, anterior midcingulate cortex, and lateral orbitofrontal cortex.

CLINICAL IMPLICATION

These findings can serve as a basis for further studies on the pathophysiology of this highly common disorder with the view to development of more-specific treatment strategies.

STRENGTH & LIMITATIONS

Findings are based on an observer-independent meta-analysis that provides robust evidence for and anatomic localization of altered brain activity related to sexual dysfunction. Our analysis cannot distinguish between the putative sources of sexual dysfunction, but it provides a more ubiquitous and general pattern of related altered neural activity.

CONCLUSION

The identified regions have previously been shown to be critically involved in mediating sexual arousal and to be part of the sympathetic division of the autonomic nervous system. This suggests that the disturbance of brain activity associated with sexual dysfunction primarily affects sexual arousal already at early stages that are controlled by the sympathetic nervous system. Poeppl TB, Langguth B, Laird AR, et al. Meta-analytic Evidence for Neural Dysactivity Underlying Sexual Dysfunction. J Sex Med 2019;16:614-617.