Patient satisfaction with testosterone supplementation for the treatment of erectile dysfunction

What are the benefits and harms of testosterone therapy for male sexual dysfunction?-a systematic review

The role of Testosterone Therapy (TTh) in the management of male sexual dysfunction remains unclear. Objective of the authors was to systematically review the relevant literature assessing the benefits and harms of TTh in men with sexual dysfunction. EMBASE, MEDLINE, Cochrane Systematic Reviews-Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane HTA, DARE, HEED), Google Scholar, WHO international Clinical Trials Registry Platform Search Portal, CINAHL databases and clinicaltrial.gov were searched systematically in March 2015 and an updated search was performed in March 2016. Randomized and non-randomized comparative studies assessing the benefits and harms of TTh in hypogonadal, borderline eugonadal and eugonadal men suffering from sexual dysfunction were included. Risk of bias and confounding assessments were performed. A narrative synthesis was undertaken. Of the 6410 abstracts identified, 36 studies were judged to be eligible for inclusion, including 25 randomized clinical trials (RCTs) and 11 non-randomized comparative studies (NRCSs), recruiting a total of 4944 patients. RCTs were judged to have low or unclear risk of bias, while NRCSs had high risk of bias and thus, overall quality of evidence was judged to be at least unclear. Based on the evidence mainly provided by the RCTs included in this systematic review, TTh could be considered for men with low or low-normal testosterone levels and problems with their sexual desire, erectile function and satisfaction derived from intercourse and overall sexual life. The exact testosterone formulation, dosage and duration of treatment remain to be clarified, while the safety profile of TTh also remains unclear. TTh could be used with caution in hypogonadal and most probably borderline eugonadal men to manage disorders of sexual desire, erectile function and sexual satisfaction. The overall low-to-moderate evidence quality highlights the need for robust and adequately designed clinical trials.

Couple satisfaction to different therapeutic modalities for organic erectile dysfunction

INTRODUCTION

Erectile dysfunction (ED) treatment studies do not measure treatment response and treatment satisfaction (both patient and partner satisfaction) where dissatisfaction reflects an aspirations/achievement gap.

AIM

To test the subjective implications of satisfaction to various therapeutic modalities for pure or mixed organic ED, and to address changes in the health-oriented quality of life (QoL) and the relation of psychiatric status of these patients to treatment satisfaction.

METHODS

A prospective study included of 354 couples classified according to their line of therapy into five treated groups: testosterone, sildenafil citrate, intracavernosal injection, external negative vacuum device, and penile prosthesis.

MAIN OUTCOME MEASURES

Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and the International Index of Erectile Function (IIEF). Satisfied patients were compared to unsatisfied cases using the PCASEE scale for QoL and Middlesex Hospital Questionnaire (MHQ) for psychiatric status.

RESULTS

Sildenafil citrate-treated group represented the highest mean value of satisfaction score on EDITS, erectile function, orgasmic function, and overall satisfaction domains of IIEF. Penile implants-treated group was the second for satisfaction score on EDITS. The testosterone-treated group represented the highest mean value for sexual desire domain score of IIEF. Low scores in various domains of QoL were significantly improved among satisfied cases more than unsatisfied subjects after therapy. High association was found between dissatisfaction and scores for anxiety, obsession, and phobia, followed by scores of depression and somatic concomitant of anxiety.

CONCLUSION

ED is best conceived as intermingle of somatic, lifestyle, psychological, and partner relationship determinants. This should be taken into account to increase sexual satisfaction with improved QoL, and not only to produce rigid erection.

Recovery of erectile function in aging hypertensive and normotensive rats using exercise and caloric restriction

INTRODUCTION

Using aging spontaneously hypertensive rats (SHR), we established that antihypertensive drugs can improve erections and penile vascular structure, and lower arterial pressure. Using kidney cross-transplantations, our findings revealed that the benefit of this treatment resulted from drug-induced changes specific to the penile circulation, and not to the kidney-mediated lowering of pressure.

AIM

The objective of the present study was to determine whether increased exercise and/or caloric restriction (CR) can reverse the decline in sexual responses in aging hypertensive and normotensive rats.

METHODS

From 30 to 40 weeks, food intake was restricted (10-40%), and SHR, Wistar, and Sprague-Dawley rats ran on treadmills (30 minutes/day, 5 days/week). Exercise was withdrawn at 40 weeks, and CR was stopped at 50 weeks. Using a separate group of older Wistars (56 weeks) and Sprague-Dawley rats (67 weeks), the effects of 10% CR or exercise plus 10-40% CR on erectile function were determined.

MAIN OUTCOME MEASURE

Apomorphine-induced erectile responses and body weight were monitored weekly.

RESULTS

An age-related decline in erections was seen from 15 to 29 weeks of age in all strains. This decline paralleled increases in body weight, particularly in the normotensive strains. Exercise and CR induced a 10% weight loss in normotensive rats and improved erections in all animals. In SHR, increased erections occurred without decreasing body weight. Body weight and erectile responses were maintained by CR alone after exercise was withdrawn, but erectile function rapidly declined soon after CR was stopped and paralleled increases in body weight. In aged Wistar and Sprague-Dawley rats treated with exercise and CR, erectile function was also significantly improved.

CONCLUSIONS

Similar to previous studies, erectile function progressively decreased with age in both hypertensive and normotensive rats. Erectile responses were found to be substantially improved by an intervention involving exercise and CR, but not necessarily involving weight loss.

Sexual function and obstructive sleep apnea-hypopnea: a randomized clinical trial evaluating the effects of oral-appliance and continuous positive airway pressure therapy

INTRODUCTION

The obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with sexual dysfunction. Although successful treatment with continuous positive airway pressure (CPAP) has been demonstrated to improve sexual function, the effects of oral-appliance therapy are unknown.

AIM

The aims of this study were to determine to what extent untreated male OSAHS patients experience sexual dysfunctions compared with control subjects, and second, to evaluate the effects of oral-appliance and CPAP therapy on sexual functioning.

METHODS

Sexual functioning was determined in 48 OSAHS patients with the Golombok Rust inventory of sexual satisfaction (GRISS) and a testosterone measurement. GRISS outcomes were compared with 48 age-matched male controls without any sexual problems. Patients were randomized for either oral-appliance or CPAP therapy. After 2-3 months of treatment, the GRISS and testosterone measurements were repeated.

MAIN OUTCOME MEASURE

The outcomes on the GRISS were used as the main outcome measure.

RESULTS

Compared with controls, OSAHS patients had significantly more erectile dysfunction (mean +/- standard deviation; OSAHS 8.7 +/- 3.8 vs. controls 6.8 +/- 2.6) and sexual dissatisfaction (mean +/- standard deviation; OSAHS 9.7 +/- 4.2 vs. controls 8.1 +/- 2.6) as indicated by the GRISS. No significant changes in the GRISS or testosterone levels were observed in the 20 and 27 patients completing the follow-up review for oral-appliance and CPAP therapy. A correlation was demonstrated between the extent of erectile dysfunction at baseline and improvements in erectile function following treatment (r = -0.547, P = 0.000).

CONCLUSIONS

This study confirms that male OSAHS patients show more sexual dysfunctions compared with age-matched control subjects. Although significant improvements in sexual functioning in neither the oral-appliance nor CPAP-treated group could be established, our findings suggest that untreated OSAHS patients with pronounced erectile dysfunction experience some improvement following treatment.

Does testosterone have a role in erectile function?

PURPOSE

Despite the well-established role of testosterone in enhancing libido, its exact contribution to erections in men remains unclear. The main objectives of this review are to clarify the role of testosterone in erectile function and evaluate its therapeutic value in men with erectile dysfunction (ED).

METHODS

Review of the relevant literature (English, French, and Spanish) from 1939 to June 2005 was conducted using data sources from MEDLINE, endocrinology text books, and hand searching of cross-references from original articles and reviews. Clinical trials, animal studies, case reports, reviews, and guidelines of major associations were included.

RESULTS

Animal and preliminary human studies suggest that testosterone may facilitate erection by acting as vasodilator of the penile arterioles and cavernous sinusoids. Following castration, most, but not all, men had partial or complete loss of erection. Hypogonadism is not a common finding in ED, occurring in about 5% of cases, and in general, there is lack of association between serum testosterone levels, when present in normal or moderately low levels, and erectile function. Most trials using testosterone for treatment of ED in hypogonadal men suffer from methodological problems and report inconsistent results, but overall, suggest that testosterone may be superior to placebo. Erectile function is more likely to improve with testosterone therapy in patients with severe degrees of hypogonadism. Testosterone treatment may ameliorate the response to the phosphodiesterase 5 (PDE5) inhibitors in hypogonadal men and men with low-normal serum testosterone. Repeated measurement of morning serum total testosterone is a fairly accurate and easy method to evaluate androgenecity, but measurement of free or bioavailable testosterone is recommended in conditions that alter the levels of sex-hormone-binding globulin (SHBG), such as in the elderly and in obesity.

CONCLUSIONS

Available data suggest that in most men circulating levels of testosterone, well below the normal range, are essential for normal erection and that higher levels of serum testosterone may not have major impact on erectile function. Screening for hypogonadism in all men with ED is necessary to identify cases of severe hypogonadism and some cases of mild to moderate hypogonadism, who may benefit from testosterone treatment.

Impact of antihypertensive treatments on erectile responses in aging spontaneously hypertensive rats

OBJECTIVE

We previously demonstrated that brief, aggressive antihypertensive therapy recovered erectile function in 40-week-old spontaneously hypertensive rats (SHR). The present study examined the impact of antihypertensive and testosterone treatments on erectile function in aging SHR.

DESIGN AND METHODS

Centrally initiated erections were determined in response to apomorphine throughout. At 30 and 49 weeks, SHR were treated for 2 weeks with enalapril or hydralazine. A third more aggressive treatment (68 weeks) involved enalapril or losartan plus a low salt diet or a triple therapy (hydralazine, nifedipine, hydrochlorothiazide). In a separate study, cross-over kidney transplantations were performed between untreated and losartan-treated SHR. Arterial pressure was assessed post-transplantation using radio-telemetric transducers.

RESULTS

There was an age-related decrease in erections between 30 and 68 weeks (3.1 +/- 0.79 versus 0.2 +/- 0.38) that was not improved by testosterone administration. Early treatment with enalapril or hydralazine did not prevent this decline, although the second treatment resulted in significant improvements (enalapril, 0.8 +/- 0.70; hydralazine, 0.8 +/- 0.41 versus control, 0.3 +/- 0.60). A 2-week aggressive antihypertensive treatment at 68 weeks increased erections approximately two-fold, with the previously treated rats receiving triple therapy having markedly improved erectile responses (0.2 +/- 0.53 versus 1.1 +/- 1.67). In the transplantation study, previously losartan-treated SHR given an untreated kidney had higher arterial pressure but twice the number of erections in comparison with the SHR with lower arterial pressure resulting from transplanting a treated kidney.

CONCLUSIONS

Aggressive antihypertensive treatments may be more beneficial in improving erectile function in aged SHR, via an effect that appears to be tissue specific, and not based on changes in blood pressure.

Testosterone replacement therapy for male hypogonadism: Part III. Pharmacologic and clinical profiles, monitoring, safety issues, and potential future agents

Male hypogonadism is associated with potentially distressing adverse effects on diverse organs and tissues. These include sexual dysfunction, particularly diminished libido, as well as mood disturbances, reduced lean body mass, and increased adipose-tissue mass. A wide range of effective and well-tolerated options exists. These include relatively noninvasive therapies, such as testosterone (T) gels and T patches; slightly more invasive treatments, such as the T buccal system; and invasive therapies, such as intramuscular T injections and subcutaneous depot implants (T pellets). Testosterone replacement therapy (TRT) can be individualized to enhance patient health and well-being. Screening and ongoing monitoring are necessary to ensure both the efficacy and safety of TRT, particularly prostate safety. Investigational agents, including selective androgen receptor modulators, may offer new pharmacodynamic and/or pharmacokinetic properties that enhance outcomes of TRT.

DOES SILDENAFIL COMBINED WITH TESTOSTERONE GEL IMPROVE ERECTILE DYSFUNCTION IN HYPOGONADAL MEN IN WHOM TESTOSTERONE SUPPLEMENT THERAPY ALONE FAILED?

PURPOSE

We evaluated the efficacy of testosterone gel (T-gel) alone and in combination with sildenafil in hypogonadal patients with erectile dysfunction (ED).

MATERIALS AND METHODS

A total of 49 hypogonadal men (mean age 60.7 years) with ED participated for a mean of 20.2 months. Blood was tested for total and bioavailable testosterone, and prostate specific antigen. Sexual function was assessed using the International Index of Erectile Function questionnaire and a global assessment question (GAQ). Men received 1% 5 gm T-gel for 6 months, and 100 mg sildenafil was added to those with a "no" response to the GAQ after 3 months on testosterone supplement.

RESULTS

A total of 31 patients reported significant improvement in the sexual desire domain (from a mean +/- SD of 4.2 +/- 0.8 to 8.6 +/- 0.4) and erectile function (EF) domain (from 13.6 +/- 1.9 to 27 +/- 0.8) following treatment with testosterone supplement alone. One patient was excluded from study after urinary retention developed and 9 reported irritation at the gel application site. In spite of normalization of total and bioavailable testosterone values, and significant improvement of sexual desire domain scores, the EF of 17 men remained less than 26 or they responded "no" to the GAQ. These men received combined T-gel and sildenafil, after which all graded EF greater than 26 and responded positively to the GAQ.

CONCLUSIONS

Combined treatment with sildenafil and T-gel has a beneficial effect on ED in hypogonadal patients in whom treatment with testosterone supplement alone failed.

Testosterone treatment improves body composition and sexual function in men with COPD, in a 6-month randomized controlled trial

The aim of this study was to assess the effect of a low-dose testosterone on body composition and pulmonary function, as well as on quality of life, sexuality, and psychological symptoms in patients with chronic obstructive pulmonary disease (COPD). Twenty-nine men with moderate to severe COPD were allocated to receive either 250 mg of testosterone or placebo intra-muscularly, every fourth week, during the 26 weeks study period. Fat-free mass increased in the treatment group (P<0.05), and a significant difference between the treatment and the control group was seen after 26 weeks (P<0.05). Fat mass decreased in the treatment group (P<0.05), and there was a significant difference between the treatment and the control group after 12 weeks (P<0.01). A significantly better erectile function was reported in the treatment group at the final visit (P<0.05), and the overall sexual quality of life was significantly better in the treatment group after 12 weeks (P<0.05). No improvement in pulmonary function was found. In conclusion, administration of a low-dose testosterone to men with COPD for 26 weeks was associated with improvement of body composition, better erectile function and sexual quality of life. Furthermore, there were no clinical or biochemical side effects.

Testosterone enhances calcium reabsorption by the kidney

The kidney is a target tissue for androgens, but the role of these hormones in the regulation of calcium (Ca2+) reabsorption remains unclear. The present study examines the effects of testosterone on Ca2+ transport by the luminal membranes of proximal and distal nephrons of the rabbit kidney. Tubule suspensions were pre-incubated in the presence or absence of the hormone, and 45C2+ uptake by the luminal membranes was measured using the rapid filtration technique. In the proximal tubules, testosterone did not influence Ca2+ uptake. In the distal tubules, a 5 min incubation with the hormone increased this uptake with a maximal response at 10(-10)M. Ca2+ transport by the distal membranes shows a dual kinetics. Testosterone enhanced the Vmax value of the low affinity component. In an attempt to identify the underlying mechanisms involved in this action, several messenger inhibitors were introduced in the tubule suspension. PD 98059 and U0 126 as well as AG 99 and genistein interfered with the hormone action suggesting the implication of a MEK kinase and a tyrosine kinase. To determine the type of the channels involved in this effect, Ca2+ uptake was measured in the presence of diltiazem, omega-conotoxin MVIIC and mibefradil, i.e. selective inhibitors of the L-type, P/Q type and T-type channels. An inhibition of Ca2+ transport was observed exclusively with mibefradil. These results indicate that testosterone enhances Ca2+ transport by opening a T-type Ca2+ channel in the distal luminal membrane, via MEK kinase and tyrosine kinase dependent mechanisms.