Epidemiology and pathophysiology of male sexual dysfunction

Coil Embolization Is Not Justified for Treating Patients with Veno-Occlusive Dysfunction: Case Series and Narrative Literature Review

Introduction: Herein, we explore whether coil embolization (CE) is effective in treating veno-occlusive dysfunction (VOD). We present five cases with seven CE episodes and a narrative literature review. Methods: From 2013 to 2018, refractory impotence prompted five men to seek penile vascular stripping (PVS), although seven CE episodes were included. All received dual cavernosography in which erection-related veins and VOD were documented. PVS entailed the venous stripping of one deep dorsal vein and two cavernosal veins. The abridged five-item version of the International Index of Erectile Function (IIEF-5) score system and the erection hardness scale (EHS) were used, and yearly postoperative follow-ups were conducted via the Internet. Using Pub Med, a narrative literature review was performed on CE treatment for VOD or varicocele. Results: Inserted coils were scattered along the erection-related veins, including the deep dorsal veins (n = 4), periprostatic plexus (n = 5), iliac vein (n = 5), right pulmonary artery (n = 2), left pulmonary artery (n = 2), and right ventricle (n = 1). PVS resulted in some improvements in the IIEF-5 score and EHS scale. Six articles highly recommend CE treatment for VOD. All claimed it is a minimally invasive effective treatment for varicocele. Conclusions: CE is not justified as a VOD treatment, regardless of its viability in the treatment of varicocele.

Emergent Penile Venous Stripping for Treating Adolescent Impotence

INTRODUCTION

Traditional anatomy-based penile venous surgery is deemed inadequate. Based on revolutionary insights into penile vasculature, penile venous stripping (PVS) shows promise in treating adolescent erectile dysfunction (AED). We aimed to report on this novel approach.

METHODS

We conducted a retrospective analysis of 223 individuals under 30 diagnosed with veno-occlusive dysfunction (VOD) between 2009 and 2023. Among them, 83 were diagnosed with AED and divided into the PVS (n = 37) and no-surgery (NS, n = 46) groups. All participants had been dissatisfied with conventional therapeutic options. Dual pharmaco-cavernosography was the primary diagnostic modality. PVS involved stripping the deep dorsal vein and two cavernosal veins after securing each emissary's vein with a 6-0 nylon suture. Erection restoration was accessed using the abridged five-item version of the International Index of Erectile Function (IIEF-5) score system and the erection hardness scale (EHS). Statistical analysis was performed using IBM SPSS 21.0.

RESULTS

There were significant differences (both p < 0.001) between the preoperative and postoperative IIEF-5 scores in the PVS and NS groups (9.8 ± 3.0 vs. 20.4 ± 2.2; 9.9 ± 2.5 vs. 9.5 ± 2.1), as well as in the EHS scores (1.7 ± 0.7 vs. 3.5 ± 0.6 and 1.8 ± 0.5 vs. 1.3 ± 0.4). The satisfaction rate was 87.9% (29/33) in the PVS group and 16.7% (17/41) in the NS group.

CONCLUSIONS

AED can be effectively treated using physiological methods, although larger patient cohorts are needed for validation.

Prevalence and risk factors of erectile dysfunction in cirrhotic patients: An observational study

Background

Erectile dysfunction (ED) is a prevalent complication observed in male patients with liver cirrhosis; however, there is limited understanding of the etiological determinants responsible for its occurrence. The objective of this investigation is to explore potential contributory factors that underlie the development of ED in male patients with liver cirrhosis.

Method

A cross-sectional study was conducted on 200 male patients with liver cirrhosis, who were divided into three groups according to the Child score. ED was studied using the International Index of Erectile Function (IIEF-5) Questionnaire and penile Doppler.

Results

The prevalence of ED among the cirrhotic patients was 80%, and it was more frequent in patients with advanced liver disease (Child C). Penile venous leakage was observed in 20% of cirrhotic patients, which increased to 28.6% in those with advanced liver cirrhosis. Multivariate logistic regression analysis showed that age, low albumin levels, elevated INR, high hemoglobin levels, and Child C were predictors of ED in cirrhotic patients.

Conclusion

Several clinical variables have been identified as potential contributors to the development of erectile dysfunction (ED) in patients with cirrhosis. These variables include advanced age, decreased levels of albumin, elevated INR, increased hemoglobin levels, and Child C classification. Early identification and treatment of these factors could potentially improve the quality of life for cirrhotic patients with ED. Notably, patients with ED in this population were observed to have elevated levels of INR, serum bilirubin, and hemoglobin, as well as reduced levels of serum albumin.

Prevalence and risk factors of erectile dysfunction in patients with liver cirrhosis: a systematic review and meta-analysis

BACKGROUND AND AIMS

Liver cirrhosis is associated with an increased risk of developing erectile dysfunction (ED). The aim of this systematic review and meta-analysis was to evaluate the prevalence of ED and its risk factors in male patients with liver cirrhosis.

METHODS

A systematic search of PubMed (Medline), EMBASE, OVID Medline, the Cochrane Library, and other databases was performed for this review. Two investigators reviewed the abstracts obtained from the search and selected manuscripts for full-text review. The event rates were calculated with random-effects model and quality effects model.

RESULTS

Fourteen studies evaluating ED with the International Index of Erectile Function (IIEF) scores were selected. A total of 770 patients with liver cirrhosis were analyzed. The prevalence of ED in cirrhotic patients was 79% [decompensated: 88.4%, CI 35.95-70.84%, I² heterogeneity 85%; compensated: 53.6%, CI 77.64-32%, I² heterogeneity 80%]. Through a meta-regression analysis, we discovered that the presence of decompensation, use of beta-blocker and diuretics were related with ED. In addition, risk factors for ED included high body mass index [odds ratio (OR) 1.13, 95% CI 1.01-1.26], advanced Child-Pugh class (OR 2.29, 95% CI 1.12-4.72), MELD score (OR 1.19, 95% CI 1.05-1.35), diabetes (OR 3.44, 95% CI 1.38-8.57), and hypertension (OR 8.24, 95% CI 1.62-41.99).

CONCLUSION

ED is relatively common in male patients with cirrhosis, and presence of risk factors increases the prevalence of ED.

CLINICAL TRIAL NUMBER

PROSPERO (International Prospective Register of Systematic Reviews), CRD42020220411.

Effect of tramadol dependence on male sexual dysfunction

Tramadol dependence became an increasing and alarming problem in the Egyptian community. Wide availability of tramadol as a pain killer and its role in the treatment of premature ejaculation may be the most apparent causes of increased magnitude of the problem among youth who believe that tramadol has a positive impact on their sexual functions. This study aimed to explore the real impact of chronic tramadol administration on sexual functions in males dependent on tramadol. The study was carried on 80 subjects (50 subjects were tramadol dependent group and 30 subjects represented the control group). Personal, family and past histories were obtained from all the participants in addition to the toxicological history from tramadol dependent group. Urine screening for tramadol was done for all cases of history of tramadol dependence then confirmation by HPLC technique to measure tramadol blood level was done. Both groups were investigated for serum testosterone and prolactin level. Curiosity (22%) and treatment of premature ejaculation (20%) were the main motives for dependence. Erectile dysfunction and decreased libido occurred in 44% and 48% of tramadol dependent group respectively. Significant increase in erectile dysfunction and decreased libido was noted as the duration of dependence increased. Additionally, significant decrease in serum testosterone level and increase in serum prolactin level as tramadol daily dose and duration increased was found. In conclusion, men who take tramadol for premature ejaculation or any other purpose must know that they are very susceptible to many sexual dysfunctions.

Computed tomography cavernosography combined with volume rendering to observe venous leakage in young patients with erectile dysfunction

OBJECTIVE:

To observe the venous leakage of penile veins through cavernosometry and cavernosography, using CT combined with three-dimensional volume rendering.

METHODS:

186 consecutive erectile dysfunction patients (20-40 years old) with suspected venous leakage diagnosed by clinicians were enrolled. All patients underwent intracavernous injection of vasoactive agents combined with Doppler ultrasound to identify venous leakage.

RESULTS:

Taking intracavernous injection combined with Doppler ultrasound as the "gold-standard", 47/186 (25.3%) patients had negative venous leakage, and 139/186 (74.7%) patients had positive venous leakage. CT cavernosography showed that 22/139 (15.8%) cases were isolated deep dorsal vein or crural vein leakage, and 117/139 (84.2%) cases were complex venous leakage. Three types of deep dorsal vein were seen: single-branch 42/139 (30.2.%), double-branch 45/139 (32.4%), and complex 31/139 (22.3%). Three types of prostatic venous plexus were seen: single-branch 26/139 (18.7%), multiple-branch 36/139 (25.9%), and plexus 39/139 (28.1%). A total of 166 crural veins were revealed in 129 patients. Crural veins had three origins: medial dorsal side (112/166, 67.5%), lateral ventral side (30/166, 18.1%) and the curs tip (24/166, 14.4%).

CONCLUSION:

To achieve the expected success rate of ligation surgery or endovascular embolization, candidates for the procedures should be carefully selected through CT cavernosography, which can provide elaborate images and information about the venous leakage.

ADVANCES IN KNOWLEDGE:

A modified evaluation method was used in this study to monitor the intracavernous pressure during examination. New classifications of the deep dorsal vein, prostatic venous plexus and crural vein are described in this study.

MAT, a Novel Polyherbal Aphrodisiac Formulation, Enhances Sexual Function and Nrf2/HO-1 Pathway While Reducing Oxidative Damage in Male Rats

Mucuna pruriens, Ashwagandha, and Tribulus terrestris are known as the enhancers for sexual health, functional activities, vitality, and longevity. These herbs had been widely used in the Ayurveda medicine as aphrodisiacs through the ages, and their efficacy was also verified separately in our previous publication. Therefore, the aim of this study was to determine the effects of Mucuna, Ashwagandha, and Tribulus complexes on sexual function in rats. Twenty-eight male rats allocated to four groups as follows: (i) negative control (C); (ii) positive control or sildenafil citrate treated group (5 mg/kg) (S); (iii) MAT1 (combination of 10 mg Mucuna (M) + 10 mg Ashwagandha (A) + 10 mg Tribulus (T)/kg BW); (iv) MAT 2 (20 mg Mucuna + 20 mg Ashwagandha + 20 mg Tribulus/kg BW). There was no significant difference found between the MAT1 and MAT2 groups while they showed significantly increased testosterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) levels when compared to the negative control. Significant increases in Nrf2/HO1 levels and decreases in NF-κB were detected in MAT groups similar to the decrease in serum and testis malondialdehyde (MDA) levels as compared to both controls. The sperm motility, count, and rate also significantly improved in both MAT groups, while ALT, AST, creatinine, ALP, and urea levels did not change in any of the groups. Oral consumption of MATs combination in male rats resulted in inhibition of NF-κB and MDA and also increased sex hormones with Nrf2-mediated HO-1 induction. MAT combinations may improve sexual functions by increasing levels of sexual hormones and regulation of NF-κB and Nrf2/HO-1 signaling pathways.

Sexual health of male cardiac patients - present status and expectations of patients with coronary heart disease

INTRODUCTION

Due to the pathogenetic association between erectile disorders and cardiovascular diseases, cardiologists consult many patients with erectile dysfunction (ED). The aim of the study was to evaluate sexual function in patients with coronary heart disease (CHD) and the use of sexual knowledge in cardiology practice, both current use and that expected by patients.

MATERIAL AND METHODS

One thousand one hundred and thirty-six patients (average age: 60.73 ±9.20) underwent a dedicated survey which encompassed demographic data and the presence of modifiable ED risk factors. The presence of ED was assessed using the International Index of Erectile Function (IIEF-5) Questionnaire.

RESULTS

Sexual problems were discussed by cardiologists with 45 (3.96%) patients. The frequency of initiating the topic was significantly associated with the respondents' education level (p = 0.0031); however, it was not associated with the patients' age, duration of CHD, presence of ED, or modifiable risk factors. Four hundred and sixteen (36.62%) respondents indicated that they expect their cardiologist to take an interest in their ED. Nine hundred and twenty-six (81.51%) patients claimed good sexual function to be important or very important to them. Attitude to sexual function was significantly associated with age (p < 0.0001), duration of CHD (p = 0.0018), education (p = 0.0011), presence of ED (p = 0.0041), diabetes (p = 0.0283) and hyperlipidaemia (p = 0.0014).

CONCLUSIONS

The low frequency with which cardiologists initiate the topic of ED is in contrast to the expectations of patients with CHD. The majority of these patients regard good sexual maintenance as an important part of their life.

Does tunica anatomy matter in penile implant?

Background

Overall prosthesis survival is important in penile implant, which remains the final viable solution to many patients with refractory erectile dysfunction (ED). This paper is to retrospectively study the role of the anatomy of tunica albuginea (TA).

Methods

From March 1987 to March 1991 while the TA was regarded as a circumferential single layer, 21 organically ED men, aged from 27 to 77, received penile prosthesis implantation and were allocated to conventional group. From August 1992 to March 2013 while the tip of Hegar’s dilator was categorically directed medial-dorsally during corporal dilatation derived from newfound TA as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat, 196 ED males, aged from 35 to 83, underwent penile implant and were categorized to advanced group. The model of prosthesis was recorded. Prosthesis loss rate and survival time were analyzed and the follow up period ranged from 22.4-26.4 (average 24.3) years and 0.4-20.6 (average 15.8) years to the conventional and advanced group respectively.

Results

To the conventional and advanced group, the number of inflatable and rigid type prosthesis used were 2, 19 and 15, 181 respectively, whereas the prosthesis loss was encountered in 50.0% (1/2), 15.8% (3/19) and 0.0% (0/15), 0.6% (1/181) respectively. And the prosthesis survival time were 5.1-6.3 (5.7) years, 1.3-26.4 (15.2) years and 6.1-16.2 (11.2) years, 0.4-20.6 (15.3) years to the conventional and advanced group respectively. Statistical significance was noted on prosthesis loss in groups (P=0.01) while the Mentor Acuform stood out in prosthesis survival.

Conclusions

Anatomy-based managing maneuver appears to deliver better surgery success in penile implant. Tunica anatomy is significant in performing implant surgery.

Herb formula enhances treatment of impotent patients after penile venous stripping: a randomised clinical trials

Herbs have been regarded as aphrodisiacs in treating impotence for many centuries despite little true scientific evidence. Our latest refined penile venous stripping (PVS) technique is effective in treating impotence, although this procedure remains controversial. A synergic effect of PVS and oral herbs was confirmed in our practice but lacked rigorous scientific proof. The objective of this report was to review our experience with this combination. From August 2010 to May 2014, 263 males underwent PVS. Among these, 67 unsatisfied men chose additional salvage therapy and were randomly assigned to oral herbs (n = 35) or placebo treatment (n = 32) which replaced herb eventually. All were evaluated with the international index of erectile function (IIEF-5) scoring and our dual pharmaco-cavernosography. The pre-op IIEF-5 score for the herb group was 9.7 ± 3.7, post-operative 13.9 ± 3.3 and post-herb 19.6 ± 3.4, while the control group scores were as follows: pre-op 9.3 ± 4.1, post-op 14.5 ± 3.6, post-placebo 15.1 ± 3.5 and post-herb 19.9 ± 3.2. Although there was no significant difference between the two groups pre-operatively, post-operatively and post-herb, a statistically significant difference was found post-salvage therapy (19.6 ± 3.4 versus 15.1 ± 3.6, P < 0.001). It appears that the combination of oral herbs and PVS treatment provides an enhanced outcome to impotent patients refractory to medicine and unsatisfied with PVS monotherapy alone.

A discrepancy of penile hemodynamics during visual sexual stimulation observed by near-infrared spectroscopy

Background

In this paper, we observed a discrepancy of penile hemodynamics dependent on location by using near infrared spectroscopy (NIRS) sensor, and showcase NIRS as a potentially suitable sensor in supplementing the diagnosis and treatment of erectile dysfunction.

Methods

To observe the effect that location has on penile hemodynamics, the NIRS sensor was placed on the top and the side of genital organ, and oxy- (HbO), deoxy-(RHb), and total (HbT) hemoglobin concentration changes were acquired. Our results from 6 healthy subjects show that hemodynamic changes vary depending on where the probe was placed. To observe a statistical difference between the signals, a Wilcoxon signed-rank test was performed.

Results

The result shows a significant difference (p < 0.05) between concentration changes of RHb and HbT depending on the probes’ location. Moreover, the sensor placed on the top of the organ shows a rise of HbO and HbT concentration while RHb concentration decreased. However, hemodynamics from the side of the organ showed that RHb concentration increased along with HbO.

Conclusions

The outcomes demonstrates an ability of NIRS to be sensitive enough to detect the different hemodynamic changes in various locations of a healthy male genital organ during visual sexual stimulation. The results also show the importance of sensor location on the genital organ for the resulting hemodynamic changes. We can foresee our results as a way for clinicians to obtain more accurate hemodynamic measurements from the penis, and also show the likelihood for NIRS enhanced diagnosis tool of male erectile dysfunction over the current standards.

Penile vascular surgery for treating erectile dysfunction: Current role and future direction

Penile vascular surgery for treating erectile dysfunction (ED) is still regarded cautiously. Thus we reviewed relevant publications from the last decade, summarising evidence-based reports consistent with the pessimistic consensus and, by contrast, the optimistically viable options for vascular reconstruction for ED published after 2003. Recent studies support a revised model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat. Additional studies show a more sophisticated venous drainage system than previously understood, and most significantly, that the emissary veins can be easily occluded by the shearing action elicited by the inner and outer layers of the tunica albuginea. Pascal's law has been shown to be a significant, if not the major, factor in erectile mechanics, with recent haemodynamic studies on fresh and defrosted human cadavers showing rigid erections despite the lack of endothelial activity. Reports on revascularisation surgery support its utility in treating arterial trauma in young males, and with localised arterial occlusive disease in the older man. Penile venous stripping surgery has been shown to be beneficial in correcting veno-occlusive dysfunction, with outstanding results. The traditional complications of irreversible penile numbness and deformity have been virtually eliminated, with the venous ligation technique superseding venous cautery. Penile vascular reconstructive surgery is viable if, and only if, the surgical handling is appropriate using a sound method. It should be a promising option in the near future.

Advances in understanding of mammalian penile evolution, human penile anatomy and human erection physiology: clinical implications for physicians and surgeons

Recent studies substantiate a model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat spanning from the bulbospongiosus and ischiocavernosus proximally and extending continuously into the distal ligament within the glans penis. The anatomical location and histology of the distal ligament invites convincing parallels with the quadrupedal os penis and therefore constitutes potential evidence of the evolutionary process. In the corpora cavernosa, a chamber design is responsible for facilitating rigid erections. For investigating its venous factors exclusively, hemodynamic studies have been performed on both fresh and defrosted human male cadavers. In each case, a rigid erection was unequivocally attainable following venous removal. This clearly has significant ramifications in relation to penile venous surgery and its role in treating impotent patients. One deep dorsal vein, 2 cavernosal veins and 2 pairs of para-arterial veins (as opposed to 1 single vein) are situated between Buck’s fascia and the tunica albuginea. These newfound insights into penile tunical, venous anatomy and erection physiology were inspired by and, in turn, enhance clinical applications routinely encountered by physicians and surgeons, such as penile morphological reconstruction, penile implantation and penile venous surgery.

Tadalafil in the treatment of erectile dysfunction

The treatment for erectile dysfunction (ED) was revolutionized with the development of phosphodiesterase type 5 (PDE5) inhibitors. Tadalafil (Cialis((R)); Eli Lilly and Company, Indianapolis, IN, USA) is the newest and most versatile PDE5 inhibitor in the clinical armamentarium for the treatment of ED. Its most unique characteristic is its long half-life of 17.5 hours, which lends itself to a longer therapeutic window with on-demand dosing and effective steady-state plasma concentrations with once-daily dosing. Clinical trials have proven its safety and efficacy with both dosing strategies for all severities and etiologies of ED, including difficult-to-treat ED. This thorough review will discuss ED, the physiology of penile erection and the role of PDE5, and all aspects of tadalafil, from its development, through its pharmacology, to its latest clinical studies and indications.

Considerations for diagnostic criteria for erectile dysfunction in DSM V

INTRODUCTION

The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., text revision (DSM-IV-TR) criteria for erectile disorder have been criticized as multiple grounds including that the criteria lack precision, that the requirement of marked distress is inappropriate, and that the specification of etiological subtypes should be deleted.

AIM

The goal of this manuscript is to review evidence relevant to diagnostic criteria for erectile disorder published since 1990.

METHOD

Medline searches from 1990 forward were conducted using the terms erectile disorder and impotence. Early drafts of proposed alterations in diagnostic criteria were submitted to advisors.

MAIN OUTCOME MEASURE

Evidence regarding modification of criteria for DSM V diagnostic criteria for erectile dysfunction was judged by whether existing data justified the adoption of precise criteria which would lead to homogenous groups for research. Another outcome measure was whether data exist to reliably differentiate fluctuations in normal function from pathological states.

RESULTS

The literature review revealed a large literature concerning erectile disorder but minimal evidence concerning an operational definition for this disorder.

CONCLUSIONS

It is recommended that erectile disorder be precisely defined in order to clearly differentiate alterations in normal function from a condition requiring medial intervention and to facilitate clinical research. It is specifically proposed that erectile dysfunction be defined as failure to obtain and maintain an erection sufficient for sexual activity or decreased erectile turgidity on 75% of sexual occasions and lasting for at least 6 months. It is also recommended that erectile disorder be defined independently of distress.