A Review of Economic Evaluations of Erectile Dysfunction Therapies

Do We Care Enough About the Presence of Sexual Problems in Diabetic Patients?

Purpose

Sexual health is not only the absence of sexual dysfunction or disability, but also the presence of physical, emotional, mental, and social well-being related to sexuality. The current study aims to determine whether all adult patients who have applied for their regular health check-ups due to diabetes mellitus had ever voluntarily expressed their sexual problems to a specialist and whether they were asked about the presence of sexual dysfunction. It also aims to determine how the physicians attach importance to the issue.

Patients and Methods

All patients aged 18-65 years with type 1 and type 2 diabetes mellitus, who applied to our hospital between the years of January 2021 and 2022, were questioned by filling out a questionnaire for the presence of sexual problems in addition to screening for chronic complications of diabetes mellitus (retinopathy, nephropathy, and neuropathy) and routine history and physical examination.

Results

The association between the presence of sexual problems and whether patients were questioned about the relevant issue in their previous controls and gender and age factors, educational background, presence of comorbidities, duration of marriage, and microvascular complications of diabetes mellitus were examined. In a population of 595 patients, 53.78% of the patients stated that they had sexual problems; however, 9.91% had been questioned about this issue by the physician. It was observed that 6.3% of female and 15.3% of male patients had previously consulted a doctor voluntarily due to their sexual problems.

Conclusion

This study presents empirical findings that shed light on the inadequacies in healthcare providers' approach to addressing sexual health concerns among individuals diagnosed with diabetes, as well as the shortcomings in patients' effective communication of these concerns.

Stem Cell Therapy for Erectile Dysfunction: A Step towards a Future Treatment

Background: The improvement of absent or partial response in the medical treatment of erectile dysfunction (ED) has led to the development of minimally invasive new treatment modalities in the field of regenerative medicine. Methods: A literature review on stem cell therapy for the treatment of ED was performed. We searched for the terms "erectile dysfunction" and "stem cell therapy" in PubMed and Clinicaltrials.gov. Literature searching was conducted in English and included articles from 2010 to 2022. Results: New treatment modalities for ED involving stem cell therapy are not only conceived with a curative intent but also aim to avoid unnecessary adverse effects. Several sources of stem cells have been described, each with unique characteristics and potential applications, and different delivery methods have been explored. A limited number of interventional studies over the past recent years have provided evidence of a safety profile in their use and promising results for the treatment of ED, although there are not enough studies to generate an appropriate protocol, dose or cell lineage, or to determine a mechanism of action. Conclusions: Stem cell therapy is a novel treatment for ED with potential future applications. However, most urological societies agree that further research is required to conclusively prove its potential benefit.

Cigarette smoking and erectile dysfunction: an updated review with a focus on pathophysiology, e-cigarettes, and smoking cessation

Introduction

Cigarette smoking has major health implications and causes substantial damage to all organ systems. Approximately one-third of men are active smokers worldwide, and most men are unaware that cigarette smoking can contribute to erectile dysfunction (ED).

Objectives

This article aims to provide a comprehensive overview of research conducted on cigarette smoking and ED, with a particular focus on pathophysiology, electronic cigarettes (e-cigarettes), and smoking cessation.

Methods

A manual literature search was conducted on all research conducted on cigarette smoking and ED up to October 2022.

Results

Substantial evidence is now available showing that past and current cigarette smoking has dose-dependent associations with ED in studies controlling for age and important health comorbidities. Cigarette smoke contains nicotine, carbon monoxide, oxidant chemicals, and metals that can damage the endothelium and disrupt erectile processes. For current smokers, smoking abstinence can strengthen the endothelium and reverse diminished erectile function. The effect of e-cigarettes on endothelial damage and ED remains largely untested. E-cigarettes expose users to fine and ultrafine particles and toxins that can increase risk of cardiovascular injury, but these acute effects appear less potent than conventional cigarettes (long-term cardiovascular effects are still unknown). E-cigarettes are therefore likely to have less harmful effects on ED than conventional cigarettes.

Conclusions

Smoking cessation programs that focus on nicotine replacement therapy (transdermal patches, gum, or inhalers), behavioral counseling, social support, and education programs can be effective approaches to ED treatment in active smokers. Temporarily transferring from regular cigarettes to e-cigarettes—which transmit some of the same carcinogens as conventional cigarettes and are likely to have some long-term cardiovascular effects that disrupt erectile function—might also be useful for long-term smoking cessation and treatment of ED.

Synchronous Surgical Management of Erectile Dysfunction and Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Reoperation Rates

INTRODUCTION

The efficacy, safety, and postoperative outcomes of synchronous surgery for concomitant erectile dysfunction (ED) and stress urinary incontinence (SUI) remain unclear.

OBJECTIVES

We performed a systematic review and meta-analysis to evaluate the available synchronous surgical approaches for concomitant ED and SUI and to assess the reoperation rates compared to asynchronous surgery and surgery only for ED or SUI.

METHODS

We searched PubMed, Cochrane Library, and Embase databases until June 2022 for relevant studies. Based on data availability, we performed a meta-analysis of odds ratios (ORs) comparing reoperation rates after synchronous surgery in patients with concomitant ED and SUI versus asynchronous surgery, as well as surgery solely for ED or SUI (PROSPERO: CRD42022326941).

RESULTS

We included 18 studies in the systematic review (16,517 patients) and 5 in the meta-analysis. Comparing synchronous implantation of penile prosthesis and artificial urinary sphincter (AUS) versus asynchronous surgery, no statistically significant differences were observed in the reoperation rates [OR:0.98, 95% confidence interval (CI): 0.52-1.84, I²:0%). Comparing synchronous implantation of both penile prosthesis and AUS versus implantation of only a penile prosthesis or an AUS, combined surgery was associated with higher reoperation rates (OR:2.02, 95%CI: 1.29-3.16, I²:36% and OR:1.7, 95%CI: 1.25-2.32, I²:0%, respectively). Synchronous surgery led to high satisfaction rates and significant improvement in ED and SUI. Evidence for the combination of penile prosthesis with a male sling or the ProACT device is low, but data suggests it may be safe and effective. The synchronous placement of a Mini-Jupette sling and penile prosthesis represents a promising treatment modality for the correction of ED and mild SUI and/or climacturia.

CONCLUSIONS

Synchronous penile prosthesis and AUS implantation appears safe and effective in patients with severe ED and SUI. Further high-quality studies are mandatory to strengthen the current scarce evidence for synchronous surgery in patients with ED and SUI. Pyrgidis N, Barham DW, Hammad M, et al. Synchronous Surgical Management of Erectile Dysfunction and Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Reoperation Rates. Sex Med Rev 2022;XX:XXX-XXX.

Intra-cavernosal injection of botulinum toxin in the treatment of erectile dysfunction: a systematic review and meta-analysis

OBJECTIVE

To evaluate the role of botulinum toxin in treating erectile dysfunction as a novel treatment strategy avoiding morbid and irreversible surgeries.

METHODS

A systematic review of literature was conducted from January 1990 through July 31, 2021. Search engines used included PubMed, Embase and Medline databases, to identify studies investigating botulinum toxin in erectile dysfunction, published in English. Seven studies in total were included in our review including two pre-clinical studies. A meta-analysis was performed on three outcomes included commonly in at least two studies. Among the different parameters assessed were, Erection Hardness Score (EHS), Peak Systolic Velocity in cavernosal artery (PSV) and the Sexual Health Inventory for Men (SHIM) score.

RESULTS

A clear benefit was noted for intracavernosal injection (ICI) of botulinum toxin (BoNT-A) on PSV with a mean difference (MD) of 10.82 [4.99, 16.65] and a heterogeneity of I2=61%. EHS results favored BoNT-A as well over placebo with a MD of 0.7 [0.47, 0.93] and a heterogeneity of I2=94%. As for SHIM score, with a heterogeneity of I2=85%, no statistically significant difference was found (MD 0.58 [-0.03, 1.20]).

CONCLUSION

Our review and meta-analysis have shown statistical significance for the benefit of BoNT-A in terms of EHS and PSV. However, this statistical significance should be interpreted in the light of the given limitations: small sample size, heterogeneity in data collection, patient selection bias, and clinical significance of the measured differences. ICI of BoNT-A should currently be limited to clinical studies to further elucidate its clinical benefit.

Contemporary cost-analysis comparison of direct-to-consumer vs. traditional prescriptions of phosphodiesterase-5 inhibitors

After a focused telehealth visit, patients can now access phosphodiesterase-5 inhibitor (PDE5 inhibitor) prescriptions through online direct-to-consumer (DTC) healthcare companies. This study seeks to quantify the cost of DTC PDE5 inhibitor treatment compared to a traditional physician visit and local pharmacy prescription. Two DTC companies, two compounding pharmacies with national reach, three online Canadian pharmacies, and sixteen American pharmacy chains were queried for prices of 90-day regimens of common PDE5 inhibitors. Prices for chains were determined using their publicly available price on GoodRx^® with coupon. Cost of physician visit was determined using 2020 Center for Medicare and Medicaid Services reimbursement for a level 3 new patient visit. For sildenafil 20 mg, a physician visit and local prescription cost a low of $125.45 compared to $144.35 for compounding, $169.34 for Canadian, and $195.00 for DTC. For sildenafil 100 mg, a physician visit and local prescription cost a low of $137.16 compared to $289.35 for compounding, $200.36 for Canadian, and $900.00 for DTC. For tadalafil 5 mg, a physician visit and local prescription cost a low of $125.80 compared to $169.35 for compounding, $195.34 for Canadian, and $720.00 for DTC. For tadalafil 20 mg, a physician visit and local prescription cost a low of $161.00 compared to $289.35 for compounding, $229.00 for Canadian, and $2880.00 for DTC. Thus, local pharmacies, in conjunction with online coupons, consistently provide a markedly less-expensive option for fulfillment of PDE5 inhibitor prescriptions than online DTC services.

Recreational Use of Oral PDE5 Inhibitors: The Other Side of Midnight

BACKGROUND

Nowadays, Oral phosphodiesterase type 5 inhibitors (PDE5Is) are widely used for the treatment of erectile dysfunction (ED). However, these drugs have become abused among some men for recreational use to enhance their sexual performance.

OBJECTIVE

To shed a light on the recreational use of oral PDE5Is.

METHODS

A literature review was performed in the PubMed, Medline Medical Subject Heading, Science Direct, Scopus, Cochrane Library, EMBASE, CINAHL, Academic Search Complete, Google scholar, Egyptian Knowledge Bank (EKB) databases, Medline, Embase, and Chem ID using the keywords; sexual health, erectile dysfunction, recreational use/abuse, phosphodiesterase type 5 inhibitors, sildenafil, tadalafil, vardenafil, avanafil, and adverse effects.

RESULTS

Overall, 52 studies were retained for review out of 166 papers. Twenty-two studies that assessed the prevalence of the problem were investigated including 25,279 men from different countries. Most of these studies were cross-sectional studies that depend on multiple questionnaires representing the extent as well as the attitude of the recreational use of PDE5Is.

CONCLUSION

Oral PDE5Is have become used among some men for recreational use to enhance their sexual performance. To counteract the possible side effects of such abuse, the media, as well as health authorities, should be aware of the potential adverse effects of such abuse and strengthen the regulatory activity to protect the customers from such risks. Mostafa T, Alghobary MF. Recreational Use of Oral PDE5 Inhibitors: The Other Side of Midnight. Sex Med Rev 2021;XX:XXX-XXX.

Is There a Role for Vascular Surgery in the Contemporary Management of Erectile Dysfunction?

Erectile dysfunction management is intended to restore capacity for penile erection. Although effective, none of the currently available treatments approved by the US Food and Drug Administration reverse erectile dysfunction pathophysiology. Penile arterial bypass surgery is intended to restore erectile function without the need for the chronic use of vasoactive medications or penile prosthesis placement. In select cases, venous ligation surgery may be beneficial, but this approach is not supported by the most recent guidelines on erectile dysfunction management. The lack of high-quality research surrounding penile vascular surgery has limited its use.

Erectile dysfunction treatment with Phosphodiesterase-5 Inhibitors: Google trends analysis of last 10 years and COVID-19 pandemic

OBJECTIVES

We aimed to analyze the trend change of the most popular Phosphodiesterase-5 Inhibitors (PDE5i) over time and geography by using Google Trends (GT) data in 10 years period and COVID-19 pandemic.

MATERIALS AND METHODS

GT is able to generate a "line-graph", showing how interest has increased or decreased over a period within specific territories. The search values for specific terms are indexed as relative search volume (RSV), which is presented on a scale from 0-100. Avarage annual percentage change (AAPC) and RSV were analyzed to evaluate gain or loss of interest in trends. Search terms were generated for Food and Drug Administration (FDA)-approved PDE5i; tadalafil, sildenafil, vardenafil, avanafil, and their most-used brand names. The data was within "worldwide" from 1 January 2010, to 31 December 2020, using the ''global'' query category.

RESULTS

The overall interest in PDE5i has doubled. Sildenafil has become the most trend PDE5i of today with a regular increase (AAPC: 0.016, p < 0.01). Although the search trend of tadalafil remained almost constant until 2014, the rate of increase in the last 6 years raised and tadalafil has become the 2nd most popular PDE5i recently (AAPC: 0.007, p < 0.01). For vardenafil there has been a decreased interest (AAPC: -0.009, p < 0.01). There is no significant change in avanafil trend (AAPC: 0.000, p: 0.5). All PDE5i interest on GT decreased notably from February to June 2020. But after June, search trends reached the level before the COVID-19 period in a month.

CONCLUSIONS

These findings show us, with its increasing prevalence, erectile dysfunction (ED) has become a major public health problem. People from different geographies search the internet for ED treatment options. Patients should be informed that ED may be the first sign of many comorbid diseases, and patients with ED should be referred to a health institution for diagnosis and treatment.

Addressing Health-Care System Inequities in the Management of Erectile Dysfunction: A Call to Action

Erectile dysfunction (ED) is a common, burdensome, and costly urologic condition strongly related to all aspects of general health, from physical to mental. ED has profound consequences as it may interfere physical well-being, quality of life (QoL), self-esteem, relationships, self-worth, and productivity. It is therefore important to ensure that all types of effective ED treatments are consistently accessible to patients. While federal and state mandates ensure access to treatment for women’s breast health, female-factor infertility, and gender affirmation to ensure that these individuals do not experience a diminished QoL, there are no comparable mandates for men’s sexual and reproductive health. The burden of ED necessitates a call to action to improve the accessibility of ED treatments. The call to action steps include: (a) coverage for pharmacological, surgical, and other ED treatments should be viewed in the same way as coverage for other health issues, whether male or female and regardless of the stages of treatment, physical dysfunction, or physical changes; (b) American Urological Association (AUA) guidelines for the management of ED should be followed, including implementation of templates in electronic medical records (EMRs) to support adherence to the guidelines; and (c) coverage criteria should explicitly state that the criteria are intended to support gender equity for sexual and reproductive health care and should not be used to prevent men from receiving medically necessary ED treatments. This call to action offers a pathway to support every man who seeks treatment for ED as a medically necessary intervention by removing systemic health-care barriers.

The Potential Role of Sildenafil in Cancer Management through EPR Augmentation

Enhanced permeation retention (EPR) was a significant milestone discovery by Maeda et al. paving the path for the emerging field of nanomedicine to become a powerful tool in the fight against cancer. Sildenafil is a potent inhibitor of phosphodiesterase 5 (PDE-5) used for the treatment of erectile dysfunction (ED) through the relaxation of smooth muscles and the modulation of vascular endothelial permeability. Overexpression of PDE-5 has been reported in lung, colon, metastatic breast cancers, and bladder squamous carcinoma. Moreover, sildenafil has been reported to increase the sensitivity of tumor cells of different origins to the cytotoxic effect of chemotherapeutic agents with augmented apoptosis mediated through inducing the downregulation of Bcl-xL and FAP-1 expression, enhancing reactive oxygen species (ROS) generation, phosphorylating BAD and Bcl-2, upregulating caspase-3,8,9 activities, and blocking cells at G0/G1 cell cycle phase. Sildenafil has also demonstrated inhibitory effects on the efflux activity of ATP-binding cassette (ABC) transporters such as ABCC4, ABCC5, ABCB1, and ABCG2, ultimately reversing multidrug resistance. Accordingly, there has been a growing interest in using sildenafil as monotherapy or chemoadjuvant in EPR augmentation and management of different types of cancer. In this review, we critically examine the basic molecular mechanism of sildenafil related to cancer biology and discuss the overall potential of sildenafil in enhancing EPR-based anticancer drug delivery, pointing to the outcomes of the most important related preclinical and clinical studies.

Update on Intraoperative Cultures, Biofilms, and Modifiable Factors During Revision of Clinically Non-Infected Penile Implants

INTRODUCTION

Penile implants have a limited lifespan, and as the population using inflatable penile prostheses ages, revision surgery has become increasingly common. Devices are frequently cultured during non-infectious revision surgeries, providing a burgeoning of evidence of positive cultures without clinical infection. However, the clinical significance of these cultures remains unclear.

OBJECTIVES

We aim to review the current literature on culture results from revision surgery for clinically non-infected devices and summarize the available data to formulate a synopsis of clinically significant organisms and their significance and modifiable approaches to prosthesis surgery.

METHODS

A literature review was performed on 1 March, 2020 in PubMed and Google Scholar. Search terms centered on penile prosthesis revision surgery, cultures, and infection. Titles and abstracts were reviewed for topical relevance with emphasis placed on literature from the last 20 years. Most publications comprised small case series aside from a single meta-analysis.

RESULTS

Since 1995, seven series have been published examining culture positivity at the time of revision surgery for clinically non-infected devices. Isolated organisms are most commonly from the Staphylococcus genus with Staphylococcus epidermidis being the most frequently isolated organism on clinically non-infected devices. Reported culture positivity rates at the time of revision range between 9.8% and 80%.

CONCLUSION

Current literature pertaining to the clinical significance of culture positivity at the time of revision surgery for clinically non-infected penile prostheses is lacking; however, multiple series do report high rates of culture positivity. This does appear to confer a higher rate of subsequent infection and a lower revision-free survival. Staphylococcus epidermidis is the most commonly isolated organism followed by other members of the Staphylococcus genus. Further studies are needed to determine the impact of modifiable variables or techniques on asymptomatic culture positivity and the ideal technologies for biofilm prevention. Nosé BD, Grimberg DCD, Lentz AC. Update on Intraoperative Cultures, Biofilms, and Modifiable Factors During Revision of Clinically Non-Infected Penile Implants. Sex Med Rev 2021;9:160-168.