Intracavernous Injections in Spinal Cord Injured Men With Erectile Dysfunction, a Systematic Review and Meta-Analysis

A novel strategy to induce penile erection during penile doppler ultrasound: oral sildenafil administration plus alprostadil injection

OBJECTIVES

To evaluate the efficacy of a novel approach to achieve the optimal penile erection during the penile doppler ultrasound (PDU) examination, which was oral sildenafil combined alprostadil injection.

MATERIALS AND METHODS

A total of 60 ED patients were enrolled in our prospective study, and they were randomly assigned to two group with different PDU order. The approaches assisted the PDU included two models, mode A meaning injection of 15 μg alprostadil and model B meaning oral sildenafil 100 mg plus injection of 15 μg alprostadil. The PDU parameters were measured continuously before induced erection, and 5, 10, 15, 20, 25 min.

RESULTS

Each group included 30 ED patients with similar clinical characteristics. After pooling the results together, the PSV, EDV, and RI were all improved significantly, when adding the oral sildenafil administration to assist PDU. Also, the clinical response of oral sildenafil administration plus alprostadil injection was better than that in alprostadil injection alone (p = 0.016). The arterial ED were decreased from 31.67% to 15.00% with the P value 0.031, and the mixed ED was also decreased statistically (23.33% vs 8.33%, p = 0.024).

CONCLUSION

Oral sildenafil administration plus alprostadil injection could improve the diagnostic accuracy of PDU.

Infection rate of penile prosthesis implants in men with spinal cord injury: a meta-analysis of available evidence

The risk of penile prosthesis implants (PPIs) infection in men with spinal cord injury (SCI), empirically theorized to be high, is widely variable among the studies. We performed a meta-analysis to define the pooled PPI infection rate and its possible risk factors in men with SCI. A thorough search of PubMed, Scopus and Web of Science was performed. The eighteen included studies provided information on 1079 implantation procedures, determining a pooled PPI infection rate of 8.0% (95% CI: 5.0-11.0%), with significant heterogeneity (I² = 67.0%). Trim-and-fill adjustment for publication bias had a small effect on the pooled estimate (adjusted odds ratio: 6.3%, 95% CI: 2.5-10.0%) with a substantial reduction in heterogeneity (I2 = 32.4%). The PPI infection rate was higher for inflatable PPIs than for malleable PPIs (16.4% vs 8.9%, p = 0.027). No differences were found between the different levels of SCI. In conclusion, the risk of PPI infection in SCI would be higher than that reported in the general population. However, the results were produced from dated and low/moderate quality studies that may not fully reflect the outcomes of modern PPIs and implantation protocols. There is an urgent need to gather more information on this topic through studies relevant to contemporary practice.

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.

Novel roles of phentolamine in protecting axon myelination, muscle atrophy, and functional recovery following nerve injury

Incomplete functional recovery after peripheral nerve injury (PNI) often results in devastating physical disabilities in human patients. Despite improved progress in surgical and non-surgical approaches, achieving complete functional recovery following PNI remains a challenge. This study demonstrates that phentolamine may hold a significant promise in treating nerve injuries and denervation induced muscle atrophy following PNI. In a sciatic nerve crush injury mouse model, we found that phentolamine treatment enhanced motor and functional recovery, protected axon myelination, and attenuated injury-induced muscle atrophy in mice at 14 days post-injury (dpi) compared to saline treatment. In the soleus of phentolamine treated animals, we observed the downregulation of phosphorylated signal transducer and activator of transcription factor 3 (p-STAT3) as well as muscle atrophy-related genes Myogenin, muscle ring finger 1 (MuRF-1), and Forkhead box O proteins (FoxO1, FoxO3). Our results show that both nerve and muscle recovery are integral components of phentolamine treatment-induced global functional recovery in mice at 14 dpi. Moreover, phentolamine treatment improved locomotor functional recovery in the mice after spinal cord crush (SCC) injury. The fact that phentolamine is an FDA approved non-selective alpha-adrenergic blocker, clinically prescribed for oral anesthesia reversal, hypertension, and erectile dysfunction makes this drug a promising candidate for repurposing in restoring behavioral recovery following PNI and SCC injuries, axonal neuropathy, and muscle wasting disorders.

Complete study for erectile dysfunction (CompED) improving diagnosis and treatment decision-making

Erectile dysfunction is a condition associated with increasing age. Patient evaluation and management should follow a comprehensive, stepwise approach. The aim of this article was to report our experience with the complete study for erectile dysfunction, including intracavernous injection rigidity test, biothesiometry and colour duplex Doppler ultrasound. Data were collected and analysed prospectively. The primary end point was to determine whether treatment decision-making was eased by the CompED test. Secondary end points were to establish which clinical variables prior to the study could impact the results of the CompED test, to finally improve patient selection for the study. 187 patients were recruited, 31.2% of the patients had an axial rigidity below 50%, 28.5% had a peak systolic velocity <25 cm/s, 13.2% had an end-diastolic velocity >5cm/s and 27.5% had an abnormal biothesiometry. The factors that best predicted an abnormal result in any of the tests were age >70 years, IIEF domain A < 14 points, and previous radical prostatectomy or radiotherapy. The CompED test stands as a new alternative for the evaluation of patients with erectile dysfunction, being less time consuming, aiding in a more accurate determination of the aetiology and guiding treatment decision-making.

[Penile prosthesis for erectile dysfunction in the neurological patient, indication, complications and satisfaction: Retrospective study on 27 patients]

INTRODUCTION

Penile prosthesis for erectile dysfunction in patients with spinal cord injury or multiple sclerosis is sometimes discussed after failure of drug or instrumental treatments (vacuum). The objective of this study was to evaluate the complications, evolution and patient satisfaction after the implantation of a penile prosthesis in the neurological patient.

MATERIALS AND METHODS

Multi-center retrospective study of 27 consecutive patients including 18 spinal cord injured patients and 9 patients with multiple sclerosis benefiting from the implantation of a penile prosthesis for erectile dysfunction purposes in two French centers between 2009 and 2019. Post-implantation complications, evolution of the use of the prosthesis and global patient satisfaction were evaluated using the standardized questionnaire Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) during a telephone call between March and May 2020.

RESULTS

The average age of implantation was 46.4 years (±12.74). The length of follow-up to date of call was 6.05 years (±2.86). 8/27 patients (29.6 %) had at least one complication of any Clavien-Dindo grade included 2 infection. 2/27 (7,4 %) patients had a mechanical prosthesis injury during follow-up. The patient's dexterity with inflation of the prosthesis was perfect in 85 % of cases, and 75 % for deflation. The satisfaction rate for prosthesis use at the time of the call was 75.36/100pts for the patient and 66.88/100pts for the partner.

CONCLUSION

This study found an increased rate of prothesis infection compared to the general population in the neurologic patient, but patient and partner satisfaction remain sustainable after more than 5 years of implantation. Dexterity was maintained over the long term, demonstrating a good selection of indications. These data invite to favorably consider the installation of a penile prosthesis in neurological patients who have failed first-line treatments.

LEVEL OF EVIDENCE

4.

Neurogenic Erectile Dysfunction. Where Do We Stand?

Erectile Dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance, causing tremendous effects on both patients and their partners. The pathophysiology of ED remains a labyrinth. The underlying mechanisms of ED may be vasculogenic, neurogenic, anatomical, hormonal, drug-induced and/or psychogenic. Neurogenic ED consists of a large cohort of ED, accounting for about 10% to 19% of all cases. Its diversity does not allow an in-depth clarification of all the underlying mechanisms nor a “one size fits all” therapeutical approach. In this review, we focus on neurogenic causes of ED, trying to elucidate the mechanisms that lie beneath it and how we manage these patients.

Erectile Functional Restoration With Genital Branch of Genitofemoral Nerve to Pelvic Nerve Transfer After Spinal Root Transection in Rats

OBJECTIVE

To investigate the feasibility of erectile function restoration by the genitofemoral nerve to pelvic nerve transfer in rats.

METHODS

Thirty-six male rats were included in this study. Rats in the nerve transfer group (n = 12) were subjected to pelvic nerve, sacral roots, and L6 roots transection and then bilateral genitofemoral nerve to pelvic nerve transfer, rats in the nerve resection group (n = 12) were subjected to pelvic nerve, sacral roots, and L6 roots transection without nerve transfer, and rats in the control group (n = 12) served as controls. After reinnervation, intracavernous pressure (ICP) assessment was performed. Fluoro-Gold was injected into the corpus cavernosum. Immediately before euthanasia, transferred nerves were stimulated to test penile intracavernous pressure. The L6, S1, and L1-2 spinal cord segments were used for retrogradely labeled neurons. Regenerative nerve morphologic examination assessment was performed.

RESULTS

Genitofemoral nerve stimulation induced an increase in ICP in the nerve transfer group. The mean ICP in this group was (33.8 ± 9.4 mm Hg), which is higher than the mean value in the nerve resection group (3.9 ± 1.0 mm Hg) but lower than that in the control group (69.8 ± 12.2 mm Hg; P < .05). The formation of new neural pathways was confirmed by the appearance of Fluoro-Gold labeled neurons in the L-1 and L-2 spinal cord segments in the nerve transfer group. Regenerative nerve morphologic examination showed good axonal regeneration after genitofemoral nerve transfer.

CONCLUSION

Nerve regeneration can be obtained by genitofemoral nerve to pelvic nerve transfer, and erectile function can be restored.

Management of Erectile Dysfunction and Infertility in the Male Spinal Cord Injury Patient

PURPOSE OF REVIEW

Men with spinal cord injury (SCI) commonly suffer from erectile dysfunction and ejaculatory dysfunction. The literature regarding the causes and treatment of these two important problems was reviewed.

RECENT FINDINGS

Many of the erectile dysfunction treatments applied to able bodied individuals are also useful in the SCI population, although there are differences in the goals and results of treatment. Ejaculatory dysfunction can be treated with either penile vibratory stimulation or electroejaculation with high success rates. Pregnancies are possible, but poor quality sperm quality in male SCI patients leads to pregnancy rates lower than is observed in the able-bodied population. Although effective treatments are available for erectile and ejaculatory dysfunction in men with SCIs, many challenges remain in optimizing the treatment of these individuals.

Sexual concerns after Spinal Cord Injury: An update on management

BACKGROUND

Spinal Cord Injury (SCI) causes neurological impairment with resultant neurogenic sexual dysfunction which can compound preexisting psychological and medical sexual concerns. Understanding these concerns is important in managing the lifelong needs of persons with SCIs.

OBJECTIVES

To provide an overview of the impact of SCI on sexuality along with a framework for treatment of sexual concerns. To briefly review male infertility and its treatments and pregnancy in females after SCI.

METHODS

Interdisciplinary literature review and synthesis of information.

RESULTS

The average age at SCI is increased, thus persons with SCIs may have preexisting sexual concerns. Sexual activity and satisfaction are decreased after SCI. Psychogenic sexual arousal is related to remaining sensation in the T11-L2 dermatomes. Orgasm occurs in approximately 50% of persons with SCIs with all injuries except subjects with complete lower motor neuron (LMN) injuries affecting the lowest sacral segments A structured approach to treatment including assessing preinjury function, determining the impact of injury, education, assessing and treating iatrogenic sexual dysfunction and treatment of concomitant problems is recommended. Basic and advanced methods to improve sexual arousal and orgasm are discussed and treatment of anejaculation and issues associated with pregnancy and SCI are reviewed.

CONCLUSIONS

Sexual satisfaction is impaired after SCI; however, education and new therapies can improve responsiveness. Future research is warranted to improve sexual function and fertility potential in persons with SCIs.

A Novel Collaborative Protocol for Successful Management of Penile Pain Mediated by Radiculitis of Sacral Spinal Nerve Roots From Tarlov Cysts

INTRODUCTION

Since 14 years of age, the patient had experienced extreme penile pain within seconds of initial sexual arousal through masturbation. Penile pain was so severe that he rarely proceeded to orgasm or ejaculation. After 7 years of undergoing multiple unsuccessful treatments, he was concerned for his long-term mental health and for his future ability to have relationships.

AIM

To describe a novel collaboration among specialists in sexual medicine, neurophysiology, and spine surgery that led to successful management.

METHODS

Collaborating health care providers conferred with the referring physician, patient, and parents and included a review of all medical records.

MAIN OUTCOME MEASURE

Elimination of postpubertal intense penile pain during sexual arousal.

RESULTS

The patient presented to our sexual medicine facility at 21 years of age. The sexual medicine physician identifying the sexual health complaint noted a pelvic magnetic resonance imaging report of an incidental sacral Tarlov cyst. A subsequent sacral magnetic resonance image showed four sacral Tarlov cysts, with the largest measuring 18 mm. Neuro-genital testing result were abnormal. The neurophysiologist hypothesized the patient's pain at erection was produced by Tarlov cyst-induced neuropathic irritation of sensory fibers that course within the pelvic nerve. The spine surgeon directed a diagnostic injection of bupivacaine to the sacral nerve roots and subsequently morphine to the conus medullaris of the spinal cord. The bupivacaine produced general penile numbness; the morphine selectively decreased penile pain symptoms during sexual arousal without blocking penile skin sensation. The collaboration among specialties led to the conclusion that the Tarlov cysts were pathophysiologically mediating the penile pain symptoms during arousal. Long-term follow-up after surgical repair showed complete symptom elimination at 18 months after treatment.

CONCLUSION

This case provides evidence that (i) Tarlov cysts can cause sacral spinal nerve root radiculitis through sensory pelvic nerve and (ii) there are management benefits from collaboration among sexual medicine, neurophysiology, and spine surgery subspecialties. Goldstein I, Komisaruk BR, Rubin RS, et al. A Novel Collaborative Protocol for Successful Management of Penile Pain Mediated by Radiculitis of Sacral Spinal Nerve Roots From Tarlov Cysts. Sex Med 2017;5:e203-e211.

Erectile Dysfunction in Young Men-A Review of the Prevalence and Risk Factors

INTRODUCTION

Erectile dysfunction (ED) is an important health concern that can significantly affect a man's psychosocial well-being. ED has traditionally been considered a disease of old age; however, contemporary evidence suggests a growing incidence of ED in men younger than 40 years. The process of achieving an erection is multifaceted; there are many potential mechanisms that can be disrupted. It is critical to identify the specific causes of ED before proceeding with potentially costly and invasive therapeutic options. Advances in diagnostic and treatment modalities offer opportunities to identify and manage young men with ED.

AIM

To provide an update on the prevalence and risk factors of ED in young men and to provide a framework to guide clinicians in identifying and managing the affected young man.

METHODS

Comprehensive review of the literature pertaining to ED in young men.

MAIN OUTCOME MEASURES

ED in young men was assessed by outlining the prevalence according to recent epidemiologic studies. The pathophysiology, diagnostic considerations, risk factors, and etiologies were reviewed.

RESULTS

Large multinational studies have estimated the prevalence of ED in young men to be as high as 30%. Several studies have stratified the etiologies of ED into psychogenic and organic causes. Psychogenic etiologies of ED include depression, anxiety, and partner-related difficulties. These patients tend to experience sudden onset of symptoms, with decreased libido and good quality of spontaneous or self-stimulated erections. Organic etiologies include vasculogenic, endocrinologic, neurogenic, iatrogenic, and structural components. These patients usually experience gradual onset of symptoms and a low to normal libido. Conservative treatments such as phosphodiesterase type 5 inhibitors continue to be the mainstay treatment.

CONCLUSIONS

ED in young men is an increasingly common condition. A careful diagnostic evaluation should focus on the identification of any underlying etiology to ensure appropriate management of patients. Nguyen HMT, Gabrielson AT, Hellstrom WJG. Erectile Dysfunction in Young Men-A Review of the Prevalence and Risk Factors. Sex Med Rev 2017;5:508-520.

Evaluation of sexual and fertility dysfunction in spinal cord-injured men in Jamaica

INTRODUCTION

Sexual dysfunction and infertility are common in males with traumatic spinal cord injuries (SCIs). The objective of this study was to determine the prevalence of sexual dysfunction and infertility in males with traumatic SCI managed in Jamaica, as well as the therapeutic options offered.

CASE PRESENTATION

A cross-sectional study including males with traumatic SCI managed at the Sir John Golding Rehabilitation Centre, Kingston, Jamaica was carried out between 1 January and 31 December 2015. Sexual function was measured with the International Index of Erectile Function Questionnaire, and further information on social history, fertility desires and treatment options offered were collected. Data were analyzed using Stata 12 for Windows (College Station, TX, USA). The mean age of patients at the time of study was 38.8±15.3 years (range 19-71) with a mean duration of injury of 3.7±2.4 years (range 1.3-15.6). Of 45 patients with traumatic SCI surveyed, 90.7% had erectile dysfunction, with 62.8% being classified as severe and 73.3% of men were unable to ejaculate. Treatment for erectile and ejaculatory dysfunction was offered in only two patients, respectively. Most (71.1%) patients indicated that they wanted to have children in the future, however, no one had been referred for assisted reproductive techniques.

DISCUSSION

Men with traumatic SCI have high rates of severe erectile and ejaculatory dysfunctions, but have preserved interests in maintaining fertility. Adherence to guidelines for sexual education for men with traumatic SCI in Jamaica and the Caribbean is needed.