Which Is First? The Controversial Issue of Precedence in the Treatment of Male Sexual Dysfunctions

From Waterloo to the Great Wall: A retrospective, multicenter study on the clinical practice and cultural attitudes in the management of premature ejaculation, in China

Premature ejaculation (PE), despite its wide prevalence, is largely underdiagnosed and undertreated. Being a multifactorial dysfunction with strong cultural characteristics, PE requires skillful attitudes in the psychosexological support, necessary to manage the patient's and the couple's expectations, as well as in the medical treatment. Dapoxetine is a short-acting selective serotonin reuptake inhibitor approved for use in lifelong and acquired PE in a number of countries. Opinions, not always generated by the evidence-based medicine, impacted the attitudes of Western andrologists, as a nocebo effect which produced a drug's Waterloo, characterized by low prescription rates much more built on the patients' and doctors' expectations than on costs, side effects, and efficacy. In the present study, we retrospectively reviewed real-life data from eight Andrology and Sexual Medicine Public Centers in China to assess the prevalence of PE among attending patients, its association with erectile dysfunction, its subtype, and the proposed treatments. In 2019, among 156,486 patients coming to the centers, 32,667 visits having PE as the chief complaint were performed (20.9%). Almost all patients received treatment prescriptions (32,641 patients, 99.92%); 23,273 patients came back for a follow-up visit in the subsequent 12 months (71.2% of those who initially received treatment). Dapoxetine, either alone or in combination with another therapy, was the most prevalent treatment, prescribed to 22,767 patients (69.7% of treated patients), followed by traditional Chinese medicine (TCM) (39.4%). At follow-up, 8174 patients were unsatisfied with treatment, and a new treatment was proposed (35.12%). Dapoxetine was the best treatment, with an overall 27.1% switching rate when used either alone or in combination: Although the switching rate for Dapoxetine alone was 44.2%, the association of the same drug with psychotherapy resulted in much lower rates (19.5%) and reached a minimum of 12% when also combined with TCM demonstrating how cultural aspects and medical attitudes may dramatically impact on the therapy of a multifaceted, complex, and culture-grounded sexual symptom such as PE. In conclusion, taking switching rates as surrogate markers of treatment failure, this real-life study-the largest in the field-shows that in a more patient-oriented (as in Chinese medical culture), and less symptom-oriented (as in Western medical attitudes), Dapoxetine is a successful treatment for PE patients, with higher reliability when used alone or as part of combined and integrated therapies.

Comparing Western and traditional Chinese medicine for male sexual dysfunction: can Klotho represent a silk road?

Traditional Chinese medicine (TCM) and Western Medicine both have shown efficacy in treating male sexual dysfunction (MSD). The aim of this perspective paper is to discuss a possible link between Western medicine and TCM in the MSD field as represented by the entity of Klotho. Klotho is a recently discovered protein, mainly expressed in the kidney, encoded by the anti-aging gene klotho. Not only is Klotho significantly correlated with the development and progression of kidney diseases and their complications, but increasing evidence indicates that it is also closely related to MSD. A comprehensive search within PubMed database was performed to retrieve available evidence on Klotho's roles, particularly in kidney and in MSD. Indeed, in the TCM theory, the concept of the "kidney" is entirely different from the Western medicine: it is closely related to metabolism and to the reproductive, nervous, endocrine systems, being more than just a urinary organ. According to the "Kidney storing essence (jīng) and governing reproduction" (KSEGR) theory, a cornerstone in TCM, the treatment of MSD mainly consists of restoring the kidney's function. Signs of decreasing kidney essence show a consistent similarity to deficiencies of Klotho, also for what regards the male sexual function. Based on the current evidence, Klotho may represent a potential biological indicator for sexual desire and sexual function and a kind of new scientific Silk Road between TCM and Western medicine for MSD; nevertheless, there is a need to conduct further high-quality research to prove this hypothesis.

Erection Hardness Score in Masturbation Can Serve as a Preliminary Screening Tool for Organic Erectile Dysfunction

OBJECTIVE

To explore the efficacy, in terms of sensitivity and specificity, of Erection Hardness Score (EHS) applied to masturbation in diagnosing predominantly organic erectile dysfunction (ED), compared to the actual standard, which is nocturnal penile tumescence and rigidity (NPTR).

MATERIALS AND METHODS

A total of 189 consecutive patients who came to our outpatient clinic from October 2019 to October 2020, reporting ED and an abridged International Index of Erectile Function (IIEF-6) score <26 were enrolled. Patients filled out two psychometric questionnaires: the IIEF-6 applied to partnered intercourse and the EHS applied to masturbation, then they underwent the NPTR test with Rigiscan for 2 consecutive nights in good sleep condition. Sensitivity, specificity, positive predictive value, and negative predictive value of EHS and IIEF-6 scales with NPTR as the standard, as well as the correlation between EHS, IIEF-6, and NPTR results were calculated.

RESULTS

Results show that the sensitivity of the EHS scale for the diagnosis of ED was 60.0%, the specificity was 95.7%, the positive predictive value was 83.3%, the negative predictive value was 86.9%, and the coincidence rate was 86.2%. The correlation coefficient was 0.572 and the area under the ROC curve was 0.78, which means the strength of erection in masturbation as evaluated by the EHS can effectively help in discriminating between predominantly organic and apparently nonorganic ED.

CONCLUSION

An EHS score of 3-4, meaning good-optimal erectile function during masturbation, decreases the likelihood of predominantly organic ED and reduces the need for further NPTR testing.

Do pornography use and masturbation play a role in erectile dysfunction and relationship satisfaction in men?

Both masturbation frequency and pornography use during masturbation have been hypothesized to interfere with sexual response during partnered sex as well as overall relationship satisfaction. However, results from prior studies have been inconsistent and frequently based on case studies, clinical reports, and simple binary analyses. The current study investigated the relationships among masturbation frequency, pornography use, and erectile functioning and dysfunction in 3586 men (mean age = 40.8 yrs, SE = 0.22) within a multivariate context that assessed sexual dysfunctions using standardized instruments and that included other covariates known to affect erectile functioning. Results indicated that frequency of pornography use was unrelated to either erectile functioning or erectile dysfunction (ED) severity in samples that included ED men with and without various sexual comorbidities or in a subset of men 30 years or younger (p = 0.28-0.79). Masturbation frequency was also only weakly and inconsistently related to erectile functioning or ED severity in the multivariate analyses (p = 0.11-0.39). In contrast, variables long known to affect erectile response emerged as the most consistent and salient predictors of erectile functioning and/or ED severity, including age (p < 0.001), having anxiety/depression (p < 0.001 except for a subset of men ≤ 30 years), having a chronic medical condition known to affect erectile functioning (p < 0.001 except for a subset of men ≤ 30 years), low sexual interest (p < 0.001), and low relationship satisfaction (p ≤ 0.04). Regarding sexual and relationship satisfaction, poorer erectile functioning (p < 0.001), lower sexual interest (p < 0.001), anxiety/depression (p < 0.001), and higher frequency of masturbation (p < 0.001) were associated with lower sexual and lower overall relationship satisfaction. In contrast, frequency of pornography use did not predict either sexual or relationship satisfaction (p ≥ 0.748). Findings of this study reiterate the relevance of long-known risk factors for understanding diminished erectile functioning while concomitantly indicating that masturbation frequency and pornography use show weak or no association with erectile functioning, ED severity, and relationship satisfaction. At the same time, although verification is needed, we do not dismiss the idea that heavy reliance on pornography use coupled with a high frequency of masturbation may represent a risk factor for diminished sexual performance during partnered sex and/or relationship satisfaction in subsets of particularly vulnerable men (e.g., younger, less experienced).

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.

Diabetes and erectile dysfunction: The relationships with health literacy, treatment adherence, unrealistic optimism, and glycaemic control

PURPOSE

The aim of this study was to evaluate the relationships between health literacy, unrealistic optimism, and adherence to glycometabolic disease management related to erectile dysfunction (ED) in male patients with type 2 diabetes (T2D) or preDM.

MATERIALS AND METHODS

This prospective observational study enroled 167 consecutive patients with T2D and ED. All patients underwent the following examinations: (a) medical history collection; (b) Body Mass Index (BMI) determination; (c) hormonal and biochemical assessment; (d) duration of T2D, complications and treatment; (e) International Index of Erectile Function-5 questionnaire to assess ED; and (f) validated questionnaire to evaluate health literacy, unrealistic optimism, and treatment adherence.

RESULTS

Overall, mean age was 62.5 ± 9.4 years (range: 20-75) and mean BMI was 28.4 ± 4.8 kg/m² (range: 18.4-46.6). The mean IIEF-5 score was 15.4 ± 5.2 (range: 5-25). The majority of patients showed high health literacy. However, low health literacy was found in patients with higher IIEF-5 scores and high BMI. Unrealistic optimism was low in most patients. Higher adherence to treatment was found in patients who reported regular physical activity, who followed a diet, and in patients with a family history of T2D. Regarding anti-diabetic treatment, patients treated with insulin showed higher health literacy than patients not treated with other medications, whereas higher adherence was found in patients using SGLT2-i.

CONCLUSIONS

This study highlighted the close relationship between metabolic compensation, BMI, ED, and psychological attitudes, including health literacy and unrealistic optimism.

Erectile dysfunction and premature ejaculation: a continuum movens supporting couple sexual dysfunction

PURPOSE

The specific underlying mechanisms supporting the association between erectile dysfunction (ED) and premature ejaculation (PE) are still not completely clarified. To summarize and discuss all available data supporting the relationship between PE and ED.

METHODS

A comprehensive narrative review was performed. In addition, to better clarify the specific factors underlining ED and PE, a meta-analytic approach of the selected evidence was also performed. In particular, the meta-analytic method was selected in order to minimize possible sources of bias derived from a personal interpretation of the data.

RESULTS

Current data confirm the close association between ED and PE and the bidirectional nature of their relationship. In particular, PE was associated with a fourfold increased risk of ED independently of the definition used. In addition, the risk increased in older patients and in those with lower education, and it was associated with higher anxiety and depressive symptoms. Conversely, ED-related PE was characterized by lower associations with organic parameters such as diabetes mellitus, arterial hypertension, dyslipidemia and with smoking habit. Finally, when ED was defined according to the International Index of Erectile Function questionnaire, the presence of a stable relationship increased the risk.

CONCLUSIONS

ED and PE should be considered in a dimensional prospective way considering the possibility that both clinical entities can overlap and influence each. Correctly recognizing the underlying factors and sexual complaint can help the clinician in deciding the more appropriate diagnostic and therapeutic work-up.

Does Bother/Distress Contribute to the Diagnosis of Premature Ejaculation?

Introduction

The role of bother/distress in the diagnosis of premature ejaculation (PE) has received minimal investigation compared with the 2 other diagnostic criteria, ejaculatory control and ejaculatory latency (EL).

Aim

This study assessed (i) the added variance explained by bother/distress to the diagnostic accuracy of PE and (ii) determined its overall contribution to a PE diagnosis.

Methods

The 3 diagnostic criteria for PE were assessed in 2,589 men (mean age = 38.2 years, SD = 13.5) in order to determine the contribution of each factor to a dysfunctional diagnosis. A series of regression and discriminant analyses were used to assess the value of bother/distress in explaining ejaculatory control and in predicting accuracy of PE group status. Commonality analysis was used to determine the relative contribution of each of these factors to the diagnosis of PE.

Main Outcome Measure

The major outcome was the quantified contribution of “bother/distress” to a PE diagnosis.

Results

Bother/distress accounted for about 3–4% of the variation in ejaculatory control and added only minimally to the prediction accuracy of PE group status (no, probable, definite PE). Commonality analysis indicated that bother/distress comprised about 3.6% of the unique explained variation in the PE diagnosis, compared with ejaculatory control and EL which contributed 54.5% and 26.7%, respectively. Common variance among factors contributed the remaining 15.5% to the PE diagnosis.

Clinical Translation

Bother/distress contributes least to the determination of a PE diagnosis. Its contribution is largely redundant with the unique and combined contributions of ejaculatory control and EL.

Strengths and Limitations

Using a well-powered and multivariate analysis, this study parsed out the relative contributions of the 3 diagnostic criteria to a PE diagnosis. The study is limited by its use of estimated EL, a single item assessment of bother/distress, and the lack of differentiation of PE subtypes, lifelong and acquired.

Conclusion

Bother/distress contributes minimally to the PE diagnosis, yet its assessment may be key to understanding the experiences of the patient/couple and to developing an effective treatment strategy.

Rowland DL, McNabney SM, Hevesi K. Does Bother/Distress Contribute to the Diagnosis of Premature Ejaculation?. Sex Med 2022;10:100548.

Erectile dysfunction as a marker of endocrine and glycemic disorders

PURPOSE

The aim of this study was to evaluate in a population of patients with erectile dysfunction (ED): (a) the prevalence of a previously unknown endocrine/glycemic disorders; (b) the correlation between ED severity and endocrine/glycemic disorders.

METHODS

1332 patients referred for ED from 2013 to 2020 were included. The ED diagnosis was made using the International-Erectile-Function-Index-5 questionnaire. ED severity was considered according to presence/absence of spontaneous erections, maintenance/achievement deficiency. All patients were subjected to search for sociodemographic and clinical characteristics: age, ethnicity, marital status, previous use of PDE5i, previous prostatectomy, diabetes mellitus (DM), prediabetes, endocrine dysfunctions.

RESULTS

The mean ± SD age was 54.3 ± 13.7 years. The 19.1% (255/1332) of patients were already in treatment for prediabetes/diabetes or endocrine dysfunctions. Among the remaining 1077, the prevalence of previously unknown endocrine and glycemic disorders was 30% (323/1077). Among them, 190/323 subjects (58.8%) were affected by hypogonadism, with high estradiol level observed in 8/190 (4.2%). The prevalence of new glycemic alterations was 17.3% (56/323) [specifically, 32/56 (57.1%) DM, and 24/56 (42.9%) prediabetes]. A thyroid dysfunction was observed in 40/323 subjects (12.3%) and hyperprolactinemia in 37/323 (11.5%). Patients with new diagnosis of DM showed more severe form of ED compared to the total group {difficulty in the achievement of erection: 46/56 [82.2%, vs 265/1332 (19.9%), p < 0.05]; absence of spontaneous erection 23/56 [41.1%, vs 321/1332 (24.1%), p < 0.05]}.

CONCLUSION

ED is an early marker of endocrine/glycemic disorder, and a previously unknown dysfunction was found in more than a quarter of patients. A newly diagnosed DM is associated with ED severity, especially in elderly man and in presence of hypertension.

A Prospectively Validated Nomogram for Predicting the Risk of PHQ-9 Score ≥15 in Patients With Erectile Dysfunction: A Multi-Center Study

Background

Although erectile dysfunction (ED) often occurs simultaneously with depression, not all patients with ED suffer major depression (MD), with a PHQ-9 score ≥15 indicating MD. Because the PHQ-9 questionnaire includes phrases such as “I think I am a loser” and “I want to commit suicide,” the psychological burdens of ED patients are likely to increase inevitably after using the PHQ-9, which, in turn, may affect ED therapeutic effects. Accordingly, we endeavored to develop a nomogram to predict individual risk of PHQ-9 score ≥15 in these patients.

Methods

The data of 1,142 patients with ED diagnosed in Xijing Hospital and Northwest Women and Children's Hospital from January 2017 to May 2020 were analyzed. While the Least Absolute Shrinkage and Selection Operator regression was employed to screen PHQ-9 score ≥15 related risk factors, multivariate logistic regression analysis was performed to verify these factors and construct the nomogram. The training cohort and an independent cohort that comprised 877 prospectively enrolled patients were used to demonstrate the efficacy of the nomogram.

Results

The IIEF-5 score, PEDT score, physical pain score, frequent urination, and feeling of endless urination were found to be independent factors of PHQ-9 score ≥15 in patients with ED. The nomogram developed by these five factors showed good calibration and discrimination in internal and external validation, with a predictive accuracy of 0.757 and 0.722, respectively. The sensitivity and specificity of the nomogram in the training cohort were 0.86 and 0.52, respectively. Besides, the sensitivity and specificity of the nomogram in the validation cohort were 0.73 and 0.62, respectively. Moreover, based on the nomogram, the sample was divided into low-risk and high-risk groups.

Conclusion

This study established a nomogram to predict individual risk of PHQ-9 score ≥15 in patients with ED. It is deemed that the nomogram may be employed initially to avoid those with a low risk of MD completing questionnaires unnecessarily.

Premature Ejaculation Measures During Partnered Sex and Masturbation: What These Findings Tell Us About the Nature and Rigidity of Premature Ejaculation

Men with premature ejaculation (PE) during partnered sex (as defined by poor ejaculatory control) show significantly reduced PE symptomology during masturbation, but the reasons for this disparity are not clear. This study investigated the other two PE-related diagnostic criteria, namely ejaculatory latency (EL) and bother/distress, in order to explore possible explanations for this disparity between types of sexual activity. Specifically, 1,447 men with either normal or poor ejaculatory control were compared on EL parameters, bother/distress, and sexual satisfaction/pleasure during both partnered sex and masturbation. Results indicated that men with PE reported longer ELs during masturbation than partnered sex, in contrast with men without PE who reported shorter ELs during masturbation. Bother/distress was lower for both groups during masturbation, but bother/distress in men with PE during masturbation was comparable to that of men without PE during partnered sex. Minimal difference in these patterns was found across lifelong and acquired PE subtypes, whereas men with PE with comorbid erectile dysfunction appeared to represent a distinct group. These findings have implications for PE management or treatment as well as for the overall conceptualization of PE as a pathophysiological condition.

Erectile dysfunction and diabetes: A melting pot of circumstances and treatments

Diabetes mellitus (DM), a chronic metabolic disease characterised by elevated levels of blood glucose, is among the most common chronic diseases. The incidence and prevalence of DM have been increasing over the years. The complications of DM represent a serious health problem. The long-term complications include macroangiopathy, microangiopathy and neuropathy as well as sexual dysfunction (SD) in both men and women. Erectile dysfunction (ED) has been considered the most important SD in men with DM. The prevalence of ED is approximately 3.5-fold higher in men with DM than in those without DM. Common risk factors for the development of DM and its complications include sedentary lifestyle, overweight/obesity and increased caloric consumption. Although lifestyle changes may help improve sexual function, specific treatments are often needed. This study aims to review the definition and prevalence of ED in DM, the impact of DM complications and DM treatment on ED and, finally, the current and emerging therapies for ED in patients with DM.

The Unfinished Business of Defining Premature Ejaculation: The Need for Targeted Research

INTRODUCTION

Fifteen years have passed since the International Society of Sexual Medicine first established the 3-pronged criteria for premature ejaculation (PE): a short ejaculation latency, lack of ejaculatory control, and bother/distress. Although the process of establishing valid criteria for any condition or disorder is an ongoing one, a dearth of targeted research on these criteria has hindered professional societies from updating and revising them.

OBJECTIVES

To review and critique existing criteria used in the diagnosis of PE, to identify specific problems with them, and to recommend studies that will address shortcomings.

METHODS

Each of the PE criteria was evaluated and compared against standard procedures for establishing validated measures. Following each analysis, targeted research to address the gaps has been recommended.

RESULTS

Each PE criterion has shortcomings and each can be improved by using standard validation procedures, as noted by the targeted research outcomes. Professional societies can play an important role by encouraging broad participation in research that generates new and relevant data supporting, validating, or challenging the existing criteria.

CONCLUSION

The concepts underlying the diagnostic criteria for PE have both broad consensus and functional utility. Nevertheless, much of the research investigating PE has uncritically adopted these criteria without concomitantly recognizing their limitations. These limitations prevent determining accurate prevalence rates, interpreting research findings with confidence, and establishing efficacious treatment outcomes. Rowland DL, Althof SE, McMahon CG. The Unfinished Business of Defining Premature Ejaculation: The Need for Targeted Research. Sex Med Rev 2021;XX:XXX-XXX.

Comorbidities Among Sexual Problems in Men: Results From an Internet Convenience Sample

INTRODUCTION

Men suffering from one sexual problem sometimes report having another sexual problem, but few studies have determined concordance rates among dysfunctions in non-clinical samples.

AIM

This study determined comorbidities among sexual dysfunctions based on an internet convenience sample of 4432 men from Hungary, the USA, and other world regions that visit social media fora.

METHOD

Participants completed an online 55-item questionnaire that included questions assessing erectile dysfunction (ED), premature ejaculation (PE), delayed ejaculation (DE), and lack of sexual interest (LSI).

MAIN OUTCOME MEASURES

Concordance rates and odds ratios among sexual dysfunctions.

RESULTS

Approximately 8% of men suffered from two or more sexual problems; men with a severe sexual problem were significantly more likely to suffer from a second sexual problem; concordance between PE and erectile dysfunction ranged from 23-29%, with subtypes of lifelong vs acquired PE showing patterns similar to one another; and most men with delayed ejaculation reported minimal problems with LSI, although LSI was generally key to understanding all other dysfunctions.

CONCLUSION

The percentage of men with one sexual problem having a second sexual problem was substantial, ranging from 23-40%. These findings will help clinicians better understand the intertwined nature of sexual problems and assist them in developing management protocols that address concomitant inadequacies in sexual response. Rowland DL, Oosterhouse LB, Kneusel JA, et al. Comorbidities Among Sexual Problems in Men: Results From an Internet Convenience Sample. Sex Med 2021;XX:XXXXXX.

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.

Self-Reported Shorter Than Desired Ejaculation Latency and Related Distress-Prevalence and Clinical Correlates: Results From the European Male Ageing Study

BACKGROUND

Few data have looked at the occurrence and clinical correlates of self-reported shorter than desired ejaculation latency (rapid ejaculation, RE) and its related distress in the general population.

AIM

To determine the prevalence and clinical correlates of self-reported RE and RE- related distress in middle age and older European men.

METHODS

Subjects were recruited from population samples of men aged 40-79 years across 8 European centers.

OUTCOMES

Self-reported RE and its related distress were derived from the European male Aging Study (EMAS) sexual function questionnaire (EMAS-SFQ). Beck's depression Inventory (BDI) was used for the quantification of depressive symptoms, the Short Form 36 health survey (SF-36) for the assessment of the quality of life, the International Prostate Symptom Score (IPSS) for the evaluation of lower urinary tract symptoms.

RESULTS

About 2,888 community dwelling men aged 40-79 years old (mean 58.9 ± 10.8 years) were included in the analysis. Among the subjects included, 889 (30.8%) self-reported RE. Among them, 211 (7.3%) claimed to be distressed (5.9% and 1.4% reported mild or moderate-severe distress, respectively). Increasing levels of RE-related distress were associated with a progressive worse sexual functioning, higher risk of ED and with couple impairment, along with a higher prevalence of depressive symptoms (all P < 0.05). Furthermore, a worse quality of life and higher IPSS score were associated with RE-related distress (all P < 0.05). The aforementioned results were confirmed even when patients using drugs possibly interfering with ejaculation or those without a stable relationship were excluded from the analysis.

CLINICAL IMPLICATIONS

RE is a frequent condition in men from the general population; however, its related distress is relatively modest. Nonetheless, men with any degree of self-reported RE show increasing levels of depression, worse quality of life and worse couple satisfaction.

STRENGTHS & LIMITATIONS

This is the first study estimating the prevalence of self-reported RE and its related distress, along with their biological and psychological correlates, in a population sample of European middle age and older men. However, is should be recognized that the diagnosis of RE was derived from patient reports and not supported by Intra-ejaculatory-Latency-Time (IELT) measurements.

CONCLUSION

Self-reported RE is relatively common in European men aged more than 40 years. The reported limited RE-related distress may explain the relatively low number of medical consultations for RE. RE-related distress is associated with worse sexual function, couple impairment, and more LUTS resulting in a worse quality of life and mood disturbances. Corona G, Rastrelli G, Bartfai G, et al. Self-Reported Shorter Than Desired Ejaculation Latency and Related Distress-Prevalence and Clinical Correlates: Results From the European Male Ageing Study. J Sex Med Rev 2021;18:908-919.

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.

Safety and efficacy of traditional Chinese medicine, Qiaoshao formula, combined with dapoxetine in the treatment of premature ejaculation: An open-label, real-life, retrospective multicentre study in Chinese men

To evaluate the safety and efficacy of Chinese medicine, Qiaoshao formula combined with dapoxetine was used for the treatment of premature ejaculation in a real-life setting. Nine hundred and five males diagnosed with premature ejaculation were reviewed in this retrospective cohort study. We divided the patients into two groups: dapoxetine alone and Qiaoshao formula combined with dapoxetine according to actual interventions provided to patients in clinics. The perceived intravaginal ejaculation latency time and the premature ejaculation profile measures markedly improved in both groups. However, in men with severe premature ejaculation (baseline perceived intravaginal ejaculation latency time <1 min) and those with baseline age ≤30 years, the perceived intravaginal ejaculation latency time was slightly but significantly longer with combined therapy than with dapoxetine alone (p < .05). Therefore, combined therapy involving the Qiaoshao formula and dapoxetine proved to safe as well as effective for treating premature ejaculation while prolonging the perceived intravaginal ejaculation latency time, which significantly improved the overall satisfaction of the patient and likely that of the couple.

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.

Lifestyles and sexuality in men and women: the gender perspective in sexual medicine

Sexual health is strictly related with general health in both genders. In presence of a sexual dysfunction, the expert in sexual medicine aims to discover the specific weight of the physical and psychological factors can cause or con-cause the sexual problem. At the same time, a sexual dysfunction can represent a marker of the future development of a Non-communicable diseases (NCDss) as cardiovascular or metabolic diseases.In the evaluation phase, the sexual health specialist must focus on these aspects, focusing especially on the risk and protective factors that could impact on both male and female sexuality.This article presents a review of researches concerning healthy and unhealthy lifestyles and their contribute in the development of sexual quality of life in a gender-dependent manner.Among the unhealthy lifestyle, obesity contributes mostly to the development of sexual dysfunctions, due to its negative impact on cardiovascular and metabolic function. Tobacco smoking, alcohol - substance abuse and chronic stress lead to the development of sexual dysfunction in a med-long term.In order to guarantee a satisfying sexual quality of life, sexual health specialists have the responsibility to guide the patient through the adoption of healthy lifestyles, such as avoiding drugs, smoke and excessive alcohol, practicing a regular physical activity, following a balanced diet and use stress-management strategies, even before proposing both pharmaco- and/or psychotherapies.

Current stepwise recommendations for hypogonadism screening in erectile dysfunction are not cost-effective

Hypogonadism is a prevalent comorbidity with erectile disfunction (ED) and current guidelines recommend screening for hypogonadism with total testosterone (TT). If low TT is detected, further assessment with LH and SHBG plus albumin are needed to establish an etiology and treatment. Our primary objective was to determine the cost benefit of current stepwise approach versus ad initium full hormonal assessment. Two hundred consecutive male patients referred for ED were screened after consent and 81 were included and assessed for hypogonadism according to the current stepwise approach with TT, and only if TT was less than 345 ng/mL, a full hormonal assessment with TT, LH, and SHBG plus albumin to calculate free testosterone was performed. Direct costs were calculated using the national public healthcare system reimbursement tables and were compared with a hypothetical initial full hormonal assessment. Screening TT was less than 345 ng/mL in 34.6% patients leading to a full hormonal assessment on these. Using a stepwise approach there was a direct cost increase of 5.82 € per patient. Moreover, one out of every three patients had two extra venipunctures and an additional follow-up appointment. Current stepwise recommendations may prove costly in high prevalence scenarios such as the ED subpopulation as a direct cost increase was observed.

Back to Stir It Up: Erectile Dysfunction in an Evolutionary, Developmental, and Clinical Perspective

In this review, we analyze erectile dysfunction (ED) in the context of sexual selection. We highlight that ED is a specific human male characteristic linked to the loss of the baculum or penile bone and results from a range of physical and psychological factors. We discuss evolutionary interpretations that consider dysfunctional penile erection as an honest signal of a low-quality male. We further emphasize the importance of considering psychosocial context and early attachment dynamics for understanding the etiology of some types of ED. Finally, we suggest that the integration of developmental factors for understanding the emergence of this sexual disorder is instrumental for the calibration of more effective therapies.

Androgen Deficiency and Phosphodiesterase Type 5 Expression Changes in Aging Male: Therapeutic Implications

The age-related decline of serum T occurs in ~20-30% of adult men and it is today defined as late-onset hypogonadism (LOH). In the elderly, such decline becomes more prevalent (up to 60%) and shows-up with erectile dysfunction (ED) and hypoactive sexual desire. A large body of experimental evidences have shown that the combination of T replacement therapy (TRT) and phosphodiesterase type 5 inhibitors (PDE5i) is, usually, effective in restoring erectile function in patients with LOH and ED who have not responded to monotherapy for sexual disturbances. In fact, PDE5is potentiate the action of nitric oxide (NO) produced by endothelial cells, resulting in a vasodilator effect, while T facilitates PDE5i effects by increasing the expression of PDE5 in corpora cavernosa. Meta-analytic data have recognized to PDE5i a protective role on the cardiovascular health in patients with decreased left ventricular ejection fraction. In addition, several studies have shown pleiotropic beneficial effects of these drugs throughout the body (i.e., on bones, urogenital tract and cerebral, metabolic, and cardiovascular levels). TRT itself is able to decrease endothelial dysfunction, oxidative stress and inflammation, thus lowering the cardiovascular risk. Furthermore, untreated hypogonadism could be the cause of PDE5i ineffectiveness especially in the elderly. For these reasons, aging men complaining ED who have LOH should undergo TRT before or at the moment when PDE5i treatment is started.

Erectile function recovery in men treated with phosphodiesterase type 5 inhibitor administration after bilateral nerve-sparing radical prostatectomy: a systematic review of placebo-controlled randomized trials with trial sequential analysis

The impact of phosphodiesterase type 5 inhibitor (PDE5I) treatment modality (on-demand vs. daily), PDE5I half-life and time from surgery to PDE5I prescription on the achievement of drug-assisted erectile function (EF) recovery is uncertain. We systematically reviewed published randomized clinical trials (RCTs). We performed meta-analyses of data on 2317 men treated with PDE5Is after nerve-sparing radical prostatectomy (NSRP). A PubMed and SCOPUS search was performed for trials published from 1 January 1969 to 30 June 2016. PDE5Is are effective in achieving drug-assisted recovery of erectile function (EF). From a statistical standpoint, these studies were subjected to Trial Sequential Analysis to determine whether the pooled data were adequately powered to verify the study outcomes. On-demand treatment with PDE5Is was significantly better than daily treatment in recovering drug-assisted EF. This effect was maintained even when the drugs were stratified according with half-life. Although not based on head-to-head trials, Avanafil used on-demand was the most effective PDE5I in recovering drug-assisted EF. Whereas tadalafil was equally effective when used both on-demand and daily, vardenafil significantly improved drug-assisted EF recovery only when used on-demand. The start of PDE5I treatment six months or more after surgery compared to treatment started earlier did not negatively affect the rate of drug-assisted EF recovery or the possibility to have successful intercourse based on the Sexual Encounter Profile question-3 (SEP-3). Current trials do not support the hypothesis that PDE5I use recovers drug-unassisted EF, although chronic low-dose tadalafil administration may help to preserve erectile tissue integrity. Potential shortcomings in the trials design may partially explain these disappointing results and several questions concerning the recovery of drug-unassisted EF remain unanswered. Thus, there is a need for well-designed new RCTs requiring changes in the timing of PDE5I administration as well as in the dose and the treatment duration.

Clinical and preclinical treatment of urologic diseases with phosphodiesterase isoenzymes 5 inhibitors: an update

Phosphodiesterase isoenzymes 5 inhibitors (PDE5-Is) are the first-line therapy for erectile dysfunction (ED). The constant discoveries of nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) cell-signaling pathway for smooth muscle (SM) control in other urogenital tracts (UGTs) make PDE5-Is promising pharmacologic agents against other benign urological diseases. This article reviews the literature and contains some previously unpublished data about characterizations and activities of PDE5 and its inhibitors in treating urological disorders. Scientific discoveries have improved our understanding of cell-signaling pathway in NO/cGMP-mediated SM relaxation in UGTs. Moreover, the clinical applications of PDE5-Is have been widely recognized. On-demand PDE5-Is are efficacious for most cases of ED, while daily-dosing and combination with testosterone are recommended for refractory cases. Soluble guanylate cyclase (sGC) stimulators also have promising role in the management of severe ED conditions. PDE5-Is are also the first rehabilitation strategy for postoperation or postradiotherapy ED for prostate cancer patients. PDE5-Is, especially combined with α-adrenoceptor antagonists, are very effective for benign prostatic hyperplasia (BPH) except on maximum urinary flow rate (Q max ) with tadalafil recently proved for BPH with/without ED. Furthermore, PDE5-Is are currently under various phases of clinical or preclinical researches with promising potential for other urinary and genital illnesses, such as priapism, premature ejaculation, urinary tract calculi, overactive bladder, Peyronie's disease, and female sexual dysfunction. Inhibition of PDE5 is expected to be an effective strategy in treating benign urological diseases. However, further clinical studies and basic researches investigating mechanisms of PDE5-Is in disorders of UGTs are required.

Diagnosis and Treatment of Premature Ejaculation by Urologists in South Korea

Purpose

This study discusses the treatment of premature ejaculation (PE) using various approaches with the goal of evaluating the methods of diagnosis and treatment of PE in clinical practice in 2014 in South Korea.

Materials and Methods

We surveyed 200 urologists and andrologists who treated patients with PE from July 1, 2014 to July 29, 2014 using an online questionnaire. The questionnaire was composed of 4 parts: disease, comorbidities, diagnosis, and treatment. Using the answers to this survey, current trends in the diagnosis and treatment of PE were investigated using weighted averages.

Results

The median number per month of patients who were diagnosed with PE was 14 patients (interquartile range, 7~24). The time to ejaculation necessary for a diagnosis of PE was considered to be <1 minute by 12% of respondents, <2 minutes by 27%, <3 minutes by 28%, <5 minutes by 13%, and 20% stated that diagnosis was based on a patient's subjective complaint. The treatment methods preferred by PE patients were reported to be pharmacological treatment (87%), surgical treatment (9.5%), and behavioral management (3.5%). The treatment methods used by respondents were pharmacological treatment (77%), surgical treatment (15%), and behavioral management (14%). The most commonly used pharmacological treatment was the oral administration of dapoxetine (97%).

Conclusions

In 2014 in South Korea, various methods were used to diagnose and treat PE. The most commonly used treatment for PE was the oral administration of dapoxetine. It was also found that surgical treatment was applied in some cases.

Effects of 22 novel CYP2D6 variants found in Chinese population on the metabolism of dapoxetine

Background

CYP2D6 is one of the most important members of the cytochrome P450 superfamily. Its genetic polymorphism significantly influences the efficacy and safety of some drugs, which might cause adverse effects and therapeutic failure.

Methods and results

The aim of this research was mainly to explore the catalytic activities of 22 newly reported CYP2D6 isoforms (2D6*87, *88, *89, *90, *91, *92, *93, *94, *95, *96,*97, *98, *R25Q, F164L, E215K, F219S, V327M, D336N, V342M, R344Q, R440C, R497C) on dapoxetine in vitro. The research was designed with an appropriate incubation system in test tubes and carried out in the constant temperature water. Through detecting its two metabolites desmethyldapoxetine and dapoxetine-N-oxide, the available data were obtained to explain the influence of CYP2D6 polymorphism on the substrate drug dapoxetine. As a result, the intrinsic clearance (V_max/K_m) values of most variants were significantly altered when compared with the counterpart of CYP2D6*1, with most of these variants exhibiting either reduced V_max and/or increased K_m values. For dapoxetine demethylation pathway (which produces desmethyldapoxetine), 2D6*89 and E215K exhibited no markedly decreased relative clearance of 92.81% and 97.70%, respectively. The relative clearance of rest 20 variants exhibited decrease in different levels, ranging from 20.44% to 90.90%. For the dapoxetine oxidation pathway (which produces dapoxetine-N-oxide), the relative clearance values of three variants, 2D6*90, *94, and V342M, exhibited no markedly increased relative clearance of 106.17%, 107.78%, and 109.98%, respectively; the rest 19 variants exhibited significantly decreased levels ranging from 27.56% to 84.64%. In addition, the kinetic parameters of two CYP2D6 variants (2D6*92 and 2D6*96) could not be detected, due to the defect of the CYP2D6 gene.

Conclusion

As the first report of all aforementioned alleles for dapoxetine metabolism, these data may help in the clinical assessment of the metabolic elimination of dapoxetine and may provide fundamental information for further clinical studies.

A Pilot Study Using a Web Survey to Identify Characteristics That Influence Hypogonadal Men to Initiate Testosterone Replacement Therapy

Men with hypogonadism (HG) who choose testosterone replacement therapy (TRT) may have distinct characteristics that provide insight as to why they may/may not initiate therapy. The aim of the current study was to identify trends in patient characteristics and attitudes in men diagnosed with HG who initiated TRT (TRT+) compared with men who were diagnosed with HG but did not initiate TRT (TRT-). The market research-based online survey conducted between 2012 and 2013 included patients from a Federated Sample, a commercially available panel of patients with diverse medical conditions. The current analysis was composed of two groups: TRT+ ( n = 155) and TRT- ( n = 157). Patient demographics, clinical characteristics, and attitudes toward HG and TRT were examined as potential predictors of primary adherence in men with HG; cohorts were compared by using Fisher's exact test. Significant associations among sexual orientation, relationship status, educational level, presence of comorbid erectile dysfunction, area of residence, and TRT initiation were present ( p ≤ .05). College-educated, heterosexual, married men with comorbid erectile dysfunction living in suburban and urban areas were more likely to initiate treatment. The most bothersome symptoms reported were lack of energy (90% vs. 81%, p = .075), decreased strength and endurance (86% vs. 76%, p = .077), and deterioration in work performance (52% vs. 31%, p = .004); lack of energy prompted men to seek help. Patients (48%) in the TRT+ group were more knowledgeable regarding HG as compared with TRT- respondents (14%, p < .001), and most men obtained their information from a health care professional (89% vs. 82%, p = .074). The current analysis identified distinct demographic and clinical characteristics and attitudes among TRT users compared with men who were diagnosed with HG yet remained untreated.

Interplay Between Premature Ejaculation and Erectile Dysfunction: A Systematic Review and Meta-Analysis

INTRODUCTION

The specific determinants and underlying factors linking erectile dysfunction (ED) and premature ejaculation (PE) have yet to be clearly identified.

AIM

The aim of this study was to review and meta-analyze all available data regarding the link between ED and PE.

METHODS

An extensive Medline Embase and Cochrane search was performed including the following words: "premature ejaculation" and "erectile dysfunction".

MAIN OUTCOME MEASURES

All observational trials comparing the risk of ED in relation to PE were included. Data extraction was performed independently by two of the authors (G.R, G.C.), and conflicts resolved by the third investigator (M.M.).

RESULTS

Out of 474 retrieved articles, 18 were included in the study for a total of 57,229 patients, of which 12,144 (21.2%) had PE. The presence of PE, however defined, was associated with a significant increase in ED risk (odds ratio: 3.68[2.61;5.18]; P < 0.0001). Meta-regression analysis showed that the risk of ED in PE subjects was higher in older individuals as well as in those with a lower level of education and in those who reported a stable relationship less frequently. In addition, subjects with PE and ED more often reported anxiety and depressive symptoms and a lower prevalence of organic associated morbidities, including diabetes mellitus, hypertension and dyslipidemia. All the latter associations were confirmed even after adjustment for age. Finally the risk of PE-related ED increased with the increased proportion of acquired ejaculatory problems (adj r = 0.414; P < 0.0001 after the adjustment for age).

CONCLUSIONS

In conclusion, the present data showed that ED and PE are not distinctly separate entities, but should be considered from a dimensional point of view. Understanding this dimensional perspective might help sexual health care professionals in providing the most appropriate therapeutic approach to realistically increase patient related outcomes in sexual medicine.

Assessing satisfaction in men with premature ejaculation after dapoxetine treatment in real-world practice

INTRODUCTION

There are limited data on the treatment satisfaction with dapoxetine in patients with premature ejaculation (PE).

AIMS

We aimed to evaluate the treatment satisfaction, effectiveness and safety of dapoxetine for PE patients.

METHODS

Subjects received dapoxetine (30 mg or 60 mg) alone or in combination with a phosphodiesterase type 5 inhibitor, if concurrent with erectile dysfunction for more than 4 weeks in clinical practice. Main outcome measures include Clinical Global Impression of Change (CGIC) and Clinical Global Impression of Satisfaction (CGIS).

RESULTS

From March 2014 to January 2015, a total of 286 PE patients received dapoxetine treatment in this study, with 137 (47.9%) patients diagnosed with lifelong PE and 149 (52.1%) patients diagnosed with acquired PE. At the final follow-up visit, the mean intravaginal ejaculatory latency time (an increase of 3.4 min) and mean score of Premature Ejaculation Diagnostic Tool (a decrease of -5.0) improved significantly from baseline, and the satisfaction rate and response rate to dapoxetine treatment were 45.0% and 74.6%, respectively. Satisfaction with dapoxetine treatment was highly correlated with treatment response, and might be improved by scheduled follow-up visits and escalation to a higher dose. Subjects with diabetes mellitus (DM) reported a lower treatment response than those without DM. Treatment-emergent adverse event (TEAEs) occurred in 47.7% of patients, but no serious TEAEs were reported.

CONCLUSION

Our real-world data highlight the effectiveness of dapoxetine and the importance of follow-up visits for the treatment of PE. Half of PE patients were not satisfied with dapoxetine treatment, which reflects an unmet need of present approach or an unrealistic expectation from PE patients.

Erectile dysfunction and its management in patients with diabetes mellitus

Diabetes can be described as a syndrome of multiple closely related conditions induced by a chronic state of hyperglycaemia resulting from defective insulin secretion, insulin action or both. Chronic complications associated with diabetes (including neuropathy, vascular disease, nephropathy and retinopathy) are common, and of these, erectile dysfunction (ED) deserves special attention. ED and its correlation with cardiovascular disease require careful evaluation and appropriate treatment. PDE5 inhibitors (PDE5is) are an important tool for the treatment of ED, with new drugs coming onto the market since the late 90s. This review offers an overview of PDE5is and their use in treating ED in diabetes. We underline the differences between different types of PDE5i, focusing on available doses, duration of action, T ½, side effects and selectivity profiles in relation to patients with diabetes. We also discuss the link between diabetes and ED in presence of various associated cofactors (obesity, hypertension and its pharmacological treatments, atherosclerosis, hyperhomocysteinaemia, neuropathy, nephropathy, hypogonadism and depression). Finally a number of past and ongoing clinical trials on the use of PDE5is in patients with diabetes are presented to offer an overview of the appropriate treatment of ED in this condition.

An Observational Study to Evaluate the Prevalence of Erectile Dysfunction (ED) and Prescribing Pattern of Drugs in Patients with ED Visiting an Andrology Specialty Clinic, Mumbai: 2012-14

INTRODUCTION

Erectile dysfunction (ED) is a common occurrence and its incidence is expected to increase significantly along with the increase in various lifestyle diseases. The drug utilization for ED is very low. Also, studies describing the prescription pattern in ED are lacking.

MATERIALS AND METHODS

We conducted a retrospective cross-sectional observational study, including a drug utilization analysis, of 606 prescriptions as per the standard guidelines (WHO and STROBE).

RESULTS

Out of 606, 249 (41%) were from the age group of 30-39 years. Addictions were present in 388 (64%). Out of 606, 186 had urological, 154 had cardiovascular and 102 had psychological co-morbid disorders. Out of 348, 201 were prescribed Tadalafil (low dose) on a once daily basis. Out of 172, 121 were prescribed Sildenafil (high dose) on an 'as and when required' basis. Nutritional/ herbal supplements were prescribed in 126/606. The ratio of 'Prescribed Daily Dose' to 'Defined Daily Dose' of Tadalafil, Sildenafil, and Dapoxetine were 1.1, 1.3 and 1.5 respectively.

CONCLUSION

Measures for de-addiction play an important role in the overall management of ED. The most common co-morbid disorders were urological, like BPH, LUTS, etc, followed by cardiovascular, psychological and diabetes. Overall, rational pharmacotherapy was observed. Tadalafil was the most commonly prescribed drug for ED. The main factor in the selection of a particular PDE5 inhibitor was its pharmacokinetics and cost. Udenafil, being the costliest, was the least prescribed. Dapoxetine was used in a significant number of individuals primarily for PE with ED. The combination of Papaverine, Chlorpromazine ± Alprostadil was used as intracavernosal injection in patients not responding to oral drugs.

Hormonal correlations of premature ejaculation

Premature ejaculation is the most frequent male sexual dysfunction, significantly impairing quality of life of both the patient and the partner and affecting up to one-third of men of every age. In the last years, our knowledge about this topic has greatly increased, and studies on the causes and treatments related to ejaculatory disorders have shed a light on previously uncharted territory. Public interest on sexual dysfunctions has likewise increased in the general population: the time lapse between the first symptoms of sexual dysfunction and the seeking of medical advice has been significantly reduced, whereas demand for a treatment has markedly increased. A role of endocrine regulation has been established in all the aspects of male reproduction; however, the endocrine control of ejaculation is not fully understood. Sex steroid, pituitary, and thyroid hormones have all been advocated as potential candidates in the regulation of the ejaculatory process, but exact mechanisms are not clear yet and further studies are required in order to identify potential targets for treatment.

Outcomes of androgen replacement therapy in adult male hypogonadism: recommendations from the Italian society of endocrinology

OBJECTIVE

We developed clinical practice guidelines to assess the individual risk-benefit profile of androgen replacement therapy in adult male hypogonadism (HG), defined by the presence of specific signs and symptoms and serum testosterone (T) below 12 nmol/L.

PARTICIPANTS

The task force consisted of eight clinicians experienced in treating HG, selected by the Italian Society of Endocrinology (SIE). The authors received no corporate funding or remuneration.

CONSENSUS PROCESS

Consensus was guided by a systematic review of controlled trials conducted on men with a mean T < 12 nmol/L and by interactive discussions. The guidelines were reviewed and sequentially approved by the SIE Guidelines Commission and Executive Committee.

CONCLUSIONS

We recommend T supplementation (TS) for adult men with severely reduced T levels (T < 8 nmol/L) to improve body composition and sexual function. We suggest that TS be offered to subjects with T < 12 nmol/L to improve glycaemic control, lipid profile, sexual function, bone mineral density, muscle mass and depressive symptoms, once major contraindications have been ruled out. We suggest that lifestyle changes and other available interventions (e.g. for erectile dysfunction) be suggested prior to TS. We suggest that TS should be combined with currently available treatments for individuals at high risk for complications, such as those with osteoporosis and/or metabolic disorders. We recommend against using TS to improve cardiac outcome and limited mobility. We recommend against using TS in men with prostate cancer, unstable cardiovascular conditions or elevated haematocrit. The task force places a high value on the timely treatment of younger and middle-aged subjects to prevent the long-term consequences of hypoandrogenism.

Chlamydia trachomatis infection is related to premature ejaculation in chronic prostatitis patients: results from a cross-sectional study

INTRODUCTION

Chronic bacterial prostatitis (CBP) is reported to be a common finding in men with acquired premature ejaculation (PE). The impact of different pathogens on PE development in chronic prostatitis patients is, however, unknown.

AIM

To assess a possible link between CBP caused by Chlamydia trachomatis (Ct) and PE.

METHODS

A consecutive series of 317 patients with clinical and instrumental diagnosis of CBP due to Ct was enrolled (group A) and compared with data obtained from a control group of 639 patients with CBP caused by common uropathogen bacteria (group B). Prostatitis symptoms were investigated with the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), while the ejaculatory status of patients was assessed using the PE Diagnostic Tool (PEDT).

MAIN OUTCOME MEASURES

All participants were asked to complete the NIH-CPSI, the International Index of Erectile Function-15 erectile function domain (IIEF-15-EFD), the PEDT, and the Short Form (SF)-36 questionnaires.

RESULTS

Patient groups A and B had comparable scores of NIH-CPSI (P = 0.07), IPSS (P = 0.32), and IIEF-15-EFD (P = 0.33) tests. PE was assessed in 118 patients in group A (37.2%) and in 73 subjects in group B (11.5%). The two groups are different in terms of PE prevalence (P < 0.0002). Compared with group B, group A showed significantly higher scores of the PEDT test (11.3 [±2.6] vs. 4.5 [±2.9], P < 0.0001) and lower scores of the SF-36 tool (96.5 [±1.1] vs. 99.7 [±1.3], P < 0.0001). In our multivariate model assessment, being positive for a Ct infection marker was independently associated with the PEDT score even after adjusting for age, smoking habit, body mass index, and education level (adjusted odds ratio = 3.21; 95% confidence interval: 2.02-4.27; P < 0.003).

CONCLUSIONS

Patients affected by CBP due to Ct infection reported higher prevalence of PE and lower quality of life when compared with patients affected by CBP caused by traditional uropathogenic bacteria.

Estrogen mediates metabolic syndrome-induced erectile dysfunction: a study in the rabbit

INTRODUCTION

Estrogen receptor (ER) α is critical in mediating the harmful effects of hyperestrogenism in fetal or neonatal life on the developing penis. In contrast, little is known on the impact of an excess of estrogens on penile function in adulthood.

AIM

To investigate the effect of estrogens on metabolic syndrome (MetS)-associated erectile dysfunction (ED).

METHODS

We employed a recently established animal model of high fat diet (HFD)-induced MetS. Subgroups of MetS rabbits were dosed with either testosterone (T) or tamoxifen. We evaluated penile responsiveness to acetylcholine (Ach) as well as the expression of genes related to penile smooth muscle relaxation and contractility.

MAIN OUTCOME MEASURE

Associations between MetS-induced penile alterations and sex steroids were investigated in an animal model of HFD-induced MetS. To understand the role of either androgen deficiency or estrogen excess on ED, we treated subgroups of MetS rabbits with either T or tamoxifen, a classical ER antagonist.

RESULTS

Feeding an HFD-induced MetS was associated to elevated estradiol (E2) and low T levels. E2, but not T, was independently and negatively associated with genes able to affect penile erection. Smooth muscle-related markers decreased as a function of E2 and were positively associated with all the variables investigated. Increasing concentrations of circulating E2 were negatively associated with Ach-induced relaxation. In HFD rabbits, in vivo T dosing significantly improved MetS and completely normalized circulating E2. Conversely, in vivo tamoxifen dosing reduced visceral adiposity and partially restored T level. Ach-induced relaxation was severely impaired by HFD and significantly restored, up to the control level, by both tamoxifen and T dosing. In rabbit smooth muscle cells cultures 17β-E2 (1 nM) significantly reduced the expression of α-smooth muscle actin, transgelin, and phosphodiesterase type 5. The effects of 17β-E2 were completely reverted by tamoxifen (100 nM).

CONCLUSIONS

This study demonstrates, for the first time, that HFD-induced ED is more associated with a high E2, rather than to a low T, milieu. HFD-induced ED is partially restored by in vivo treatment not only with T but also with the nonsteroidal ER antagonist, tamoxifen.

Endocrine evaluation of erectile dysfunction

Erectile dysfunction is highly prevalent, affecting up to half of men in their 50-70s, and has been variably associated to a variety of causes including unhealthy lifestyles, such as smoking or overweight, or comorbidities such as hypertension, diabetes mellitus, and neurological disorders. General interest toward ED has exploded since the introduction of phosphodiesterase type 5 inhibitors-oral drugs that are widely accepted as the first line treatment in patients suffering from this conditions. In the last decade, the time lapse between first symptoms of sexual disorders and seeking of medical advice has greatly reduced. Unfortunately, none of the PDE5i has been proven curative, but rather acts as a symptomatic treatment. The availability of very active and safe drugs, however, diminished the space for diagnosis and search of etiological treatments. This is particularly true for the several endocrinopathies associated with ED. A number of epidemiological data support an inverse relationship between sexual health and testosterone levels, and it is well accepted that testosterone deficiency is a good marker of sexual and physical frailty. However, several other hormones, including LH, prolactin, TSH, and FT4 are involved in sexual functioning and should be investigated in a proper work-out of ED. Existing guidelines provide information almost entirely focusing on late-onset hypogonadism and therapeutic strategies; this mini-review aims to provide a wider spectrum of the diagnostic endocrine work-out of ED patients unrevealing the complexity of conditions, overt or subclinical, which can affect ED.

Long-term treatment patterns of testosterone replacement medications

INTRODUCTION

Testosterone replacement therapy (TRT) is prescribed to men diagnosed with hypogonadism to alleviate symptoms, improve quality of life, and improve overall health. However, most men use TRT for only a short duration.

AIM

To evaluate the long-term treatment patterns in hypogonadal men using topical TRT or short-lasting TRT injections.

METHODS

Using the Truven MarketScan(®) Database, 15,435 men who received their first (index) topical TRT prescription and 517 men who received their short-lasting TRT injection index prescription in 2009 were followed from 12 to 30 months after treatment initiation. Treatment interruption was defined as a medication gap of >30 days. Patients who remained off treatment were classified as having discontinued treatment. Patients who restarted therapy after 30 days were classified as cyclic users. Patients were required to have continuous insurance coverage during 1 year prior to treatment initiation and at least 1 year afterward.

MAIN OUTCOME MEASURES

Main outcome measures were length of therapy, discontinuation, and restarts of topical TRT or short-lasting TRT injections.

RESULTS

The patient characteristics were similar for patients who received topical TRT or short-lasting TRT injections. Of the patients who discontinued therapy during the follow-up period, the percentages of patients who were still on therapy after 3 months were 52% and 31% for topical TRT and short-lasting TRT users, respectively. For cyclic users, there was an attrition rate of approximately 40% to 50% of patients in each cycle. For both topical TRT and short-lasting TRT injections, the gap between stopping and restarting therapy tended to decrease over time.

CONCLUSIONS

In this analysis, high discontinuation rates were observed. The treatment pattern of TRT may be related to the disease state rather than dosing, daily use, or mode of administration.

An Update of the International Society of Sexual Medicine's Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years. Althof SE, McMahon CG, Waldinger MD, Serefoglu EC, Shindel AW, Adaikan PG, Becher E, Dean J, Giuliano F, Hellstrom WJG, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, and Torres LO. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med 2014;2:60-90.

An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years.

The SIAMS-ED Trial: A National, Independent, Multicentre Study on Cardiometabolic and Hormonal Impairment of Men with Erectile Dysfunction Treated with Vardenafil

Increased cardiovascular risk has been associated with reduced response to proerectile drugs. The Italian Society of Andrology and Sexual Medicine (SIAMS) promoted an independent, multicenter study performed in 604 men (55 ± 12 yrs) suffering from erectile dysfunction (ED) to assess multiple health outcomes and response to 6-month vardenafil challenge in a real-life setting. Overall, 30.8% men had metabolic syndrome. Cardiovascular risk stratification revealed a greater number of ED subjects with moderate risk of a major adverse cardiovascular event than the general population (P < 0.01). Age-adjusted pulse pressure was positively correlated with ED severity and negatively with androgens and waist circumference (P < 0.01). A decline in total testosterone was observed with increasing arterial pulse pressure (P < 0.05), which was not accompanied by compensatory LH rise. Follow-up on 185 men treated with vardenafil in an nonrandomized, open, single-arm trial documented a significant rise in IIEF-5 (delta = 6.1 ± 4.8) that was maintained in men with high cardiovascular risk. Mild adverse events occurred in <5%, with no differences between cardiovascular risk classes. In summary, ED is a frequent symptom in patients with an elevated, but often unknown, risk of future cardiovascular events. Androgens predict vascular resistance in ED patients. Vardenafil's response and safety profile were preserved in subjects with higher cardiovascular risk.