The effectiveness of sildenafil citrate in patients with erectile dysfunction and lower urinary system symptoms and the significance of asymptomatic inflammatory prostatitis

Sildenafil beyond erectile dysfunction and pulmonary arterial hypertension: Thinking about new indications

Sildenafil, approved two decades ago, is the inhibitor of phosphodiesterase 5 (PDE5). First of all, it was designated for angina pectoris, but soon it showed a wonderful efficacy in erectile dysfunction (ED) and then pulmonary arterial hypertension (PAH). Due to the distribution of phosphodiesterase (PDE) in almost all organs, maybe it effects other diseases. Hence, a great number of investigations began to understand the role of PDEi in different organs. Preliminary research on sildenafil in cell culture and animal models has yielded promising results. Soon, a greater number of animal researches and clinical trials joined them. The results disclosed sildenafil can have beneficial effects in each organ such as heart, liver, kidney, brain, and intestines. Furthermore, it has significantly improved the prognosis of organ ischemia in various animal models. Clinical trials in several diseases, such as recurrent spontaneous miscarriage, fatty liver disease, bronchopulmonary dysplasia (BPD), heart failure, and premature ejaculation (PE) brought promising results. Although some clinical trials are available on the effects of sildenafil on various diseases, further studies on humans are needed to consolidate the ultimate effects of sildenafil. The aim of this review was to describe the effects of sildenafil on each organ and explain its mechanisms of action. Further, other PDE inhibitors such as tadalafil and vardenafil have been briefly discussed in parts of this review.

Prospective Study on Association of Prostatic Calcifications with Clinical Symptoms and Results of Treatment in Men with type III prostatitis

The purpose is to investigate the clinical significance of prostatic calculi in patients with chronic prostatitis and to discuss the possible treatment.The data from 277 young males with CP/CPPS were analyzed prospectively. Symptom severity was measured using the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and the International Prostatic Symptoms Score (IPSS). Sexual function was assessed by the International Index of Erectile Function (IIEF-5) questionnaire. After four weeks of therapy, the NIH-CPSI, IPSS, and IIEF-5 tests were repeated. The variables were compared between patients with and without prostatic calcifications using the Students t-test or chi-square test. No significant differences were found between CP/CPPS patients with and without prostatic calcifications regarding age, body mass index, prostate volume, CPSI, IPSS and IIEF-5. Men with calcifications endured symptoms significantly longer (37.9 ± 25.2 versus 19.0 ± 16.4 months, P < 0.01), and had significantly higher white blood cell counts per high power field in expressed prostatic secretions (7.7 ± 12.8 versus 3.9 ± 4.7; P < 0.01), than patients without prostatic calcifications, who responded better to medication compared with patients with prostatic calcifications. In conclusion, patients with calcifications were more likely to have category IIIA disease and they required a longer medication period.

Phosphodiesterase Type 5 Inhibitor and Erectile Dysfunction in Lower Urinary Tract Symptoms

Benign prostatic hyperplasia (BPH) is one of the most common diseases in older men and mostly induces lower urinary tract symptoms (LUTS). Multiple studies have shown that BPH inducing LUTS are intensely correlated with erectile dysfunction (ED) and that severity of LUTS was proportional to ED severity. Although a direct causal relationship has not been clarified, a tentative pathophysiology has been suggested to interpret the relationship between two disorders. Androgen plays an important role in the maintenance of the functional and structural integrity of the lower urinary tract and penis. Low testosterone, especially free testosterone, worsened detrusor overactivity and replacement of testosterone improved LUTS in the hypogonadal BPH patients. Nitric oxide synthase and nitric oxide are decreased in the transition zone of the hyperplastic prostate but phosphodiesterase types 4, 5, 11 are prominent in transition zone of hyperplastic prostate. Phosphodiesterase type 5 (PDE5) inhibitor with a long half-life could obtain the desired effect; therefore, tadalafil and undenafil frequently have been used to evaluate the effects in the two disorders. In clinical trials, tadalafil showed improvement of BPH-induced LUTS, but few of the studies showed a significant improvement on uroflowmetry. PDE5 inhibitors increase the concentration of cyclic guanosine monophosphate (cGMP) in plasma and smooth muscle, promoting erection of the penis, as well as relaxation of the bladder neck and prostate, leading to natural voiding. Sexual function and LUTS should be assessed and discussed with the patient when choosing the appropriate strategy and the patient's response to treatment should also be evaluated at the same time.

Adherence and Persistence Patterns in Medication Use Among Men With Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia

Medication adherence and persistence patterns among patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) were analyzed. Electronic medical records of patients from the Reliant Medical Group were examined to evaluate adherence and persistence patterns. A total of 1,807 patients with LUTS/BPH were included in the study, and the number of patients at least 50 years of age was 1,748/1,807 (97%). Overall, 15.77% of patients were prescribed index prescription once, and no patients on combination alpha-blocker and 5-alpha reductase inhibitor therapies were prescribed their index prescriptions once. For all patients with LUTS/BPH, the mean number of prescriptions filled was 6.26, and the percentage of men persisting on index therapy for ≥4 years was 48%. Patients with LUTS/BPH showed a high proportion of both adherent and persistent treatment patterns, especially among patients taking combination therapy. The long follow-up time in our study provides evidence that patients are experiencing sufficient symptom relief to tolerate the challenges of remaining adherent and persistent.

The role of phosphodiesterase-5 inhibitors in prostatic inflammation: a review

Clinical and basic experimental evidence indicates that chronic inflammation is the greatest factor in benign prostatic hyperplasia (BPH) progression, which is the most common cause of Lower Urinary Tract Symptoms (LUTS). The use of anti-inflammatory agents such as steroids, cyclooxygenase-2 (COX-2) and phytotherapics have been investigated as forms of treatment for various prostate diseases. Recent evidence has demonstrated that PDE5 inhibitors (PDE5Is) improve symptoms of BPH/LUTS, possibly as a result of the relaxing of the smooth muscle fibers of the bladder and prostate by NO/cGMPc signaling, or by improving RhoA/Rho-kinase (ROCK), and reduction of the hyperactivity of the autonomic nervous system. However, some results have suggested that besides vasodilatation and their anti-proliferative effect, PDE5Is exert a direct anti-inflammatory effect, by raising cGMP. Given that inflammation is major factor in benign prostatic hyperplasia (BPH) progression, PDE5Is could act also restore prostatic function as they act as potent anti-inflammatory drugs. This review aims to provide a comprehensive summary of the use of phosphodiesterase-5 inhibitors to treat prostatic inflammation.

A prospective study on association of prostatic calcifications with sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)

INTRODUCTION

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common debilitating condition of unclear etiology. Sexual dysfunction is an important component of the clinical phenotype of CP/CPPS. Patients often have prostatic calcifications, but a link to sexual dysfunction is unknown.

AIM

The aim of this study was to evaluate the association of prostatic calcifications with sexual dysfunction in this condition.

METHODS

A total of 358 males with CP/CPPS were consecutively enrolled, and a prospectively maintained database of these patients was analyzed. Calcifications were diagnosed using ultrasound imaging of the prostate. Symptom severity was measured using the National Institutes of Health Chronic Prostatitis Symptom Index (CPSI). Sexual dysfunction was evaluated using the validated 15-item International Index of Erectile Function (IIEF-15) questionnaire and 5-item Premature Ejaculation Diagnostic Tool scales. The variables were compared between patients with prostatic calcifications and those without using the Student's t-test, Wilcoxon unpaired test, or chi-square test.

MAIN OUTCOME MEASURE

Logistic regression models were developed to explore a possible association between prostatic calcifications and sexual dysfunction.

RESULTS

Measurable calcifications in the prostate were found in 175 (48.9%) of the 358 patients. Patients with calcifications were more likely to have higher white blood cell counts or positive bacteria cultures in their prostatic fluid, longer symptoms duration, and lower scores for the total IIEF-15, IIEF-erectile function, and IIEF-intercourse satisfaction domains (P < 0.001 for each). However, the scores for CPSI, premature ejaculation, and IIEF-orgasmic function, IIEF-sexual desire, and IIEF-overall satisfaction domains were identical between men with and without calcifications (P > 0.05 for each). Furthermore, logistic regression analyses revealed that intraprostatic calcification is significantly associated with self-assessed erectile dysfunction (ED) (odds ratio:3.632, 95% confidence interval: 2.405-5.822, P < 0.001).

CONCLUSION

Our results showed that prostatic calcifications are significantly associated with the presence of ED in CP/CPPS males.

Sexual dysfunction in chronic prostatitis/chronic pelvic pain syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), or NIH category III prostatitis, is a common clinical syndrome characterized by genital/pelvic pain and lower urinary tract symptoms in the absence of urinary tract infection. There is also growing recognition of the association of sexual dysfunction with CP/CPPS including erectile dysfunction, ejaculatory pain, and premature ejaculation. In this review, we discuss the association between CP/CPPS and sexual dysfunction, potential mechanisms for sexual dysfunction, and treatment strategies for erectile dysfunction in CP/CPPS.

Clinical utility of the UPOINT phenotype system in Chinese males with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): a prospective study

BACKGROUND

Recent data showed that a six-domain UPOINT is a flexible and responsive new classification system that has the clinical applicability in CP/CPPS. However, the utility of UPOINT algorithm in men in China with CP/CPPS has not been comprehensively studied. For international validation and adoption, we evaluated this clinical phenotype system for a large cohort of Chinese CP/CPPS patients and correlated it with patient symptoms and erectile dysfunction (ED). We also investigated the addition of an ED domain in regard to symptom correlation.

METHODS

A total of 389 Chinese males with CP/CPPS were prospectively collected and classified in each domain of the UPOINT system. Symptom severity was measured using the NIH-CPSI and IPSS. The erectile function was evaluated using the IIEF-5. Clinically relevant associations were calculated.

RESULTS

The percentage of patients positive for each domain was 54.0%, 42.1%, 41.9%, 20.8%, 26.7%, and 40.4% for the Urinary, Psychosocial, Organ-specific, Infection, Neurological/systemic, and Tenderness, respectively. There were significant correlations between the number of positive UPOINT domains and total NIH-CPSI (r = 0.706, p<0.001), IPSS (r = 0.682, p<0.001) and IIEF-5 scores (r = 0.631, P = 0.007) in Chinese cohort. Except for patients age, symptom duration was associated with a significantly greater number of positive domains (r = 0.638, P  = 0.005). After adding an ED domain to create a modified UPOINT system, the correlation between the number of phenotypic domains and symptom severity was improved (0.706 to 0.844, p<0.001).

CONCLUSIONS

The clinical applicability of using UPOINT phenotyping system has been validated in the Chinese patients with CP/CPPS. In our cohort, the number of positive domains was also correlated with ED symptoms and the significant association between the number of UPOINT domains and NIH-CPSI scores was further refined by adding a domain for ED. Our findings presented here support the utility of using ED as a stand-alone item in the UPOINT domain.

A case-control study on the association between chronic prostatitis/chronic pelvic pain syndrome and erectile dysfunction

What's known on the subject? and What does the study add? In recent years, a number of studies have reported a high prevalence of erectile dysfunction (ED) among patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Several studies have reported that the prevalence of ED ranges from 15.0 to 40.5% in men in China with CP/CPPS; however, the previous studies focusing on the prevalence of ED among patients with CP/CPPS all neglected to explore the magnitude of this association. Our study found an association between ED and previously diagnosed CP/CPPS. The odds of previous CP/CPPS were 3.62 times greater for cases than for controls, after adjusting for patient socio-demographic characteristics, comorbidities, obesity, and alcohol abuse/alcohol dependence syndrome.

OBJECTIVE

To examine the association between erectile dysfunction (ED) and a previous diagnosis of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) using a population-based dataset.

PATIENTS AND METHODS

The data for this case-control study was obtained from the National Health Insurance database. A total of 3194 males, who were ≥18 years of age when they first received a diagnosis of ED, were identified and 15 970 controls were randomly selected. The prevalence and risk of CP/CPPS among cases and controls were calculated by using conditional logistic regression analysis.

RESULTS

In total, 667 (3.5%) of the 19 164 sampled subjects had been diagnosed with CP/CPPS before the index date; CP/CPPS was found in 276 (8.6%) cases and in 391 (2.5%) controls (P < 0.001). Regression analysis indicated that cases were more likely to have had previous CP/CPPS (odd ratio 3.62, 95% confidence interval 3.07-4.26) after adjusting for patient monthly income, geographical location and urbanization level, as well as hypertension, diabetes, coronary heart disease, renal disease, obesity and alcohol abuse/alcohol dependence syndrome status, when compared with controls.

CONCLUSIONS

We conclude that there was an association between ED and having been previously diagnosed with CP/CPPS. Urologists should be alert to the association between CP/CPPS and ED, and assess the erectile function of patients suffering from CP/CPPS.