COMMENTARY: Subclinical Erectile Dysfunction: Proposal for a Novel Taxonomic Category in Sexual Medicine

Recommendations for the diagnosis and evaluation of premature ejaculation

OBJECTIVES

The Association Interdisciplinaire Post-Universitaire de Sexologie (AIUS) has brought together a panel of experts to draw up French recommendations for the management of premature ejaculation. This article presents the recommendations for the diagnosis and evaluation of premature ejaculation.

METHODS

Systematic review of the literature between 01/1995 and 02/2022. Using the method of recommendations for clinical practice (RPC).

RESULTS

We recommend using the SIAMS definition for everyday clinical practice. PE is defined as: (i) a persistent and recurrent subjective perception of loss of control (management) of the ejaculatory mechanism in the presence of appropriate erotic stimuli; (ii) subjective, PE-related distress induced in the patient and sexual dissatisfaction or PE-related anorgamy in the partner; (iii) a short intravaginal ejaculatory latency time, whether subjectively perceived by the patient and the partner or objectively measured as less than 180seconds (generally). We suggest that the same definition be applied to practices other than vaginal penetration, such as masturbation, oral or anal intercourse, as well as to non-heterosexual contexts. We suggest using information reported by the patient, possibly supplemented by assessment tests/questionnaires (IPE, PEP, PEDT). We recommend investigating the presence of other sexual dysfunctions, in particular erectile dysfunction (ED), as well as any sexual dysfunctions of partners. We recommend taking a medical and psychosexological history, and carrying out a targeted physical examination in patients complaining of PE.

CONCLUSION

These recommendations should help to improve the management of PE.

Effect of Angiotensin 1-7 Peptide Agonist AVE 0991 on Diabetic Endothelial Dysfunction in an Experimental Animal Model: A Possible Tool to Treat Diabetic Erectile Dysfunction

Background The renin-angiotensin system and its metabolites are crucial in the pathogenesis and progression of complications of diabetes. Aim In this study, we aimed to evaluate the effect of angiotensin 1-7 non-peptide agonist AVE 0991 (576 ug/kg/day i.p.) on diabetic endothelial dysfunction. Materials and methods In this experimental animal study, we investigated the effects of angiotensin 1-7 non-peptide agonist AVE 0991 (576 ug/kg/day i.p.) treatment in male Wistar rats. Diabetes was created via injecting streptozotocin (55 mg/kg/i.p., single dose). Following the cavernous tissue submaximal phenylephrine contraction, relaxation responses were obtained by applying electrical field stimulation (0.5 ms, 40 V) for 15 seconds at 2, 4, 8, 16, 32, and 64 Hz, with two-minute intervals, respectively. To evaluate the effect of nitric oxide, the responses were compared by incubating with 100 mM N(gamma)-nitro-L-arginine methyl ester (L-NAME) for 20 minutes. Additionally, Y-27632 and sodium nitroprusside responses were evaluated in tissues contracted with submaximal doses of phenylephrine. Results Following a submaximal contraction of phenylephrine in the aorta rings, relaxation responses obtained with acetylcholine, sodium nitroprusside, and Y-27632 were impaired in diabetic rats; however, significant results were obtained with treatment. Although there was no significance between the groups in the electrical field stimulation responses, there was a significant dose-dependent difference in the treatment group in this parameter after L-NAME, sodium nitroprusside, and Y-27632 relaxation. Conclusions We determined that treatment with a non-peptide receptor antagonist of angiotensin 1-7, an enzyme detected in the aortic and cavernosum endothelium, may be a promising alternative for treating the complications of diabetes.

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.

Recreational use of oral erectile dysfunction medications among male physicians - A cross-sectional study

Introduction

Erectile dysfunction (ED) is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. Bypassing health-care providers and obtaining ED medications (EDM) without a prescription are an issue that is faced globally.

Aim

We attempt to assess erectile function (EF) among a local sample of physicians, the psychological effects of recreational EDM use, and compare EF among different user groups.

Methods

This is a cross-sectional study done solely on physicians in Saudi Arabia. A self-designed questionnaire including demographics, sexual characteristics, use of ED medication, sexual satisfaction, and the validated international index of EF (IIEF).

Outcome

Physicians misused EDM.

Results

A total of 503 physicians completed the questionnaire. Among participants reporting sexual problems, only 23% received counseling and 3.4% were professionally diagnosed with ED. Among users, 71.2% were using EDM recreationally, 14.4% prophylactically, and 14.4% were prescribed. Participants aged 20-29 IIEF-5 score was significantly lower than participants aged 30-39 years. Prescribed users had a lower IIEF-5 score compared to both recreational users and nonusers.

Clinical Implications

Many healthy sexually active men use EDMs recreationally to increase sexual performance.

Strengths and Limitations

One of the limitations of our study is that we did not use standardized tools to determine the diagnosis of some important disorders like premature ejaculation. Our study strengths include the very high response rate, with our results truly showing a nationwide self-assessment of sexual dysfunction.

Conclusion

Recreational use of oral EDMs may adversely impact the psychological aspects of sexual function. In our study, physicians misused EDM. We recommend labeling EDMs as restricted medication that requires a prescription to use by a licensed physician.

Erectile Dysfunction: Causes, Diagnosis and Treatment: An Update

Erectile Dysfunction (ED) is defined as "recurrent and persistent inability, partial or complete, to achieve or maintain an erection firm enough for satisfactory sexual intercourse in the presence of proper erotic stimuli"; the concept of ED replaced the previous definition of "impotence" [...].

The Role of the "Anti-Inflammatory" Couple for the Management of Hyperuricemia With Deposition

INTRODUCTION

Gout is the most prevalent inflammatory crystal arthropathy worldwide and is a chronic disease requiring strict, lifelong adherence to drug therapy and healthy lifestyles. Gout has a heavy burden on the patient's sexual health, owing to the associated inflammatory status, long-term complications, and chronic pain; however, the effects of gout also extend to the partner's sexual health.

AIMS

We aimed to investigate how the presence of a partner could influence the complex interaction between risk factors for sexual dysfunctions in gout in order to define novel strategies to improve sexual health and disease management.

METHODS

Clinical and experimental data on the role of the couple in chronic diseases, as well as on the association between gout and sexual health, were searched through Pubmed.

MAIN OUTCOME MEASURES

Evidence from studies describing how the presence of a couple and leveraging sexual health can improve management and clinical outcomes for chronic diseases.

RESULTS

Treatment adherence can improve the sexual health of gout patients and their partners; likewise, by leveraging sexual health, it would be possible to promote better health-seeking behaviors, ultimately improving gout management.

CLINICAL IMPLICATIONS

Promoting awareness of the sexual health relevance of gout can potentially be a pivotal strategy to improve disease management and prevent the progression of sexual dysfunctions from subclinical to overt forms.

STRENGTHS AND LIMITATIONS

Identifying a bidirectional association between sexual health and disease management paves the way for improved disease control and can potentially prevent the development of sexual dysfunctions in couples affected by gout. However, the relevance of the couple has not been adequately addressed in gout management, and most evidence comes from other chronic diseases.

CONCLUSION

Improving gout management results in better sexual health, and vice-versa promoting better sexual health can improve disease control for gout. The presence of a partner improves the behavioral well-being of gout patients, with beneficial effects on both sexual health and gout management. Sansone A, Reisman Y, Meto S, et al. The Role of the "Anti-Inflammatory" Couple for the Management of Hyperuricemia With Deposition. Sex Med 2022;10:100562.

Qualitative and quantitative analysis of doctor-patient interactions during andrological consultations

INTRODUCTION

Although a trustworthy connection between doctor and patient is crucial in clinical practice, it could be hindered by different cultural and linguistic backgrounds. Moreover, an effective doctor-patient interaction could be even more challenging in andrological fields, in which psychological and social components are predominant.

AIM

To analyse the doctor-patient relationship in the andrological field, applying both qualitative and quantitative analyses.

METHODS

monocentric, cross-sectional, observational study was performed between May and December 2018. During the study, all patients aged >18 years attending the Modena Andrology Unit for couple infertility or erectile dysfunction were enrolled and the doctor-patients interaction recorded. Patients were divided into two groups depending on their medical seeking and were further divided between native and non-native speakers of Italian. All patients underwent a routine andrological examination. Every first medical consultation was audio-recorded and transcribed using "ELAN" software for socio-linguistic analysis. Transcriptions underwent qualitative analysis through conversation analysis. Then, quantitative analyses were performed, and interaction parameters underwent correlation analyses.

RESULTS

Twenty-five patients were enrolled. The analysis of the andrological interview allowed to recognize five consecutive phases, following a semi-standardized pattern. Patients without linguistic barriers and with infertility problems showed more autonomous contribution during the consultation. No difference arose in sexual dysfunctions group. Doctor's explanations were frequent, but when linguistic barrier was present or Italian patients seemed less talkative, explanations were shorter, and doctors tried to use other conversational mechanisms to promote understanding. Patient's variables were significantly lower compared to the doctor, considering the number of turns (p = 0.025) and their minimum (p = 0.032), maximum (p<0.001), and average durations (p<0.001). Only patient's latency was significantly higher than the doctor's (p = 0.001).

CONCLUSION

This is the first attempt to analyse the doctor-patient relationship in andrology using authentic audio-recorded consultations. The results confirmed that a patient-centred communication must be applied also in andrological consultations. However, the topics discussed may require more "medical formulation" to be acceptable to the participants in this context. This article is protected by copyright. All rights reserved.

A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine (ESSM)

INTRODUCTION

Although erectile dysfunction (ED) involves an interaction between physiological and psychological pathways, the psychosocial aspects of ED have received considerably less attention so far.

AIM

To review the available evidence on the psychosocial aspects of ED in order to develop a position statement and clinical practice recommendations on behalf of the European Society of Sexual Medicine (ESSM).

METHOD

A comprehensive, narrative review of the literature was performed.

MAIN OUTCOME MEASURES

Specific statements and recommendations according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence criteria were provided.

RESULTS

A multidisciplinary treatment, in which medical treatment is combined with a psychological approach, is preferred over unimodal treatment. There is increasing evidence that psychological treatments of ED can improve medical treatments, the patient's adherence to treatment, and the quality of the sexual relationship. The main components of psychological treatment of ED involve cognitive and behavioral techniques aimed at reducing anxiety, challenging dysfunctional beliefs, increasing sexual stimulation, disrupting sexual avoidance, and increasing intimacy and communication skills in a relational context. When applicable and possible, it is strongly recommended to include the partner in the assessment and treatment of ED and to actively work on interpartner agreement and shared decision-making regarding possible treatment options. To ensure a better integration of the biopsychosocial model into clinical practice, developing concrete treatment protocols and training programs are desirable.

CONCLUSION

Because the psychosocial approach to ED has been underexposed so far, this position statement provides valuable information for clinicians treating ED. Psychological interventions on ED are based on existing theoretical models that are grounded in empirical evidence. However, the quality of available studies is low, which calls for further research. The sexual medicine field would benefit from pursuing more diversity, inclusivity, and integration when setting up treatments and evaluating their effect. Dewitte M, Bettocchi C, Carvalho J, et al. A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine (ESSM). Sex Med 2021;9:100434.

The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine

INTRODUCTION

The "lost penis syndrome" (LPS) is a term often used in non-clinical settings to describe the subjective perception of the loss of cutaneous and proprioceptive feelings of the male organ during vaginal penetration. Although deserving clinical attention, this syndrome did not receive any consideration in the medical literature. Notwithstanding, it represents a relatively unexceptional condition among patients in sexual medicine clinics, and it is often reported together with other sexual dysfunctions, especially delayed ejaculation, anejaculation, male anorgasmia and inability to maintain a full erection.

OBJECTIVES

To draft a new conceptual characterization of the LPS, defined as a lack of penile somesthetic sensations during sexual penetration due to various causes and leading to several sexual consequences in both partners.

METHODS

Based on an extensive literature review and physiological assumptions, the mechanisms contributing to friction during penovaginal intercourse, and their correlation to LPS, have been explored, as well as other nonanatomical factors possibly contributing to the loss of penile sensations.

RESULTS

Efficient penile erection and sensitivity, optimal vaginal lubrication and trophism contribute to penovaginal friction. Whenever one of these processes does not occur, loss of penile sensation defined as LPS can occur. Sociocultural, psychopathological and age-related (ie, couplepause) factors are also implicated in the etiology. Four types of LPS emerged from the literature review: anatomical and/or functional, behavioral, psychopathological and iatrogenic. According to the subtype, a wide variety of treatments can be employed, including PDE5i, testosterone replacement therapy and vaginal cosmetic surgery, as well as targeted therapy for concomitant sexual comorbidity.

CONCLUSION

We held up the mirror on LPS as a clinically existing multifactorial entity and provided medical features and hypotheses contributing to or causing the occurrence of LPS. In the light of a sociocultural and scientific perspective, we proposed a description and categorization of this syndrome hypothesizing its usefulness in daily clinical practice. Colonnello E, Limoncin E, Ciocca G, et al. The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine. Sex Med Rev 2021;XX:XXX-XXX.

The Inferto-Sex Syndrome (ISS): sexual dysfunction in fertility care setting and assisted reproduction

PURPOSE

Infertility represents a peculiar social burden affecting more than 15% of couples, provoking it a real threat to the general quality of life and to the sexual health. The medicalization (diagnosis, therapy and follow up) of the lack of fertility is frequently a challenge in term of personal and couple's involvement. In particular, while the Assisted Reproductive Technology (ART) has allowed many infertile couples to achieve pregnancy, the therapeutic process faced by the couple bears a strong psychological stress that can affect the couple's quality of life, relationship and sexuality. Despite infertility affects both female and male sexual health, only recently the interest in the effects of ART on the couple's sexuality has grown, especially for women.

METHODS

A literature research on the sexual dysfunction in fertility care and particularly in ART setting was performed.

RESULTS

Literature largely found that intimacy and sexuality appear specifically impaired by intrusiveness of treatments and medical prescriptions. Moreover, there is a close relationship between emotional, psychological and sexual aspects, which can be integrated in the new concept of Inferto-Sex Syndrome (ISS) that can impair the ART treatment outcomes. Evidence demonstrates that the assessment of sexual function is necessary in couples undergoing diagnosis of infertility and ART.

CONCLUSION

A close relationship between infertility and sexuality, both in the female and male partners, was detected. ART treatments may heavily impact on the couple's psychosexual health. A couple-centred program for the integrated management of psychological and sexual dysfunction should be considered in the context of ART programs.

Love in the time of COVID-19: a scoping review on male sexual health

The coronavirus disease 2019 (COVID-19) outbreak constitutes an unparalleled socioeconomic burden on the global scale. In critically ill COVID-19 patients, the disease manifests as a state of hyper inflammation causing the 'cytokine storm', which leads to various pulmonary, cardiovascular, and spurious manifestations. One such reported sequelae of COVID-19 is sexual dysfunction in males even after recovery from the disease. Various mechanisms have been proposed regarding the erectile dysfunction a patient suffers after COVID-19. Most important is the hypothesis of endothelial dysregulation, subclinical hypogonadism, psychosocial misery, and pulmonary impairment contributing to erectile dysfunction. Assessment of testicular function and hormonal axis is needed to assess the novel association of COVID-19 with sexual and reproductive health issues in males.

Management of premature ejaculation: a clinical guideline from the Italian Society of Andrology and Sexual Medicine (SIAMS)

Premature ejaculation (PE) is the most prevalent male sexual dysfunction, and the most recently defined. PE is often mistakenly considered a purely psychosexological symptom by patients: the lacking awareness in regards to the pathophysiology and treatments often lead to resignation from the patients' side, making PE the most underdiagnosed sexual complaint. However, an ever-growing body of evidence supporting several organic factors has been developed in the last decades and several definitions have been suggested to encompass all defining features of PE. In the present document by the Italian Society of Andrology and Sexual Medicine (SIAMS), we propose 33 recommendations concerning the definition, pathophysiology, treatment and management of PE aimed to improve patient care. These evidence-based clinical guidelines provide the necessary up-to-date guidance in the context of PE secondary to organic and psychosexological conditions, such as prostate inflammation, endocrine disorders, and other sexual dysfunctions, and suggest how to associate pharmacotherapies and cognitive-behavioral therapy in a couple-centered approach. New therapeutic options, as well as combination and off-label treatments, are also described.

"Mask up to keep it up": Preliminary evidence of the association between erectile dysfunction and COVID-19

Background

Erectile dysfunction (ED), as the hallmark of endothelial dysfunction, could be a short‐ or long‐term complication of COVID‐19. Additionally, being ED a clinical marker and predictor of non‐communicable chronic diseases, particularly cardiovascular, subjects with ED could potentially have a higher risk of contracting COVID‐19.

Objectives

To investigate the prevalence of ED among subjects with a reported diagnosis of COVID‐19 and to measure the association of COVID‐19 and ED.

Materials and methods

We reviewed data from the Sex@COVID online survey (performed between April 7 and May 4, 2020, in Italy) to retrieve a sample of Italian male sexually active subjects with reported SARS‐CoV‐2 infection. A matching sample of COVID‐19‐negative male sexually active subjects was also retrieved using propensity score matching in a 3:1 ratio. The survey used different standardized psychometric tools to measure effects of lockdown and social distancing on the intrapsychic, relational, and sexual health of Italian subjects.

Results

One hundred subjects were included in the analysis (25 COVID‐positive; 75 COVID‐negative). The prevalence of ED, measured with the Sexual Health Inventory for Men, was significantly higher in the COVID+ group (28% vs. 9.33%; p = 0.027). Logistic regression models confirmed a significant effect of COVID‐19 on the development of ED, independently of other variables affecting erectile function, such as psychological status, age, and BMI [OR 5.66, 95% CI: 1.50–24.01]. Likewise, subjects with ED were more likely to have COVID‐19, once corrected for age and BMI [OR 5.27, 95% CI: 1.49–20.09].

Discussion and conclusion

On top of well‐described pathophysiological mechanisms, there is preliminary evidence in a real‐life population of ED as a risk factor of developing COVID‐19 and possibly occurring as a consequence of COVID‐19. Universal vaccination against the COVID‐19 and the personal protective equipment could possibly have the added benefit of preventing sexual dysfunctions.

Redefining a sexual medicine paradigm: subclinical premature ejaculation as a new taxonomic entity

Premature ejaculation (PE) and poor ejaculatory control are multidimensional sexual symptoms estimated to affect almost one-third of men, severely impairing the overall quality of life of patients and their partners. However, patients who do not completely fulfil the definition criteria for PE rarely receive a diagnosis or adequate treatment, with the risk of subsequent progression from initial, subclinical symptoms to clinically overt PE, frequently with other sexual comorbidities. Thus, the current definitions of PE warrant review, in order to consider and propose a new taxonomy encompassing other unaddressed, crucial clinical aspects of PE. These newly proposed criteria include the recommendation for a primary screening for erectile dysfunction (ED), as PE and ED can be comorbid in up to 50% of patients but have never before been considered as a unified clinical entity. In order to facilitate clinical practice and improve clinical management of men with PE and comorbid conditions, we propose and define the new taxonomic clinical entities of subclinical PE (SPE) and loss of control of erection and ejaculation (LCEE). Application of these diagnoses to men who meet the criteria for SPE and/or LCEE, but not the overt conditions, could improve access to treatment for these patients and reduce progression to the more serious clinical disorder.

Addressing male sexual and reproductive health in the wake of COVID-19 outbreak

PURPOSE

The COVID-19 pandemic, caused by the SARS-CoV-2, represents an unprecedented challenge for healthcare. COVID-19 features a state of hyperinflammation resulting in a "cytokine storm", which leads to severe complications, such as the development of micro-thrombosis and disseminated intravascular coagulation (DIC). Despite isolation measures, the number of affected patients is growing daily: as of June 12th, over 7.5 million cases have been confirmed worldwide, with more than 420,000 global deaths. Over 3.5 million patients have recovered from COVID-19; although this number is increasing by the day, great attention should be directed towards the possible long-term outcomes of the disease. Despite being a trivial matter for patients in intensive care units (ICUs), erectile dysfunction (ED) is a likely consequence of COVID-19 for survivors, and considering the high transmissibility of the infection and the higher contagion rates among elderly men, a worrying phenomenon for a large part of affected patients.

METHODS

A literature research on the possible mechanisms involved in the development of ED in COVID-19 survivors was performed.

RESULTS

Endothelial dysfunction, subclinical hypogonadism, psychological distress and impaired pulmonary hemodynamics all contribute to the potential onset of ED. Additionally, COVID-19 might exacerbate cardiovascular conditions; therefore, further increasing the risk of ED. Testicular function in COVID-19 patients requires careful investigation for the unclear association with testosterone deficiency and the possible consequences for reproductive health. Treatment with phosphodiesterase-5 (PDE5) inhibitors might be beneficial for both COVID-19 and ED.

CONCLUSION

COVID-19 survivors might develop sexual and reproductive health issues. Andrological assessment and tailored treatments should be considered in the follow-up.

The Social Aspects of Sexual Health: A Twitter-Based Analysis of Valentine’s Day Perception

Sentiment analysis (SA) is a technique aimed at extracting opinions and sentiments through the analysis of text, often used in healthcare research to understand patients’ needs and interests. Data from social networks, such as Twitter, can provide useful insights on sexual behavior. We aimed to assess the perception of Valentine’s Day by performing SA on tweets we collected between 28 January and 13 February 2019. Analysis was done using ad hoc software. A total of 883,615 unique tweets containing the word “valentine” in their text were collected. Geo-localization was available for 48,918 tweets; most the tweets came from the US (36,889, 75.41%), the UK (2605, 5.33%) and Canada (1661, 3.4%). The number of tweets increased approaching February 14. “Love” was the most recurring word, appearing in 111,981 tweets, followed by “gift” (55,136), “special” (34,518) and “happy” (33,913). Overall, 7318 tweets mentioned “sex”: among these tweets, the most recurring words were “sexy” (2317 tweets), “love” (1394) and “gift” (679); words pertaining to intimacy and sexual activity, such as “lingerie”, “porn”, and “date” were less common. In conclusion, tweets about Valentine’s Day mostly focus on the emotions, or on the material aspect of the celebration, and the sexual aspect of Valentine’s Day is rarely mentioned.

Practical Approaches to Treat ED in PDE5i Nonresponders

Erectile dysfunction (ED) is a common sexual disorder in adult males and one of the most important factors affecting their quality of life and that of their partners. Although PDE5 inhibitors (PDE5is) are the first choice for improving erectile function, there is a substantial proportion of ED patients, termed PDE5i nonresponders, who do not respond to PDE5is. Because of the lack of effective therapies, these patients always have serious social and psychological problems due to ED, which should be addressed. Here, we review the available literature about ED and PDE5is and propose several strategies for mitigating ED in PDE5i nonresponders.

Evaluation of the Mistakes in Self-Diagnosis of Sexual Dysfunctions in 11,000 Male Outpatients: A Real-Life Study in An Andrology Clinic

Purpose: The aim of this study was to compare the initial request for sexual consultation with the final diagnosis and to evaluate the limits of the active andrological anamnesis concerning unclassified male sexual dysfunction. Methods: In this 12-year observational retrospective study, we collected data from patients referring to an andrological outpatient clinic, evaluating the requests, perceptions, needs, and self-diagnosis at their first visit and comparing them with the final diagnosis reached after a complete clinical, laboratory, and instrumental investigation. Results: A total of 11,200 patients were evaluated. The main request of andrological consultation was erectile dysfunction (ED) (52%), followed by premature ejaculation (PE) (28%), and low sexual desire (11.5%). Among the patients seeking help for ED, about 30% were ultimately found to have a different type of dysfunction and 24% were diagnosed with an “unmet need”, which included issues not present in the current nosography nonetheless affecting sexual and relational life. Among the patients referring for PE, the final diagnosis was lifelong PE for the large majority of them, regardless of whether initially they thought to have an acquired form. Several of those who sought consultation for acquired PE were frequently found to be able to compensate for lifelong PE by a subsequent coitus or were able to induce orgasm in the partner with different modalities. Among the patients referring for low sexual desire, only 57.5% were confirmed to have it; 23% had ED and 18.5% showed a raised threshold of penile sensitivity. Conclusions: The results of this study show that the reason for consultation is frequently misleading and raise the relevance of being aware of the so-called “unmet needs” and to discuss with the patient and the couple to explore the sexual history behind the self-diagnosis. These findings also suggest the need to expand the current taxonomy of male sexual dysfunctions.

EDEUS, a Real-Life Study on the Users of Phosphodiesterase Type 5 Inhibitors: Prevalence, Perceptions, and Health Care-Seeking Behavior Among European Men With a Focus on 2nd-Generation Avanafil

INTRODUCTION

Erectile dysfunction (ED) is a multidimensional disorder with an estimated prevalence of 1% to 10% in men younger than 40 years and up to 100% in men in their 70s and 80s.

AIM

To evaluate the real-life characteristics and unmet needs of men with ED, its impact on well-being, and treatment rates across Europe.

METHODS

Adult men in Belgium, France, Germany, Italy, Poland, Portugal, and Spain were invited to participate in the survey. Men who did not use at least a drug for sexual health in the past 3 months, had cancer or spinal cord injuries, and/or underwent non-nerve-sparing radical prostatectomy were excluded.

MAIN OUTCOME MEASURES

The 15-item International Index of Erectile Function (IIEF-15) with study-specific, self-constructed questions was used.

RESULTS

Overall, 940 subjects (age = 46.2 ± 13.4 years) were considered. Subjects (n = 778) using on-demand phosphodiesterase type 5 inhibitors (PDE5is) were designated "performers" (60%) without a formal ED diagnosis or "patients" with a medical diagnosis. Patients were older than performers, with more self-reported comorbidities; patients used a higher PDE5i dosage and purchased it from official pharmacies more often than performers did. Of avanafil users (n = 39), no differences in total IIEF or subdomain scores were observed after adjusting for confounders. However, avanafil users less often declared its use without an ED diagnosis and a physician prescription. Overall, the latter condition was associated with higher PDE5i-related satisfaction.

CONCLUSION

The survey shows 2 different attitudes toward ED and PDE5i use: for recreational use and without a medical prescription or with a formal diagnosis and medical prescription. Avanafil, a 2nd-generation PDE5i with a good balance between efficacy and tolerability profile, is more frequently prescribed by doctors than self-prescribed compared with other PDE5is. Because the major challenge is to decrease the high dropout of 1st-generation PDE5is, further studies will be needed to clarify this topic. Corona G, Maggi M, Jannini EA. EDEUS, a Real-Life Study on the Users of Phosphodiesterase Type 5 Inhibitors: Prevalence, Perceptions, and Health Care-Seeking Behavior Among European Men With a Focus on 2nd-Generation Avanafil. Sex Med 2018;6:15-23.

Health-related characteristics and unmet needs of men with erectile dysfunction: a survey in five European countries

INTRODUCTION

Data suggest that ED is still an underdiagnosed and undertreated condition. In addition, it seems that men with ED are unsatisfied about their relationship with their physician and with the available drugs.

AIM

The study aims to identify health-related characteristics and unmet needs of patients suffering from erectile dysfunction (ED) in big 5 European Union (EU) nations (France, Germany, Italy, Spain, and UK).

METHODS

Data were collected from the 2011 5EU National Health and Wellness-Survey on a population of 28,511 adult men (mean age: 47.18; SD 16.07) and was focused on men (5,184) who self-reported ED in the past 6 months. In addition, the quality of life (QoL) and work productivity/activity were explored.

MAIN OUTCOME MEASURES

Health-related QoL (HRQoL) and work productivity were measured with SF-12v2 and WPAI validated psychometric tools.

RESULTS

One in every 20 young men (age 18-39) across 5EU experienced ED in the past 6 months. About half of men (2,702/5,184; [52%]) with ED across all ages did not discuss their condition with their physician. Interestingly, among those men who did discuss their condition with their physician, 68% (1,668/2,465) do not currently use medication. These findings were more evident in the age group of 18-39 years. Only 48% (2,465/5,184) had a closer relationship with their physician, suggesting that this quality of relationship may be unsatisfactory. Compared with controls, ED patients have a significantly higher intrapsychic and relational psychopathological comorbid burden and relevant decreasing in HRQoL, with a significantly higher impairment on work productivity/activity.

CONCLUSION

Data suggest that there is a need for a new therapeutic paradigm in ED treatment which images the achievement of a new alliance between physician and patient. Hence, alternative drug delivery strategies may reduce the psychological and social impact of this disease.

A pilot study to evaluate the effects of vardenafil on sexual distress in men with obesity

There are no interventional studies on the impact of sexual distress (SD) in men with obesity. We investigated the effects of vardenafil (VAR) on SD in middle-aged (mean age 49 ± 8), healthy, obese men in the absence of premature ejaculation, ED or hypogonadism. After a 4-week run-in period, 20 men with high body mass index (BMI=40 ± 8) and SD at the Sexual Distress Esteem Questionnaire-Male (mean score 65 ± 20 AU) were randomized to receive either VAR 10 mg on demand (N=10) or matched-placebo (PLB, N=10). Primary endpoints were variations from baseline in the intravaginal ejaculatory latency time (IELT) measured by the stopwatch technique; secondary endpoints were variations from baseline in Self-Esteem and Relationship (SEAR) and Male Sexual Health Questionnaire-Ejaculatory domain (MSHQ-EjD) scores. VAR significantly improved IELT (P<0.0001), as well as SEAR (P<0.001) and MSHQ-EjD (P<0.005) scores, whereas no changes were observed after PLB. Interestingly, an inverse relationship between BMI and IELT was found in all the men studied (r(2)=0.37, P<0.001). SD in healthy obese men seems to be correlated mainly with inadequate ejaculatory control, especially in men with higher BMI. Our preliminary results suggest that treatment with VAR may improve ejaculatory control, thus ameliorating self-esteem and sexual performance in men with obesity.

Organic vs. psychogenic? The Manichean diagnosis in sexual medicine

INTRODUCTION

The Manichean diagnosis, psychogenic or organic, is the first and most frequent diagnostic scope managing sexual disorders. The aim of this Controversy is to discuss if this philosophy is still useful both in the conceptual and clinical perspective.

METHODS

Five scientists (an endocrinologist, two psychologist, and two urologists) with expertise in the area of psychosexology and sexual medicine were asked to contribute with their opinions.

MAIN OUTCOME MEASURE

Expert opinion supported by the critical review of the currently available literature.

RESULT

Expert # 1, who is Controversy's section Editor, suggests that the term psychogenic is redundant, because all sexual dysfunctions involve the mind and the relationship with (at least) one partner. Furthermore, he is strongly against the exclusion diagnosis, in agreement with the Expert # 5. The idea that the psychogenic etiology is always present is also sustained with good arguments by the Expert # 2. On the other hand, the two Experts # 3 and 4 argue that a pharmacological treatment such as type 5 phosphodiesterase inhibitors or dapoxetine work in both organic and psychogenic conditions and that the attempt to perform a diagnostic effort is frequently useless. Last but not least, the Expert # 5 concludes that the mind-body dualism is to be considered obsolete and unhelpful in a modern approach to the patient with a sexual dysfunction.

CONCLUSIONS

The reader of the Journal will judge if there is still a room for the Manichean diagnosis of different sexual dysfunctions or if it is time to completely change our perspective on this essential aspect of clinical sexual medicine.

The Role of Penile Color-Duplex Ultrasound for the Evaluation of Erectile Dysfunction

INTRODUCTION

In the era of orally active agents, dynamic penile color-duplex ultrasound (D-PCDU) is not considered a necessary first screening for all patients with erectile dysfunction (ED). Various parameters, such as peak systolic flow velocity, end diastolic velocity, resistance index, acceleration time, and degree of arterial dilatation, have been suggested for the diagnosis of vascular ED by D-PCDU.

AIM

To highlight the clinical utility and evidence-based interpretation of D-PCDU criteria.

METHODS

Extensive, unsystematic PubMed literature search reviewing relevant data on D-PCDU in the evaluation of male ED.

RESULTS

The advantage of ultrasound is the minimally invasive nature of the procedure and the ability to screen patients to identify a normal arterial response of cavernous arteries. Men with sexual dysfunctions above 55 years of age and comorbidities are more likely to have multi-organ vascular dysfunction and may necessitate further testing because erectile failure may be the first presenting symptom requiring investigation and treatment even in the absence of cardiovascular risk factors. All patients affected with Peyronie's disease and younger men with persistent ED, a history of pelvic traumas, or fractures of the penile shaft should be offered ultrasonographic penile blood flow studies before referral to surgery or more invasive vascular investigations.

CONCLUSIONS

In the near future, D-PCDU may be used in preference to patients presenting with or without vascular risk factors, particularly those not responding to first-line orally active drugs and seeking an explanation as to why these agents failed.