Injection anxiety and pain in men using intracavernosal injection therapy after radical pelvic surgery

Transpelvic Magnetic Stimulation Enhances Penile Microvascular Perfusion in a Rat Model: A Novel Interventional Strategy to Prevent Penile Fibrosis after Cavernosal Nerve Injury

PURPOSE

Penile microvascular dysfunction is a known contributor to erectile dysfunction (ED) and penile fibrosis has been shown to impair microvascular perfusion (MVP). Our objectives were to: (i) determine beneficial effects of TPMS to modulate penile MVP, (ii) determine its mechanism, (iii) evaluate impact of cavernosal nerve injury (CNI) on penile MVP, and (iv) determine time-course of cavernosal tissue elastin changes after CNI in rats.

MATERIALS AND METHODS

Adult male rats (n=5) were anesthetized and subjected to TPMS (13%, 15%, and 17%) and MVP changes were recorded using laser speckle contrast imaging (LSCI). Another group of male rats were subjected to either bilateral cavernosal nerve injury (CNI; n=7) or sham surgery (n=7). After recovery, animals were monitored for MVP using LSCI before and after TPMS. Rat penile tissues were harvested and analyzed for fibrosis using a marker for elastin.

RESULTS

Rat TPMS resulted in a stimulus dependent increase in MVP; maximal perfusion was observed at 17%. L-N(G)-Nitroarginine methyl ester (L-NAME) resulted in a marked decrease in TPMS induced MVP increase (393.33 AU vs. 210.67 AU). CNI resulted in 40% to 50% decrease in MVP. CNI produced a remarkable increase in elastin deposits that are noticeable throughout the cavernosal tissues post injury.

CONCLUSIONS

TPMS is a novel and non-invasive intervention to improve penile MVP after CNI. Potential application includes treatment of ED and sexual function preservation following cancer treatment, possibly through improved penile hemodynamics that might help prevent penile hypoxia and fibrosis.

Pre- and Post-Injection Needle Pain in Patients Undergoing First Intracavernosal Injection

BACKGROUND

Intracavernosal injections (ICI) are a well-established treatment option for men with erectile dysfunction (ED); however, the anticipation of pain with injection remains a significant barrier to the use of ICI.

AIM

To evaluate the patient-anticipated degree of pain versus the experienced degree of pain pre- and post-ICI in men undergoing their first injection with an erectile agent.

METHODS

We studied 51 patients who underwent their first ICI in our men's health clinic. Anticipated needle-associated pain was judged with a pre-injection score, and pain experienced during the injection was judged with a post-injection score. All patients graded their pre- and post-ICI pain using a standard 10-point scale (0-10).

OUTCOMES

Pre- and post-ICI pain was defined with the visual analogue scale (0-10) in men undergoing their first penile injection.

RESULTS

Medians and interquartile ranges (IQRs) of the patients' age [65 years (54.5-68.0)], pre-injection pain [5 (4-7)], and post-injection pain [1 (1-2)] were recorded. Most men in the study had erectile dysfunction (68.6%) and/or Peyronie's Disease (64.7%). The average pre-injection prediction pain score was 5.45 ± 2.15; the average post-injection perceived pain score was 1.20 ± 0.73. Thus, there was an average discrepancy of over 4 points in predicted pain vs perceived pain. A paired t-test was performed which showed a statistically significant difference between pre- and post-injection scores (P < .05). A Wilcoxson Signed Rank Test showed statistical significance in the difference between pre- and post-injection pain scores (P < .05).

CLINICAL IMPLICATIONS

ICI is a safe, effective treatment for patients with ED and is associated with significantly less pain than is anticipated by patients.

STRENGTHS & LIMITATIONS

This is the first report to describe the discrepancy between pre-ICI anticipated pain and post-ICI experienced pain. Limitations include an overall small sample size.

CONCLUSION

Patients experience significantly less pain with ICI than they anticipate having. This represents an important factor to consider when counseling patients about available ED treatments. Baird B, Wajswol E, Ericson C et al. Pre- and Post-Injection Needle Pain in Patients Undergoing First Intracavernosal Injection. J Sex Med 2022;19:590-593.

Meditation Monologue can Reduce Clinical Injection-Related Anxiety: Randomized Controlled Trial

Background.

Strategies to reduce anxiety prior to injection procedures are not well understood. The purpose is to determine the effect of a meditation monologue intervention delivered via phone/mobile application on pre-injection anxiety levels among patients undergoing a clinical injection. The following hypothesis was tested: patients who listened to a meditation monologue via phone/mobile application prior to clinical injection would experience less anxiety compared to those who did not.

Methods.

A prospective, randomized controlled trial was performed at an orthopedics and sports medicine clinic of a tertiary level medical center in the New England region, USA. Thirty patients scheduled for intra- or peri-articular injections were randomly allocated to intervention (meditation monologue) or placebo (nature sounds) group. Main outcome variables were state and trait anxiety inventory (STAI) scores and blood pressure (BP), heart rate, and respiratory rate.

Results.

There were 16 participants who were allocated to intervention (meditation monologue) while 14 participants were assigned to placebo (nature sounds). There was no interaction effect. However, a main time effect was found. Both state anxiety (STAI-S) and trait anxiety (STAI-T) scores were significantly reduced post-intervention compared to pre-intervention (STAI-S: p = 0.04, STAI-T: p = 0.04). Also, a statistically significant main group effect was detected. The pre- and post- STAI-S score reduction was greater in the intervention group (p = 0.028). Also, a significant diastolic BP increase between pre- and post-intervention was recorded in the intervention group (p = 0.028), but not in the placebo group (p = 0.999).

Conclusion.

Listening to a meditation monologue via phone/mobile application prior to clinical injection can reduce anxiety in adult patients receiving intra- and peri-articular injections. Registration:ClinicalTrials.gov NCT02690194

Prostatic irradiation-induced sexual dysfunction: A review and multidisciplinary guide to management in the radical radiotherapy era (Part II on Urological Management)

Prostate cancer is the most common malignancy in men and the second leading cause of cancer-related death in men. Radiotherapy is a curative option that is administered via external beam radiation, brachytherapy, or in combination. Sexual dysfunction is a common toxicity following radiotherapy, similar to men undergoing radical prostatectomy, but the etiology is different. The pathophysiology of radiation-induced sexual dysfunction is multi-factorial, and the toxicity is a major cause of impaired quality of life among long-term prostate cancer survivors. Management of a patient's sexual function during and after radiotherapy requires multidisciplinary coordination of care between radiation oncology, urology, psychiatry, pharmacy, and dermatology. This review provides a framework for clinicians to better understand prostatic radiotherapy-induced sexual dysfunction diagnosis, evaluation, and a patient-centered approach to toxicity preventive strategies and management.

Current approaches to the diagnosis of vascular erectile dysfunction

Vascular erectile dysfunction (ED) is closely related to cardiovascular events, and early diagnosis of vascular ED may be helpful to predict the occurrence of cardiovascular events and improve prognosis. At present, there are many approaches to diagnose ED, but each method has its advantages and limitations. This study retrospectively reviewed all available literature focusing on the diagnosis of vascular ED through a systematic PubMed and EMBASE search. According to the different application scenarios, the main methods for the diagnosis of vascular ED are divided into four categories. Intra-cavernous injection of vasoactive drugs is the earliest method used in the diagnosis of vascular ED and is a basic test. For the diagnosis of arterial ED, color duplex Doppler ultrasound, selective penile angiography, magnetic resonance imaging, and computed tomography are more commonly used. While for the diagnosis of venous ED, shear wave elastography, dynamic infusion cavernosometry and cavernosography are more accurate. Endo-peripheral arterial tonometry (PAT) has also been used to detect vascular endothelial function. Although various existing examinations are widely used for the evaluation of vascular ED, they still have some shortcomings, such as invasiveness, contingency, high false positive (negative) rate. New methods of long-term dynamic detection are needed.

Novel Emerging Therapies for Erectile Dysfunction

Currently, several treatments exist for the improvement of erectile dysfunction (ED). These include medical therapies such as phosphodiesterase type 5 inhibitors (PDE5-Is), invasive methods such as intracavernosal injection therapy of vaso-active substances, vacuum erection devices, and penile prosthesis implants. However, the percentage of patients that are unresponsive to available treatments and who drop out from treatments remains high. Current evidence reveals that the pathogenesis of ED is related to multiple factors including underlying comorbidities, previous surgery, and psychological factors. Diverse approaches using novel molecular pathways or new technologies have been tested as potential therapeutic options for difficultto-treat ED populations. Melanocortin receptor agonist, a centrally acting agent, showed promising results by initiating erection without sexual stimulation in non-responders to PDE5-Is. Recent clinical and pre-clinical studies using human tissues suggested that new peripherally acting agents including the Max-K channel activator, guanylate cyclase activator, and nitric oxide donor could be potential therapies either as a monotherapy or in combination with PDE5-Is in ED patients. According to several clinical trials, regeneration therapy using stem cells showed favorable data in men with diabetic or post-prostatectomy ED. Low-intensity shock wave therapy also demonstrated promising results in patients with vasculogenic ED. There are growing evidences which suggest the efficacy of these emerging therapies, though most of the therapies still need to be validated by well-designed clinical trials. It is expected that, should their long-term safety and efficacy be proven, the emerging treatments can meet the needs of patients hitherto unresponsive to or unsatisfied by current therapies for ED.

Acceptance and Commitment Therapy to Increase Adherence to Penile Injection Therapy-Based Rehabilitation After Radical Prostatectomy: Pilot Randomized Controlled Trial

INTRODUCTION

Despite the importance of using penile injections as part of a penile rehabilitation program, men have difficulty complying with these programs.

AIM

To test a novel psychological intervention based on Acceptance and Commitment Therapy for erectile dysfunction (ACT-ED) to help men utilize penile injections.

METHODS

This pilot randomized controlled trial (RCT) recruited men who were beginning a standard care (SC) structured penile rehabilitation program following radical prostatectomy. The SC program instructed patients to use penile injections 2 to 3 times per week. Participants were randomized to SC+ACT-ED or SC+enhanced monitoring (EM). Over 4 months, patients in the SC+ACT-ED group received SC plus 4 ACT sessions and 3 ACT phone calls; those in the EM group received SC plus 7 phone calls from an experienced sexual medicine nurse practitioner. Participants were assessed at study entry and at 4 and 8 months. For this pilot study, the goal was to determine initial efficacy (ie, effect sizes, where d = 0.2 is small, d = 0.5 is medium, and d = 0.8 is large).

MAIN OUTCOME MEASURE

Primary outcomes were feasibility and use of penile injections. Secondary outcomes were ED treatment satisfaction (ie, Erectile Dysfunction Inventory of Treatment Satisfaction, or EDITS), sexual Self-Esteem and Relationship (SEAR) quality, sexual bother (SB), and prostate cancer treatment regret.

RESULTS

The 53 participants were randomized (ACT, n = 26; EM, n = 27). The study acceptance rate was 61%. At 4 months, the ACT-ED group utilized more penile injections per week (1.7) compared to the EM group (0.9) (d = 1.25; P = .001) and was more adherent to penile rehabilitation compared to the EM group (ACT, 44%; EM, 10%; relative risk [RR], 4.4; P = .02). These gains were maintained at 8 months for injections per week (ACT, 1.2; EM, 0.7; d = 1.08; P = .03) and approached significance for adherence (ACT, 18%; EM, 0%; P = .10). At 4 months, ACT-ED, compared to EM, reported moderate effects for greater satisfaction with ED treatment (d = 0.41; P = .22), greater sexual self-esteem (d = 0.54; P = .07) and sexual confidence (d = 0.48; P = .07), lower sexual bother (d = 0.43; P = .17), and lower prostate cancer treatment regret (d = 0.74; P = .02). At 8 months, moderate effects in favor of ACT-ED were maintained for greater sexual self-esteem (d = 0.40; P = .19) and less treatment regret (d = 0.47; P = .16).

CLINICAL IMPLICATIONS

ACT concepts may help men utilize penile injections and cope with the effects of ED.

STRENGTHS AND LIMITATIONS

Strengths include use of an innovative intervention utilizing ACT concepts and pilot RCT. Limitations include the pilot nature of the study (eg, small samples size, lack of statistical power).

CONCLUSION

ACT-ED is feasible and significantly increases the use of penile injections. ACT-ED also shows promise (moderate effects) for increasing satisfaction with penile injections and sexual self-esteem while decreasing sexual bother and prostate cancer treatment regret. Nelson CJ, Saracino RM, Napolitano S, et al. Acceptance and Commitment Therapy to Increase Adherence to Penile Injection Therapy-Based Rehabilitation After Radical Prostatectomy: Pilot Randomized Controlled Trial. J Sex Med 2019; 19:1398-1408.

Recent advances in the understanding and management of erectile dysfunction

Erectile dysfunction (ED) is important to a man’s well-being and health, since it not only affects the individual but also causes strain on a couple’s lifestyle and relationship. There are multiple non-invasive treatments that exist for ED including lifestyle changes, oral medications (phosphodiesterase type 5 inhibitors), vacuum-assisted erectile devices, and intraurethral suppositories. While lifestyle changes and oral medications are typically first-line treatments for ED, more-invasive treatments including intracavernosal injections and surgically implanted prosthetic devices may be required for the management of complex cases. Additionally, novel therapies are currently being developed, and future treatment options may include shock-wave therapy, external prosthetic devices, and injection of stem cells or platelet-rich plasma. The current manuscript seeks to highlight advances in management and may eventually alter the treatment paradigm to allow more-inclusive care pathways.

[Sexual consequences after treatment of prostate cancer: Inquiry among members of the Association Nationale des Malades du Cancer de la Prostate]

INTRODUCTION

Complications of prostate cancer treatments are responsible of a lower quality of life. We evaluated the prevalence and the perceptions of sexual consequences of prostate cancer treatments.

MATERIALS AND METHODS

A retrospective self-administered questionnaire was sent to all the members of the Association Nationale des Malades du Cancer de la Prostate (ANAMACAP). All the answers were analyzed.

RESULTS

226 questionnaires were analyzed, the average age was 67.3 years old, the average follow-up was 58.1 months. 110 patients had surgery only, 29 had hormone therapy plus radiotherapy, 28 had radiation therapy only and 49 had combined treatments. After the treatment of the prostate cancer, an erectile dysfunction was reported by 75.2% of the patients; an orgasmic dysfunction by 69%; a climacturia by 21%; a reduced penile length by 70% of them and a less sensitive glans by 59%. They were responsible of a lower quality of life for 75% to 90% of the patients depending on the symptom. A PDE5-inhibitor treatment was effective for only 25.6% of them when taken daily and for 39% on demand.

CONCLUSION

Functional consequences of prostate cancer treatments are common, diverse and directly involved in the sexual life. It is necessary to improve therapeutical education and onco-sexology with the help of patients' associations, to build a new balance in the couples.

LEVEL OF EVIDENCE

3.

Erectile dysfunction

Erectile dysfunction is a multidimensional but common male sexual dysfunction that involves an alteration in any of the components of the erectile response, including organic, relational and psychological. Roles for nonendocrine (neurogenic, vasculogenic and iatrogenic) and endocrine pathways have been proposed. Owing to its strong association with metabolic syndrome and cardiovascular disease, cardiac assessment may be warranted in men with symptoms of erectile dysfunction. Minimally invasive interventions to relieve the symptoms of erectile dysfunction include lifestyle modifications, oral drugs, injected vasodilator agents and vacuum erection devices. Surgical therapies are reserved for the subset of patients who have contraindications to these nonsurgical interventions, those who experience adverse effects from (or are refractory to) medical therapy and those who also have penile fibrosis or penile vascular insufficiency. Erectile dysfunction can have deleterious effects on a man's quality of life; most patients have symptoms of depression and anxiety related to sexual performance. These symptoms, in turn, affect his partner's sexual experience and the couple's quality of life. This Primer highlights numerous aspects of erectile dysfunction, summarizes new treatment targets and ongoing preclinical studies that evaluate new pharmacotherapies, and covers the topic of regenerative medicine, which represents the future of sexual medicine.

Pharmacologic and surgical therapies for sexual dysfunction in male cancer survivors

The recent recognition that many men experience sexual dysfunction following their diagnosis and treatment of genitourinary cancers, has led to the development multiple varied strategies that attempt to restore or preserve that function. In this manuscript we review the understanding of why it happens, highlight novel management strategies and discuss the concept of penile rehabilitation (PR) following prostate cancer (PCa) treatment, glans preserving strategies among men diagnosed with penile cancer and address the controversial issue of testosterone therapy in men with PCa.

Men's experience with penile rehabilitation following radical prostatectomy: a qualitative study with the goal of informing a therapeutic intervention

BACKGROUND

Erectile rehabilitation (ER) following radical prostatectomy (RP) is considered an essential component to help men regain erectile functioning; however, many men have difficulty adhering to this type of program. This qualitative study explored men's experience with ER, erectile dysfunction (ED), and ED treatments to inform a psychological intervention designed to help men adhere to ER post-RP.

METHODS

Thirty men, 1-to-3-years post-RP, who took part in an ER program, participated in one of four focus groups. Thematic analysis was used to identify the primary themes.

RESULTS

Average age was 59 years (standard deviation = 7); mean time since surgery was 26 months (standard deviation = 6). Six primary themes emerged: (1) frustration with the lack of information about postsurgery ED; (2) negative emotional impact of ED and avoidance of sexual situations; (3) negative emotional experience with penile injections and barriers leading to avoidance; (4) the benefit of focusing on the long-term advantage of ER versus short-term anxiety; (5) using humor to help cope; and (6) the benefit of support from partners and peers.

CONCLUSIONS

Men's frustration surrounding ED can lead to avoidance of sexual situations and ED treatments, which negatively impact men's adherence to an ER program. The theoretical construct of acceptance and commitment therapy was used to place the themes into a framework to conceptualize the mechanisms underlying both avoidance and adherence in this population. As such, acceptance and commitment therapy has the potential to serve as a conceptual underpinning of a psychological intervention to help men reduce avoidance to penile injections and adhere to an ER program.