1
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Does Testosterone Salvage PDE5i Non-Responders? A Scoping Review. ENDOCRINES 2023. [DOI: 10.3390/endocrines4010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Erectile physiology, in order to function normally, requires the complex coordination of endocrine, neurocognitive, neuromuscular and vascular mechanisms. Testosterone (T) influences male sexuality as well as penile erections at multiple levels, including a direct influence on the nitric oxide synthase (NOS)/cGMP/phosphodiesterase 5 pathway in the penis. However, the precise role of testosterone replacement (TRT) to “salvage” men with mixed ED failing phosphdiesterase-5 inhibitors (PDE5i) remains unclear. We conducted a scoping review identifying the rationale for TRT in ED failing PDE5i, and we critically discuss clinical trials that have examined TRT in the setting of PDE5i use. Overall, TRT replacement appears to be well tolerated and may enhance the response to PDE5i and quality of life, particularly for men with mixed ED, and particularly among men with very low levels of testosterone. However, most of the available literature examines concurrent TRT alone or simultaneous TRT + PDE5i usage, without necessarily selecting for PDE5i failure cases. The present studies are limited to heterogenous studies with small sample sizes, without an exact predominant etiologic factor causing ED. Furthermore, studies showing the most benefit are non-placebo-controlled trials; however, the correction of more profound hypogonadism may lead to an improved response to PDE5i. Stronger conclusions would require properly selected patient populations and larger placebo-controlled RCTs.
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Chung E, Lowy M, Gillman M, Love C, Katz D, Neilsen G. Urological Society of Australia and New Zealand (
USANZ
) and Australasian Chapter of Sexual Health Medicine (
AChSHM
) for the Royal Australasian College of Physicians (
RACP
) clinical guidelines on the management of erectile dysfunction. Med J Aust 2022; 217:318-324. [DOI: 10.5694/mja2.51694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 06/04/2021] [Accepted: 06/17/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Eric Chung
- Princess Alexandra Hospital Brisbane QLD
- University of Queensland Brisbane QLD
- AndroUrology Centre Brisbane QLD
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3
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Mullgardt RS, Mathis HC. A “Rule of Four” Approach to the Male Genital-Rectal Examination. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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4
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Gou C, Liu T, Chen Z, Zhou Z, Song T, Mao K, Chen C, Chen B. Effects of unilateral/bilateral amputation of the ischiocavernosus muscle in male rats on erectile function and conception. Basic Clin Androl 2022; 32:1. [PMID: 34983365 PMCID: PMC8729152 DOI: 10.1186/s12610-021-00151-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 12/07/2021] [Indexed: 11/21/2022] Open
Abstract
Background The ischiocavernosus muscle (ICM) encompasses a pair of short pinnate muscles attached to the pelvic ring. The ICM begins at the ischial tuberosity and ends at the crus of the penis while covering the surface of the crus. According to the traditional view, the contraction of the ICM plays an auxiliary role in penile erection. However, we have previously shown that the ICM plays an important role in penile erection through an indirect method of diagnosing erectile dysfunction (ED) caused by ICM injury by observing the infertility of paired female rats. Since intracavernosal pressure (ICP) is the current gold standard for diagnosing ED, this study aimed to amputate unilaterally/bilaterally the ICM to establish an ED model by detecting the ICP, recording the infertility of matching female rats, and comparing the two methods. Results Forty sexually mature adult male rats were selected and randomly divided into the following groups: the control group (n = 10), sham operation group (n = 10), unilateral ischiocavernosus muscle (Uni-ICM) amputation group (n = 10), and bilateral ischiocavernosus muscle (Bi-ICM) amputation group (n = 10). Eighty female reproductive rats were randomly assigned to the above groups at a ratio of 2:1. We evaluated the time to conception for the paired female rats and the effects of unilateral/bilateral severing of the ICM on erectile function. The results showed that the baseline and maximum intracavernosal pressure (ICP) in the control group, sham operation group, Uni-ICM amputation group, and Bi-ICM amputation group were 17.44±2.50 mmHg and 93.51±10.78 mmHg, 17.81±2.81 mmHg and 95.07±10.40 mmHg, 16.73±2.11 mmHg and 83.49±12.38 mmHg, and 14.78±2.78 mmHg and 33.57±6.72 mmHg, respectively, immediately postsurgery. The max ICP in the Bi-ICM amputation group was lower than that in the remaining three groups (all P<0.05). The pregnancy rates were 100, 100, 90, and 0% in the control group, sham operation group, Uni-ICM amputation group, and the Bi-ICM amputation group, respectively. The pregnancy rate in the Bi-ICM amputation group was significantly lower than that in the remaining groups (all P<0.05). The time to conception was approximately 7–10 days later in the Uni-ICM amputation group than in the control and sham groups (all P<0.05). Conclusions Male rats undergoing Bi-ICM amputation may develop permanent ED, which affects their fertility. In contrast, rats undergoing Uni-ICM amputation may experience transient ED.
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Affiliation(s)
- Chengren Gou
- Department of Urology, the Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China
| | - Tong Liu
- Department of Urology, the Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China.,Department of Pediatric Surgery, the First Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
| | - Zongping Chen
- Department of Urology, the Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China.
| | - Zidong Zhou
- Department of Urology, the Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China
| | - Tao Song
- Department of Urology, the Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China.,Department of Urology, Eastern Hospital of Sichuan Provincial People's Hospital, Chengdu, 610035, China
| | - Kaiyi Mao
- Department of Urology, the Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China
| | - Congcong Chen
- Department of Urology, the Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China
| | - Bo Chen
- Department of Urology, the Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China
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5
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Sudyka J, Wick JY. Treating Erectile Dysfunction with Prescription Medications & Natural Products: A Pharmacist's Guide. Sr Care Pharm 2021; 36:632-644. [PMID: 34861904 DOI: 10.4140/tcp.n.2021.632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Stigma surrounding erectile dysfunction creates a difficult environment for appropriate management. Knowledge of the condition and treatment options presents a unique opportunity for pharmacists to optimize a safe and affordable plan that meets patient needs.
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6
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Domes T, Najafabadi BT, Roberts M, Campbell J, Flannigan R, Bach P, Patel P, Langille G, Krakowsky Y, Violette PD, Brock GB, Yafi FA. Canadian Urological Association guideline: Erectile dysfunction. Can Urol Assoc J 2021; 15:310-322. [PMID: 34665713 DOI: 10.5489/cuaj.7572] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Erectile dysfunction (ED) impacts the wellness and quality of life of millions of Canadians. An evaluation focused on the identification of reversible and irreversible underlying factors is recommended for patients presenting with ED. Through a shared decision-making model framework, the goal of ED treatment is to improve functional outcomes and enhance sexual satisfaction while minimizing adverse effects associated with treatment. Given that ED is assessed and treated by multiple different types of health practitioners, the purpose of this guideline is to provide the best available evidence to facilitate care delivery through a Canadian lens. After a narrative review of ED assessment and treatment for general readership, five key clinical questions relating to priority areas of ED are assessed using the GRADE and evidence-to-decision-making frameworks.
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Affiliation(s)
- Trustin Domes
- Division of Urology, Department of Surgery, University of Saskatchewan, Saskatoon, SK, Canada
| | - Borna Tadayon Najafabadi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Matthew Roberts
- Division of Urology, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey Campbell
- Division of Urology, Department of Surgery, Western University, London, ON, Canada
| | - Ryan Flannigan
- Department of Urological Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Phil Bach
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Premal Patel
- Division of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | | | - Yonah Krakowsky
- Division of Urology, Women's College Hospital & Sinai Health System, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Philippe D Violette
- Department of Surgery, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gerald B Brock
- Professor Emeritus, Western University, London, ON, Canada
| | - Faysal A Yafi
- Department of Urology, University of California Irvine, Irvine, CA, United States
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7
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Chen Z, Shao X, He M, Shen M, Gong W, Wang M, Zhang Y, Liu W, Ma Z, Ye Z, Lu Y, Yang N, Chen S, Hu L, Li Y, Wang Y, Zhao Y, Zhang Z. Erectile Dysfunction Is Associated With Excessive Growth Hormone Levels in Male Patients With Acromegaly. Front Endocrinol (Lausanne) 2021; 12:633904. [PMID: 34017310 PMCID: PMC8129559 DOI: 10.3389/fendo.2021.633904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 04/19/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To determine the risk factors for erectile dysfunction (ED) in male patients with acromegaly and to prospectively investigate the short-term changes of erectile function after surgery or medical treatment. Methods Sixty-three male patients were subjected to nocturnal penile tumescence and rigidity (NPTR) test for the evaluation of erectile function. The measurement of serum nitric oxide (NO) was also performed. Twenty-seven patients were re-evaluated by NPTR after surgery or long-term somatostatin analogues (SSA) treatment. Results Twenty-two patients (34.9%) had ED. Patients with ED showed higher random GH (17.89 [10.97-44.19] μg/L vs 11.63 [4.31-28.80] μg/L, p = 0.020) and GH nadir (GHn) (10.80 [6.69-38.30] μg/L vs 8.76 [3.62-18.19] μg/L, p = 0.044) during oral glucose tolerance test (OGTT). The NO levels of ED patients were lower than non-ED patients (9.15 [5.58-22.48] μmol/L vs 16.50 [12.33-31.78] μmol/L, p = 0.012). After treatment, patients who present improvement in erectile function showed lower post-GHn (0.07 [0.03-0.12] ng/ml vs 1.32 [0.09-3.60] ng/ml, p = 0.048) and post-IGF-1 index (1.03 ± 0.38 vs 1.66 ± 0.95, p = 0.049). The multivariate analysis indicated post-GHn was still associated with the improvement of erectile function after correction of other covariates (OR: 0.059, 95% CI: 0.003-1.043, p = 0.053). Conclusions Excessive GH is related to ED in male patients with acromegaly. GH normalization after treatment is beneficial for short-term erectile function recovery.
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Affiliation(s)
- Zhengyuan Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoqing Shao
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Min He
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ming Shen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Wei Gong
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Meng Wang
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yichao Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenjuan Liu
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zengyi Ma
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhao Ye
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Yongning Lu
- Reproductive Medicine Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Nianqin Yang
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shanwen Chen
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China
| | - Lydia Hu
- Department of Biochemistry and Cellular and Molecular Biology, College of Arts and Sciences, The University of Tennessee, Knoxville, Knoxville, TX, United States
| | - Yiming Li
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yongfei Wang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Yao Zhao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Regeneration, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhaoyun Zhang
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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8
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Erectile dysfunction management: a critical appraisal of clinical practice guidelines with the AGREE II instrument. Int J Impot Res 2021; 34:471-476. [PMID: 33941879 DOI: 10.1038/s41443-021-00442-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/31/2021] [Accepted: 04/14/2021] [Indexed: 11/09/2022]
Abstract
Our study aimed to assess the methodological strengths and weaknesses of erectile dysfunction clinical practice guidelines (CPGs) for individuals using the AGREE II tool. Erectile dysfunction related CPGs were identified from three databases: the National Guideline Clearinghouse, the Guidelines International Network, and PubMed between 2000 and 2020. We designed an independent assessment for each of the erectile dysfunction related CPGs using the AGREE II tool. Four appraisers performed these assessments. The literature search identified 8 CPGs that met our inclusion criteria. The evaluation of the AGREE II domains of each individual revealed that the median scores of domains related to applicability were quite low (39%). Also, the median scores of domains related to the rigour of development and the stakeholder involvement were relatively low (53% and 63%). We determined the highest median scores in three AGREE II domains: clarity of presentation (80.5%), editorial independence (77%), and scope and purpose (89.5%). We found that the European Association of Urology (EAU), the American Urological Association (AUA), and the British Society for Sexual Medicine (BSSM) guidelines had >60% in >4 domains and that their average AGREE II scores were over 70%. In the Canadian Diabetic Association (CDA) and the Japanese Society for Sexual Medicine (JSSM) guidelines, we found that >4 domains were >60%, but their average AGREE II scores were below 70%. The British Medical Journal (BMJ), the Canadian Urologic Association (CUA), and the Malaysian Urologic Association (MUA) guidelines had >60% in <3 domains. We highly recommended EAU, AUA and BSSM guidelines, while we moderately recommended CDA and JSSM guidelines. BMJ, CUA and MUA guidelines were weakly recommended. The quality of the guidelines for erectile dysfunction was variable according to AGREE II. We noted significant deficiencies in the methodological quality of the CPGs developed by different organisations in the areas of applicability and rigour of development.
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9
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Ramli FF, Azizi MH, Syed Hashim SA. Treatments of Sexual Dysfunction in Opioid Substitution Therapy Patients: A Systematic Review and Meta-Analysis. Int J Med Sci 2021; 18:2372-2380. [PMID: 33967614 PMCID: PMC8100642 DOI: 10.7150/ijms.57641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/30/2021] [Indexed: 11/05/2022] Open
Abstract
Sexual dysfunction is a common condition in the opioid substitution therapy (OST) population. We aimed to determine the efficacy and safety of treatment for sexual dysfunction in the OST population. We searched for interventional studies from Medline, PubMed, and Scopus. Three independent authors conducted a risk-of-bias assessment (RoB 2). A total of seven studies (five randomized-controlled trials, two quasi-experimental), including 473 patients with sexual dysfunction, were identified. Among these, three bupropion (n=207), one trazodone (n=75), two rosa Damascena (n=100), and one ginseng (n=91) studies had reported significantly improve various sexual functioning domains in both genders. In a meta-analysis, bupropion significantly increased male sexual function with standardized mean difference of 0.53; 95% confidence interval of 0.19-0.88; P < 0.01; I2=0. The adverse effects were minor for all agents, and no significant difference between treatment and placebo groups in randomized-controlled trials. These agents have a promising future as therapy for sexual dysfunction in the OST population. However, given the limited sample size and number of studies, further studies should be conducted to confirm the use of these agents.
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Affiliation(s)
- Fitri Fareez Ramli
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Muhammad Hasif Azizi
- Unit of Urology, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Syed Alhafiz Syed Hashim
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
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10
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Alkandari MH, Sadri I, Carrier S. Case - Conservative management of deep penile skin infection post-three-piece penile prosthesis implantation. Can Urol Assoc J 2021; 15:E516-E518. [PMID: 33591904 DOI: 10.5489/cuaj.7056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Not required
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Affiliation(s)
| | - Iman Sadri
- McGill University Health Centre, Montreal, QC, Canada
| | - Serge Carrier
- McGill University Health Centre, Montreal, QC, Canada
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11
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Lima SVC, Chagas HM, Monteiro CCP, Ferraz-Carvalho RS, Albuquerque AV, Silva AA, Lira MMDM, Vilar FO. Injectable semi rigid penile prosthesis: study in rabbits and future perspectives. Transl Androl Urol 2021; 10:841-850. [PMID: 33718085 PMCID: PMC7947431 DOI: 10.21037/tau-20-1128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Penile prostheses are the third option in the treatment of erectile dysfunction, however, despite their proven effectiveness, the occurrence of infections, advanced age of patients and comorbidities are the main limiting factors for this treatment modality. In the continuous search for biointegrated, clinically durable and minimally invasive treatment options, a possible model of penile prosthesis was sought through the use of intracavernous bacterial cellulose (BC) gel, in an experimental model of orchiectomized rabbits. Methods Thirty adult New Zealand rabbits were equally distributed into three groups: BC; vehicle and control. Each group was then subdivided according to the follow-up time of 3 and 6 months. Bilateral orchiectomy was performed 3 weeks before injection in the BC and vehicle groups. Pachymetry measurements of the penile axis, diameter and length were performed in situ. Histomorphometry analyzes of the corpora cavernosa (CC), thickness of the tunica albuginea, cell density, collagen and elastic fibers post-injection were also performed, in addition to immunohistochemistry for newly formed vessels. Results The implant of BC increased both the length and thickness of the penis three and six months after the last injection, with a consequent increase in the diameter of the CC. On the other hand, the filling effect was not observed in the control and vehicle groups, confirming the degradation of this tissue after orchiectomy and the effectiveness of BC as a filling agent. Histomorphometry analyzes corroborate the mass effect of BC integrated into the tissue, permeated by predominantly lymphomononuclear inflammatory infiltrate, multinucleated giant foreign body cells, fibroblasts, elastic fibers and newly formed vessels, without degradation or loss of volume, even after six months of implantation. Conclusions Biocompatibility and biointegration to the host tissue make BC a prosperous penile filling material, with local application and minimally invasive.
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Affiliation(s)
- Salvador Vilar Correia Lima
- Nucleus for Experimental Surgery, Post-graduate Program in Surgery, Department of Surgery, Health Sciences Center, Federal University of Pernambuco, Recife, Brazil
| | | | | | - Rafaela Siqueira Ferraz-Carvalho
- Nucleus for Experimental Surgery, Post-graduate Program in Surgery, Department of Surgery, Health Sciences Center, Federal University of Pernambuco, Recife, Brazil
| | - Amanda Vasconcelos Albuquerque
- Nucleus for Experimental Surgery, Post-graduate Program in Surgery, Department of Surgery, Health Sciences Center, Federal University of Pernambuco, Recife, Brazil
| | - Anderson Arnaldo Silva
- Departament of Anatomy, Biosciences Center, Federal University of Pernambuco, Recife, Brazil
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Whalen S, Langille G, White J, Bailly G. Access to penile prostheses differ across provinces in Canada: A survey of Canadian urologists. Can Urol Assoc J 2020; 15:E346-E349. [PMID: 33382371 DOI: 10.5489/cuaj.6867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Surgical implantation of a penile prosthesis is the gold standard treatment for refractory erectile dysfunction. The purpose of this study was to investigate the use of and access to these procedures in Canada. METHODS Canadian urologists known to perform penile prostheses procedures were surveyed on areas such as surgical volume, type of device used, and the direct cost to patients for both malleable and inflatable devices. RESULTS Of the 50 urologists invited to participate in the study, 34 (68%) completed the online survey. Participants represented nine Canadian provinces and included a mix of academic (65%) and community (35%) urologists. Most participants (79%) performed less than 10 procedures per year. Roughly three-quarters of participants (74%) used inflatable devices in over 90% of cases, while half implanted inflatable devices exclusively. The most common devices implanted were American Medical Systems (AMS). Participants from Alberta, Manitoba, New Brunswick, and Newfoundland reported full coverage for both malleable and inflatable devices. Saskatchewan was the only province where no coverage was reported. The remaining provinces were found to have variable degrees of coverage. Across all centers without full coverage, the median reported cost to patients for a malleable and inflatable device was $5000 and $6000, respectively. CONCLUSIONS The urologists surveyed most commonly perform inflatable penile prostheses procedures. Significant geographical differences exist with respect to reported coverage for these procedures. This study highlights the need for continued advocacy on behalf of the urological community towards the goal of equity in coverage for penile prostheses across Canada.
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Affiliation(s)
- Stewart Whalen
- Department of Urology, Dalhousie University, Halifax, NS Canada
| | - Gavin Langille
- Department of Urology, Dalhousie University, Saint John, NB, Canada
| | - Josh White
- Department of Urology, Dalhousie University, Halifax, NS Canada
| | - Greg Bailly
- Department of Urology, Dalhousie University, Halifax, NS Canada
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Zacharie N, Dieudonné ML, Modeste WN, Ide NM, Landry KB, Emma B, Noël E, Armel M, Yebga T, G MPV, Camille NND. Potential activity of Aframomum daniellii (Zingiberaceae) dry seeds: A case study of its action mechanism on the Wistar rat strain with testicular deficiency. Biomed Pharmacother 2020; 131:110759. [PMID: 33152923 DOI: 10.1016/j.biopha.2020.110759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/11/2020] [Accepted: 09/13/2020] [Indexed: 11/24/2022] Open
Abstract
This work was undertaken to evaluate the biological activity of the aqueous extract of the dry seeds of Aframomum daniellii seeds on the copulatory performance of rats with testicular deficiency. Hypogonadal adult male rats (30) were divided into 6 groups: group I received distilled water (10 ml/kg), group II received sildenafil citrate (5 mg/kg), group III received intramuscular injections of testosterone enanthate (3. 6 mg/kg), group IV, V, and VI received the aqueous extract of A. daniellii at the respective doses of 100, 200, and 400 mg/kg/po/day for 14 days. The copulatory performance of the animals were assessed on days 1, 7 and 14 through the following copulation parameters: Mount, intromission, and ejaculation latency (ML, IL, and EL) and frequency (MF, IF and EF), average interval of copulation (AIC) and post-ejaculatory interval (PEI)). We noticed a significant decrease of ML (p < 0.05), IL (p < 0.01), EL (p < 0.001) and the increase of MF, IF and EF (p < 0.01) particularly at doses of 100 and 400 mg/kg when compared to group I and II. In addition, we noticed a significant increase of AIC from day 7 (p < 0.05) to day 14 (p < 0.001) at the same two doses while the PEI significantly decreased from the 1st (p < 0.01) to the 14th day (p < 0.001) when compared to group I and II. These findings demonstrated that A. daniellii aqueous extract of seeds enhanced pro-sexual potential and pro-sexual desire in male rats with testicular deficiency.
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Affiliation(s)
- Nde Zacharie
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon
| | - Massoma Lembè Dieudonné
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon.
| | - Wankeu Nya Modeste
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon
| | - Ngaha Marie Ide
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon
| | - Koloko Brice Landry
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon
| | - Bend Emma
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon
| | - Etaga Noël
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon
| | - Mbock Armel
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon
| | - Toham Yebga
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon
| | - Mboumwa Paul Valerie G
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon
| | - Nyonseu Nzeubang Doriane Camille
- Laboratory of Biology and Physiology of Animal Organisms, Faculty of Sciences of Douala University, PO Box: 24157, Douala, Cameroon
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14
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Taşkapu HH, Sönmez MG, Kılınç MT, Altınkaya N, Aydın A, Balasar M. Efficiency of intracavernosal alprostadil and oral clomiphene citrate combination treatment in penile vasculogenic erectile dysfunction patients accompanied by late-onset hypogonadism. Andrologia 2020; 52:e13759. [PMID: 33617097 DOI: 10.1111/and.13759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 11/30/2022] Open
Abstract
In this study, the efficiency of intracavernosal alprostadil + oral clomiphene citrate (CC) treatment in late-onset hypogonadism (LOH) accompanied by penile vasculogenic erectile dysfunction (PVED) in patients irresponsive to phosphodiesterase type 5 inhibitor treatment was evaluated. A total of 31 patients with concurrent PVED and LOH were included in the study. The patients were given intracavernosal alprostadil (10-20 μg) and oral CC (50 mg) every day for 12 weeks. Before and after treatment, a 15-question International Index of Erectile Function (IIEF-15) questionnaire, Erection Hardness Score (EHS), Sexual Encounter Profile (SEP)2 and SEP3 levels were analysed, and follicle stimulating hormone (FSH), luteinising hormone (LH), total testosterone and prostate-specific antigen (PSA) levels were measured. In all, 41.9% of patients had pure arterial deficiency, 19.3% had pure venous deficiency, and 38.7% had arterial + venous (mixed) deficiency. A significant increase was detected in total testosterone, FSH, LH and PSA values after treatment when compared to values before treatment (p < .001, p < .001, p < .001 and p = .034 respectively). A significant recovery was observed in IIEF-15 subscores, EHS and SEP2-SEP3 results. In PVED patients accompanied by LOH, intracavernosal alprostadil and oral CC combination is an efficient, low cost, safely applicable and tolerable treatment.
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Affiliation(s)
- Hakan Hakkı Taşkapu
- Department of Urology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Mehmet Giray Sönmez
- Department of Urology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Muzaffer Tansel Kılınç
- Department of Urology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Nurullah Altınkaya
- Department of Urology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Arif Aydın
- Department of Urology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Mehmet Balasar
- Department of Urology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
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15
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Kingsberg SA, Nambiar S, Karkare S, Hadker N, Lim-Watson M, Williams LA, Krop J. Hypoactive sexual desire disorder (HSDD) is not "female erectile dysfunction (ED)": challenges with the characterization of HSDD in women based on a systematic literature review. Curr Med Res Opin 2020; 36:1069-1080. [PMID: 32301355 DOI: 10.1080/03007995.2020.1754181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: Hypoactive sexual desire disorder (HSDD) in women has been viewed inaccurately by some in the medical and payer community as analogous to erectile dysfunction (ED) in men. This literature review aims to highlight the distinctions between HSDD and ED.Methods: Two systematic literature searches were conducted on the epidemiology, symptomatology and biopsychosocial outcomes of HSDD and ED. Studies published since 2007 were considered for HSDD; studies published since 2012 were considered for ED.Results: HSDD in women is primarily a central nervous system condition related to neuroendocrine factors, whereby neural pathways that regulate sexual excitation and/or inhibition appear to be involved. A combination of organic and psychogenic factors often contributes to ED. HSDD and ED are associated with similar psychological and interpersonal consequences, but affect different phases of the sexual response model (desire versus arousal) and have different pathophysiologies, therefore requiring different treatment and outcome paradigms. ED is measured by objective, physiological responses (erection and sexual function), but quantitative assessments for HSDD are more difficult because loss of desire with associated distress has to be assessed. Outcome measures used to assess ED, such as the number of satisfying sexual events, are far less informative as an endpoint for randomized clinical trials of treatments for HSDD.Conclusions: HSDD and ED are distinct conditions affecting different phases of the sexual response model, and thus require clear and unique clinical characterization and adequate communication between the health care professional and patient for appropriate diagnosis, management and treatment.
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Affiliation(s)
- Sheryl A Kingsberg
- Department of Obstetrics/Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | | | | | | | | | - Julie Krop
- AMAG Pharmaceuticals, Inc., Waltham, MA, USA
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16
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Ma M, Yu B, Qin F, Yuan J. Current approaches to the diagnosis of vascular erectile dysfunction. Transl Androl Urol 2020; 9:709-721. [PMID: 32420178 PMCID: PMC7215019 DOI: 10.21037/tau.2020.03.10] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Ming Ma
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu 610041, China.,Department of Urology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Botao Yu
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu 610041, China.,Department of Urology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Feng Qin
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jiuhong Yuan
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu 610041, China.,Department of Urology, West China Hospital, Sichuan University, Chengdu 610041, China
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17
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Mulhall JP, Chopra I, Patel D, Hassan TA, Tang WY. Phosphodiesterase Type-5 Inhibitor Prescription Patterns in the United States Among Men With Erectile Dysfunction: An Update. J Sex Med 2020; 17:941-948. [PMID: 32144034 DOI: 10.1016/j.jsxm.2020.01.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 01/21/2020] [Accepted: 01/30/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND While phosphodiesterase type-5 inhibitors (PDE5Is) are highly effective for the treatment of erectile dysfunction (ED) and well tolerated, updated data on prescription patterns have been limited in real-world settings. AIM To describe men in the United States who are prescribed PDE5Is for ED treatment and to evaluate patterns of initiation, switching, and treatment overlap. METHODS This retrospective claims study used MarketScan Commercial and Medicare Supplement Databases from January 1, 2010, to December 31, 2015, to identify initial PDE5I claims (index date) for sildenafil, tadalafil, and/or vardenafil. Adults aged ≥18 years with ED were identified between July 1, 2010, and December 31, 2014, allowing for a 6-month preindex and 12-month follow-up period from the index date. OUTCOMES Outcomes included patient demographics and treatment-related patterns after treatment initiation. RESULTS A total of 106,206 identified patients met all inclusion criteria. Of these, 51,694, 40,193, and 14,319 had initial claims for sildenafil, tadalafil, and vardenafil, respectively. Mean age was 50.35 years, and comorbidities included dyslipidemia (44.17%), hypertension (43.09%), diabetes (15.32%), and depression (10.61%). More patients (48.67%) initiated on sildenafil than tadalafil (37.85%) or vardenafil (13.48%). Rate of switching was lower in the 60 days after the end of day supply of the initial prescription in the sildenafil cohort (2.71%) compared with the tadalafil (2.81%) and vardenafil (3.88%) cohorts (P < .001 for sildenafil vs tadalafil or vardenafil). Treatment overlap was lower in the sildenafil cohort (0.35%) than in the tadalafil (0.75%) and vardenafil (0.62%) groups (P < .001 for sildenafil vs tadalafil or vardenafil). CLINICAL IMPLICATIONS These findings provide insight into updated patterns of PDE5I prescriptions in the United States and may aid in clinical decision-making. STRENGTHS & LIMITATIONS Strengths include the large sample size, long data coverage period, and the real-world nature of the study. Limitations include the retrospective study design, use of data collected with a primary focus of claims, and lack of further details regarding reasons that drive switching. Actual rates of ED and impact on prescription patterns may be underestimated because the claims database only captured patients electing to visit a health-care provider. CONCLUSION Among men with ED in the United States, rates of switching and treatment overlap were low for all PDE5Is but were found to be the lowest for sildenafil compared with tadalafil and vardenafil. Mulhall JP, Chopra I, Patel D, et al. Phosphodiesterase Type-5 Inhibitor Prescription Patterns in the United States Among Men With Erectile Dysfunction: An Update. J Sex Med 2020;17:941-948.
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Affiliation(s)
- John P Mulhall
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Ishveen Chopra
- Health Economics and Outcomes Research, Pharmerit International, Bethesda, MD, USA
| | - Dipen Patel
- HEOR & Market Access, Pharmerit International, Bethesda, MD, USA
| | | | - Wing Yu Tang
- Patient & Health Impact, Pfizer Inc, New York, NY, USA
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18
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Campbell JD, Milenkovic U, Usta MF, Albersen M, Bivalacqua TJ. The good, bad, and the ugly of regenerative therapies for erectile dysfunction. Transl Androl Urol 2020; 9:S252-S261. [PMID: 32257866 PMCID: PMC7108995 DOI: 10.21037/tau.2019.10.06] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Erectile dysfunction (ED) is a common condition which reduces quality of life of both patients and their partners, and is a significant health care expense every year. Although phosphodiesterase type-5 inhibitors are the current first-line treatment for men with ED, they are limited by their on-demand dosing, intolerance, and variable efficacy in complex patient populations such as men with multiple medical comorbidities or ED after pelvic surgery. Regenerative medicine has been introduced and investigated in andrology as an encouraging strategy to restore diseased erectile tissue structure and function. Novel regenerative therapies for ED are controversial but are perceived to offer a durable and safe tissue restorative approach to act as a long-term solution to this cumbersome disease process. Here, we review platelet-rich plasma, amniotic fluid membranes, low-intensity extracorporeal shockwave therapy, and stem cell therapy as regenerative strategies to treat ED. Most of these approaches have preclinical and occasionally clinical data to support their ongoing investigation; however, none of these treatments are currently supported for use in ED patients outside of clinical trials.
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Affiliation(s)
- Jeffrey D Campbell
- Department of Surgery, Division of Urology, Western University, London, ON, Canada
| | - Uros Milenkovic
- Laboratory for Experimental Urology, Department of Development and Regeneration, University of Leuven, Leuven, Belgium
| | - Mustafa Faruk Usta
- Department of Urology, Section of Andrology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Maarten Albersen
- Laboratory for Experimental Urology, Department of Development and Regeneration, University of Leuven, Leuven, Belgium
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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19
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Aging and Sexual Health: A Cross-Sectional Survey of Patients in a Canadian Urban Academic Family Health Team. Can J Aging 2020; 39:365-372. [PMID: 32008597 DOI: 10.1017/s0714980819000734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Primary care physicians are in a position to recognize sexuality as a core component of health. Data examining the sexual behaviours of Canadians over the age of 50 and the role of primary care in this domain is lacking. A cross-sectional survey was administered to patients over the age of 50, which assessed the importance of sexual activity, problems, and preferences in discussing sexual health with their primary care providers. A total of 39 per cent of patients indicated ongoing sexual activity and 52% of male participants reported current sexual activity compared with 25 per cent of females (p < 0.01). More males reported sexual activity as important than did females (69% vs. 45%, p < 0.01). Participants identifying sexual health concerns discussed physical dysfunctions more than emotional, social, or global health concerns (p < 0.01). More male participants discussed sexual health concerns with their family physician than did females (p < 0.01). The results of our study indicate that many individuals over the age of 50 continue to be sexually active, and that physical and non-physical concerns directly impact participation in sexual activity.
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20
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Sandoval-Salinas C, Saffon JP, Corredor HA. Quality of Clinical Practice Guidelines for the Diagnosis and Treatment of Erectile Dysfunction: A Systematic Review. J Sex Med 2020; 17:678-687. [PMID: 32001203 DOI: 10.1016/j.jsxm.2019.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/14/2019] [Accepted: 12/23/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Clinical practice guidelines (CPGs) guide the diagnosis and treatment of erectile dysfunction using different methodologies. Nonetheless, the quality of published CPGs is unknown. AIM To evaluate the quality of CPGs for diagnosis and treatment of patients with erectile dysfunction. METHODS The Medline, Embase, and LILACS databases were searched using structured strategies. The evidence was complemented by searches on websites of scientific societies and guideline developers. The CPG quality was assessed using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument. MAIN OUTCOME MEASURE The outcome measure included the quality of CPGs in accordance with the AGREE II instrument score. RESULTS 17 guidelines met the selection criteria. 15 had recommendations for diagnosis, 16, had recommendations for treatment, and 1 included a follow-up. Most of the guidelines were developed in Europe (35.3%) and North America (29.4%), 2 were prepared by specialized groups (11.7%), and 1 was funded by public resources. The most common development method was the panel of experts (9 guides, 52.9%). 5 guidelines were of high quality as per the methodological rigor, as follows: Cancer Care Ontario 2016 (76.5%), European Urology Association 2018 (65.6%), American Urological Association 2018 (62.5%), American College of Physicians (62.5%), and Japanese Society for Sexual Medicine (60.4%). There was a significant relationship (P = .043) between the methodological quality of the guidelines and the funding source. CLINICAL IMPLICATIONS By knowing the quality of the clinical practice guidelines, users can make more objective decisions about their use, which has an impact on patient care. STRENGTH & LIMITATIONS High-quality CPGs frequently used in health-care practice were identified. Solely CPGs in Spanish, English, and Portuguese were included, which generates selection bias in the results. CONCLUSIONS The number of CPGs for erectile dysfunction developed using international standards that meet the AGREE II quality criteria is low. Scientific societies have a strong interest in developing guidelines on this topic, whereas the participation of governmental organizations is limited. Sandoval-Salinas C, Saffon JP, Corredor HA. Quality of Clinical Practice Guidelines for the Diagnosis and Treatment of Erectile Dysfunction: A Systematic Review. J Sex Med 2020;17:678-687.
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Affiliation(s)
| | - José P Saffon
- Elexial Research Center, Clinical Research Group, Bogotá, Colombia
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21
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Ciocanel O, Power K, Eriksen A. Interventions to Treat Erectile Dysfunction and Premature Ejaculation: An Overview of Systematic Reviews. Sex Med 2019; 7:251-269. [PMID: 31300388 PMCID: PMC6728733 DOI: 10.1016/j.esxm.2019.06.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/03/2019] [Accepted: 06/03/2019] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Sexual dysfunction in men is common, and optimal treatment is complex. Although several systematic reviews concerning treatment approaches exist, a comprehensive overview without limitations concerning the population, interventions, or outcomes is lacking. AIM To conduct a "review of reviews" to compare the effectiveness of pharmacologic, non-pharmacologic, and combined interventions. METHODS 9 electronic databases, relevant journals, and reference lists up to July 2018 were searched. For each intervention, only the most recent and comprehensive meta-analysis or systematic review was included. The methodologic quality of the reviews was appraised using the Assessment of Multiple Systematic Reviews-2 tool. MAIN OUTCOME MEASURE Sexual functioning (via intravaginal ejaculatory latency time and international index of erectile function), sexual satisfaction, and adverse effects. RESULTS 30 systematic reviews were included. For premature ejaculation, several treatments, including oral pharmacotherapy (selective serotonin inhibitors, phosphodiesterase type 5 [PDE5] inhibitors, tricyclic antidepressants, and opioid analgesics), topical anesthetics, and combined drug and behavioral therapies demonstrated significant improvements of 1-5 minutes in the intravaginal ejaculatory latency time. Pharmacologic interventions (PDE5 inhibitors, penile injection, and testosterone), shockwave therapy, lifestyle modifications, and combined therapies (PDE5 inhibitors and psychological intervention) were effective in treating erectile dysfunction. Most pharmacologic therapies were associated with adverse effects. CONCLUSIONS There is suggestive evidence that pharmacologic interventions or combined therapies are more effective than non-pharmacologic interventions for treating sexual dysfunction in men; however, a range of treatment options should be presented to individual patients so they may consider the risks and benefits of treatments differently. Evidence related to behavioral and psychological interventions is insufficient compared with that related to drug trials, highlighting the necessity for larger and better randomized controlled trials. Ciocanel O, Power K, Eriksen A. Interventions to Treat Erectile Dysfunction and Premature Ejaculation: An Overview of Systematic Reviews. Sex Med 2019;7:251-269.
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Affiliation(s)
- Oana Ciocanel
- Sexual Health and Blood Borne Virus Managed Care Network, Public Health Directory, NHS Tayside, Kings Cross Hospital, Dundee, United Kingdom.
| | - Kevin Power
- Adult Psychological Therapies Service, NHS Tayside, Dundee, United Kingdom
| | - Ann Eriksen
- Sexual Health and Blood Borne Virus Managed Care Network, Public Health Directory, NHS Tayside, Kings Cross Hospital, Dundee, United Kingdom
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22
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Erectile Dysfunction: A Primer for in Office Management. Med Sci (Basel) 2019; 7:medsci7090090. [PMID: 31470566 PMCID: PMC6780163 DOI: 10.3390/medsci7090090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction: Optimizing erectile dysfunction (ED) remains a clinically significant endeavor as insufficient outcomes from oral, injectable and even surgical approaches to treatment remain less than ideal. In this report, we integrate evolving knowledge and provide an algorithmic approach for the clinician to fine-tune management. Methods: We performed a PubMed and Medline search of Erectile Dysfunction treatment optimization, enhanced patient efficacy for ED, and why men fail ED treatment. All relevant papers for the past two decades were reviewed. Results: Establishing the goals and objectives of the patient and partner while providing detailed instructions for treatment can minimize failures and create an environment that allows treatment optimization. A thorough work-up may identify reversible or contributing causes. We identified several areas where treatment of ED could be optimized. These include; management of associated medical conditions, lifestyle improvements, PDE5 inhibitor prescription strategies, management of hypogonadism and the initiation of intracavernosal injection therapy (ICI). Conclusions: In our view, once a man presents for help to the clinician, use of the simple strategies identified in this review to optimize the tolerability, safety and effectiveness of the selected treatment should result in enhanced patient and partner satisfaction, with improved outcomes.
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23
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Zucchi A, Costantini E, Scroppo FI, Silvani M, Kopa Z, Illiano E, Petrillo MG, Cari L, Nocentini G. The first-generation phosphodiesterase 5 inhibitors and their pharmacokinetic issue. Andrology 2019; 7:804-817. [PMID: 31350821 PMCID: PMC6790582 DOI: 10.1111/andr.12683] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 12/26/2022]
Abstract
Background Erectile dysfunction (ED) is a relatively frequent disease that negatively impacts the overall quality of life, well‐being, and relationships. Although the use of phosphodiesterase 5 inhibitors (PDE5is) has revolutionized the treatment of ED, a high percentage of ED patients discontinue PDE5i treatment. Objectives (i) To analyze the reasons for patient dissatisfaction leading to PDE5i discontinuation; (ii) analyze the pharmacokinetics of new formulations focusing on the time needed to reach an effective plasma concentration of PDE5is (Tonset) following drug intake; and (iii) summarize the physicochemical properties of sildenafil to understand which excipients may increase the absorption rate. Material and methods An online PubMed literature search was conducted to identify English language publications from inception to January 2019. Results The main reasons for patient dissatisfaction when using PDE5is on demand are the relatively long Tonset after taking vardenafil and sildenafil, including formulations such as film‐coated tablets, fine granules, orally disintegrating tablets (ODTs), and oral thin films (ODFs). The relatively long Tonset, further worsened when accompanied by eating, highlights the following: (i) the need for planning intercourse, determining partner‐related issues; (ii) issues when having sex before the maximum effect of the drug; and (iii) lower drug‐related placebo effects. Some data suggest that sildenafil is a ‘difficult’ molecule, but Tonset can be improved following absorption by buccal mucosa using appropriate excipients. Conclusions We conclude that several ODT and ODF formulations can improve the ‘discretion’ issue because they are taken without water, but they have similar pharmacokinetics to corresponding film‐coated tablet formulations. One ODF formulation of sildenafil was characterized by a shorter Tonset and could potentially increase patient satisfaction following treatment. However, more clinical studies are needed to confirm the findings. Surfactants and ascorbic acid appear to be crucial excipients for achieving a high absorption rate, but more studies are needed.
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Affiliation(s)
- A Zucchi
- Department of Surgical and Biomedical Sciences, Urology and Andrology Clinic, University of Perugia, Perugia, Italy
| | - E Costantini
- Andrology and Urogynecological Clinic, Santa Maria Hospital, University of Perugia, Perugia, Italy
| | - F I Scroppo
- Urology Unit, Ospedale di Circolo di Varese, Varese, Italy
| | - M Silvani
- Urology Department, Santa Rita Clinic, Vercelli, Italy
| | - Z Kopa
- Andrology Centre, Department of Urology, Semmelweis University, Budapest, Hungary
| | - E Illiano
- Andrology and Urogynecological Clinic, Santa Maria Hospital, University of Perugia, Perugia, Italy
| | - M G Petrillo
- Signal Transduction Laboratory, Department of Health and Human Services, NIEHS, NIH, Durham, NC, USA
| | - L Cari
- Department of Medicine, Section of Pharmacology, University of Perugia, Perugia, Italy
| | - G Nocentini
- Department of Medicine, Section of Pharmacology, University of Perugia, Perugia, Italy
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24
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Zhou Z, Chen H, Wu J, Wang J, Zhang X, Ma J, Cui Y. Meta-Analysis of the Long-Term Efficacy and Tolerance of Tadalafil Daily Compared With Tadalafil On-Demand in Treating Men With Erectile Dysfunction. Sex Med 2019; 7:282-291. [PMID: 31307951 PMCID: PMC6728809 DOI: 10.1016/j.esxm.2019.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/10/2019] [Accepted: 06/17/2019] [Indexed: 12/04/2022] Open
Abstract
Background Erectile dysfunction (ED) is highly prevalent in aging men. Tadalafil daily and on-demand are widely used for the treatment of ED. Aim We performed a meta-analysis to evaluate the efficacy and safety of tadalafil daily compared with tadalafil on-demand in treating men with ED after at least 24 weeks of long-term treatment. Methods Randomized controlled trials of tadalafil daily vs on-demand in treating men with ED were searched using MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. Systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. The data was calculated by RevMan version 5.3.0. The references of related articles were also searched. Outcomes International Index of Erectile Function-Erectile Function domain, sexual encounter profile question 2 (SEP2), SEP question 3 (SEP3), any treatment-emergent adverse event (AE), discontinuation due to AEs, myalgia, back pain, headache, dyspepsia, and nasopharyngitis. Results 4 articles, including 1,035 participants were studied. The analysis found that tadalafil daily had a greater improvement than tadalafil on-demand in terms of International Index of Erectile Function-Erectile Function (mean difference (MD) 1.24; 95% CI 0.03−2.44; P = .04), SEP2 (MD 10.08; 95% CI 9.15−11.01; P < .00001) and SEP3 (MD 8.19; 95% CI 2.09−14.29; P = .009) in treating ED after at least 24 weeks treatment cycle. For safety, tadalafil on-demand had a higher incidence of any treatment-emergent AE (odds ratio 0.73; 95% CI 0.56−0.96; P = .02) compared with tadalafil daily, but for other aspects, including discontinuation due to AEs, myalgia, back pain, headache, dyspepsia, and nasopharyngitis, there were no significant difference between the 2 treatments. Clinical Implications Tadalafil daily may offer a better effect for ED than on-demand for long-term treatment. Strengths and Limitations From the perspective of evidence-based medicine, we evaluated the efficacy and safety of tadalafil daily compared with tadalafil on-demand in treating men with ED after a long-term treatment. The quality of these studies included is flawed, primarily in difference in tadalafil doses and severity of the ED. Conclusion Tadalafil daily provides a preferable therapeutic effect for ED with a lower incidence of treatment-emergent side effects relative to tadalafil on-demand after at least 24 weeks of long-term treatment. Zhou Z, Chen H, Wu J, et al. Meta-Analysis of the Long-Term Efficacy and Tolerance of Tadalafil Daily Compared With Tadalafil On-Demand in Treating Men With Erectile Dysfunction. J Sex Med 2019;7:282–291.
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Affiliation(s)
- Zhongbao Zhou
- Binzhou Medical University, Yantai, Shandong, China; Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Hongyan Chen
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Jitao Wu
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Jipeng Wang
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Xuebao Zhang
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Jiajia Ma
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Yuanshan Cui
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China.
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Oboh G, Adebayo AA, Ademosun AO. Hunteria umbellata seed extract administration modulates activities of phosphodiesterase-5 and purinergic enzymes relevant to erection in normal male rats. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s13596-019-00368-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Erectile dysfunction: a global review of intracavernosal injectables. World J Urol 2019; 37:1007-1014. [DOI: 10.1007/s00345-019-02727-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 03/09/2019] [Indexed: 01/22/2023] Open
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Elterman DS, Petrella AR, Walker LM, Van Asseldonk B, Jamnicky L, Brock GB, Elliott S, Finelli A, Gajewski JB, Jarvi KA, Robinson J, Ellis J, Shepherd S, Saadat H, Matthew A. Canadian consensus algorithm for erectile rehabilitation following prostate cancer treatment. Can Urol Assoc J 2018; 13:239-245. [PMID: 30526799 DOI: 10.5489/cuaj.5653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The present descriptive analysis carried out by a pan-Canadian panel of expert healthcare practitioners (HCPs) summarizes best practices for erectile rehabilitation following prostate cancer (PCa) treatment. This algorithm was designed to support an online sexual health and rehabilitation e-clinic (SHARe-Clinic), which provides biomedical guidance and supportive care to Canadian men recovering from PCa treatment. The implications of the algorithm may be used inform clinical practice in community settings. METHODS Men's sexual health experts convened for the TrueNTH Sexual Health and Rehabilitation Initiative Consensus Meeting to address concerns regarding erectile dysfunction (ED) therapy and management following treatment for PCa. The meeting brought together experts from across Canada for a discussion of current practices, latest evidence-based literature review, and patient interviews. RESULTS An algorithm for ED treatment following PCa treatment is presented that accounts for treatment received (surgery or radiation), degree of nerve-sparing, and level of pro-erectile treatment invasiveness based on patient and partner values. This algorithm provides an approach from both a biomedical and psychosocial focus that is tailored to the patient/partner presentation. Regular sexual activity is recommended, and the importance of partner involvement in the treatment decision-making process is highlighted, including the management of partner sexual concerns. CONCLUSIONS The algorithm proposed by expert consensus considers important factors like the type of PCa treatment, the timeline of erectile recovery, and patient values, with the goal of becoming a nationwide standard for erectile rehabilitation following PCa treatment.
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Affiliation(s)
- Dean S Elterman
- Division of Urology, University Health Network, Toronto, ON, Canada
| | - Anika R Petrella
- Division of Urology, University Health Network, Toronto, ON, Canada
| | - Lauren M Walker
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | | | - Leah Jamnicky
- Division of Urology, University Health Network, Toronto, ON, Canada
| | - Gerald B Brock
- Department of Surgery, St. Joseph's Hospital, London, ON, Canada
| | - Stacy Elliott
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Antonio Finelli
- Division of Urology, University Health Network, Toronto, ON, Canada
| | - Jerzy B Gajewski
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Keith A Jarvi
- Murray Koffler Urologic Wellness Center, Mount Sinai Hospital, Toronto, ON, Canada
| | - John Robinson
- Clinical Psychology Department, University of Calgary, Calgary, AB, Canada
| | - Janet Ellis
- Department of Psychology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Shaun Shepherd
- Division of Urology, University Health Network, Toronto, ON, Canada
| | - Hossein Saadat
- Division of Urology, University Health Network, Toronto, ON, Canada
| | - Andrew Matthew
- Division of Urology, University Health Network, Toronto, ON, Canada
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Nocturnal penile erections: A retrospective study of the role of RigiScan in predicting the response to sildenafil in erectile dysfunction patients. J Adv Res 2018; 14:93-96. [PMID: 30109146 PMCID: PMC6090085 DOI: 10.1016/j.jare.2018.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/23/2018] [Accepted: 06/10/2018] [Indexed: 01/11/2023] Open
Abstract
Sildenafil enhances the nitric oxide–cGMP pathway of erection, which is claimed to have a role in nocturnal penile tumescence and rigidity (NPTR). This study aimed to find whether RigiScan can predict the response to sildenafil among erectile dysfunction (ED) patients and to find which RigiScan parameter produces the best prediction. Medical records of 172 ED patients were revised regarding their full sexual history, standard andrology examination, NPTR monitoring by the RigiScan device, and the degree of response to sildenafil. Of 172 ED patients, 94 patients (54.7%) were sildenafil responders. All RigiScan parameters were higher in the sildenafil responder group. The RigiScan parameters with the most differentiating power between both sildenafil responders and non-responders were base rigidity (AUC 0.860) and then tip rigidity (AUC 0.831). The cut-off value of base and tip rigidity with the highest diagnostic accuracy was 42.5%. This finding was found to be more specific than the sensitivity in predicting a positive response to sildenafil (85.9% vs. 70.2% and 92.3% vs. 59.6%, for base and tip rigidity, respectively). Sildenafil response in ED cases can be predicted through NPTR monitoring using the RigiScan device and ED patients with RigiScan base or tip rigidity less than 42% are not expected to respond well to sildenafil.
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Campbell JD, Milenkovic U, Albersen M, Bivalacqua TJ. What Is the Future of Erectile Dysfunction Therapy? CURRENT SEXUAL HEALTH REPORTS 2018. [DOI: 10.1007/s11930-018-0153-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hyperbaric oxygen can induce angiogenesis and recover erectile function. Int J Impot Res 2018; 30:292-299. [DOI: 10.1038/s41443-018-0023-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/29/2018] [Accepted: 04/07/2018] [Indexed: 01/28/2023]
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Yang B, Xu P, Shi Y, Xu J, Zheng L, Li H, Ma L, Yang S, Zhao Y, Zhang Y, Du Q, Chu Q, Chen B, Tan Y, Li X, Li C, Sun F, Zhu Y, Li H. Erectile Dysfunction and Associated Risk Factors in Chinese Males of Infertile Couples. J Sex Med 2018; 15:671-677. [PMID: 29576430 DOI: 10.1016/j.jsxm.2018.02.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/01/2018] [Accepted: 02/19/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Knowledge on the occurrence of erectile dysfunction (ED) and timely ovulatory intercourse failure (TOIF) in Chinese men of infertile couples is limited. AIM To obtain representative estimates of ED and TOIF in Chinese men of infertile couples and to analyze potential risk factors associated with ED. METHODS 4,299 Chinese men of infertile couples with an average age of 32.85 ± 5.98 years were surveyed using the 5-item International Index of Erectile Function (IIEF-5) questionnaire for their ED occurrence. Multiple logistic regression analysis was used to disclose risk factors associated with ED. OUTCOMES The occurrence of ED was 57.8% and that of TOIF was up to 26.2% in Chinese men of infertile couples. RESULTS Based on IIEF-5 criteria, 34.9% of men had mild ED and only 2.6% had severe ED. Secondary infertility, infertility with known causes, and chronic prostatitis were significant risk factors associated with ED. TOIF was significantly higher (23.3%) in men of infertile couples with ED than in those without ED (8.6%), indicating that TOIF is likely a contributing factor to male infertility. CLINICAL IMPLICATIONS Understanding the occurrence and types of ED and TOIF in men of infertile couples and their associated risk factors will help physicians treat clinical cases of male infertility more effectively. STRENGTHS AND LIMITATIONS Large numbers of infertile outpatients from multiple hospital clinics across the country were included in this study. The concept of TOIF was raised for the 1st time and studied preliminarily in Chinese men of infertile couples. The lack of participants' psychological status, a control group of men of fertile couples, and measurement of testosterone levels was a limitation in this clinic-based study. CONCLUSION The occurrence of ED was higher in Chinese men of infertile couples than in the general Chinese male population. Yang B, Xu P, Shi Y, et al. Erectile Dysfunction and Associated Risk Factors in Chinese Males of Infertile Couples. J Sex Med 2018;15:671-677.
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Affiliation(s)
- Bin Yang
- Department of Urology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Peng Xu
- Reproductive Center of Jinghua Hospitals, Shenyang Oriental Medical Group, Shenyang, Liaoning, China
| | - Yichao Shi
- Center for Reproduction, Changzhou Number 2 People's Hospital, affiliated with Nanjing Medical University, Changzhou, Jiangsu, China
| | - Jixiu Xu
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Lianwen Zheng
- Reproductive Center of the Second Hospital of Jilin University, Changchun, Jilin, China
| | - Haisong Li
- Department of Andrology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Lianghong Ma
- Department of Urology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Shenmin Yang
- Center for Reproduction and Genetics, Suzhou Municipal Hospital, Suzhou Hospital, affiliated with Nanjing Medical University, Suzhou, Jiangsu, China
| | - Yong Zhao
- Reproductive Medical Center, Navy General Hospital, Beijing, China
| | - Yan Zhang
- Department of Urology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qiang Du
- Department of Reproduction, ShengJing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Qingjun Chu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Bin Chen
- Department of Urology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan Tan
- Department of Andrology, the People's Hospital of Shiyan, Shiyan, Hubei, China
| | - Xiangru Li
- Andrology Clinic, Shengli Hospital of Shengli Petroleum Administrative Bureau, Dongying, Shandong, China
| | - Chaobin Li
- Department of Andrology, Woman and Child Health Hospital, Baoji, Shanxi, China
| | - Fa Sun
- Department of Urology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Yongtong Zhu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Hongjun Li
- Department of Urology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
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Bella AJ, Lee JC, Grober ED, Carrier S, Benard F, Brock GB. 2018 Canadian Urological Association guideline for Peyronie's disease and congenital penile curvature. Can Urol Assoc J 2018; 12:E197-E209. [PMID: 29792593 DOI: 10.5489/cuaj.5255] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Peyronie’s disease (PD) is a highly prevalent condition that affects the physical and psychosocial well-being and quality of life (QoL) for thousands of Canadian men. The specific etiology of PD remains poorly understood and there remains a paucity of randomized placebo-controlled trials evaluating treatment interventions.1-3 PD can be found in up to 8.9% of men, a remarkable increase in cited prevalence that is attributable to growing awareness (as historical data suggested a rate of less than 1%); the burden of disease is significant, and PD is often present in otherwise healthy men. The following guidelines were crafted by the committee with a full awareness of the limitations of the literature, and sought to provide actionable recommendations to guide PD care in the Canadian health system.
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Affiliation(s)
- Anthony J Bella
- Ottawa Urology and Men's Health and Ottawa Hospital Research Institute, Ottawa ON; Canada
| | - Jay C Lee
- Department of Surgery, Division of Urology, University of Calgary, Calgary, AB; Canada
| | - Ethan D Grober
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON; Canada
| | - Serge Carrier
- Division of Urology, McGill University Health Centre, Montreal, QC; Canada
| | - Francois Benard
- Department of Surgery, Université de Montreal, Montreal, QC; Canada
| | - Gerald B Brock
- Department of Surgery, Division of Urology Western University, London, ON; Canada
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Wang H, Ding XG, Yang JJ, Li SW, Zheng H, Gu CH, Jia ZK, Li L. LncRNA MIAT facilitated BM-MSCs differentiation into endothelial cells and restored erectile dysfunction via targeting miR-200a in a rat model of erectile dysfunction. Eur J Cell Biol 2018; 97:180-189. [PMID: 29486902 DOI: 10.1016/j.ejcb.2018.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/06/2018] [Accepted: 02/06/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Bone-marrow derived mesenchymal stem cells (BM-MSCs) implantation effectively restored rats' erectile dysfunction (ED). Long noncoding RNA (LncRNA)-myocardial infarction-associated transcript (MIAT) has been reported to play an important role in regulating endothelial cells (ECs) function via vascular endothelial growth factor (VEGF) that induced BM-MSCs differentiation into ECs. However, the molecular functions and biological roles of lncRNA MIAT in ED remained unclear. METHODS The rat model of ED was established. Quantitative real-time PCR (qRT-PCR) and western blotting were used to detect the expression of lncRNA MIAT, von Willebrand factor (vWF), vascular endothelial cadherin (VE-cadherin), endothelial NO synthase (eNOS) and VEGF following BM-MSCs transfection. Erectile function was evaluated by intra-cavernous pressure/mean artery pressure (ICP/MAP). Furthermore, RNA immunoprecipitation (RIP) assay and RNA pull down as well as luciferase reporter assay were carried out to examine the interaction among lncRNA MIAT, miR-200a and VEGF. RESULTS BM-MSCs restored ED by upregulating lncRNA MIAT. LncRNA MIAT was upregulated in a time-dependent manner during BM-MSCs differentiation into ECs. LncRNA MIAT regulated VEGF via targeting miR-200a, thereby promoting BM-MSCs differentiation into ECs. LncRNA MIAT knockdown in vivo abolished the effect of BM-MSCs on ED. CONCLUSION LncRNA MIAT promoted BM-MSCs differentiation into ECs and restored ED via miR-200a.
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Affiliation(s)
- Hui Wang
- Department of Urology and Andrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, PR China.
| | - Xie-Gang Ding
- Department of Urology and Andrology, Zhongnan Hospital, Wuhan University, Wuhan 430071, PR China
| | - Jin-Jian Yang
- Department of Urology and Andrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, PR China
| | - Shi-Wen Li
- Department of Urology and Andrology, Zhongnan Hospital, Wuhan University, Wuhan 430071, PR China
| | - Hang Zheng
- Department of Urology and Andrology, Zhongnan Hospital, Wuhan University, Wuhan 430071, PR China
| | - Chao-Hui Gu
- Department of Urology and Andrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, PR China
| | - Zhan-Kui Jia
- Department of Urology and Andrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, PR China
| | - Lu Li
- Health Science and Technology (Beijing) Co., Ltd., Boao Yiheshanzhuang, Beijing 102209, PR China
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Pascoal EL, Slater M, Guiang C. Discussing sexual health with aging patients in primary care: Exploratory findings at a Canadian urban academic hospital. CANADIAN JOURNAL OF HUMAN SEXUALITY 2017. [DOI: 10.3138/cjhs.2016-0011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Sexuality is an important component of overall health and quality of life, yet evidence suggests many aging adults are not discussing sexual health with their physician. The objective of this study was to understand practices of primary care physicians in discussing sexual health with aging patients. An electronic survey was distributed to primary care physicians and family medicine residents at an urban academic hospital in Ontario, Canada. The survey captured the self-reported prevalence of discussions of sexual health with patients aged 50 and above as well as patient, physician and contextual factors influencing the likelihood of discussion. Descriptive statistics were used to summarize the results. Among the 37 physicians who responded to the survey (response rate of 24%), physicians were more likely to discuss sexual health with patients aged 50–75 years than with patient s>75 years with both males (p<0.0001) and females (p<0.0001). Most frequently discussed issues with males were erectile dysfunction and sexually transmitted infection, while atrophic vaginitis, bleeding, and pain during intercourse were most often discussed with females. Factors limiting discussion include lack of time, multiple patient comorbidities and a perceived disinterest in sexual activity. 54% of respondents report having adequate knowledge to discuss and manage later life sexual health issues. Proactively discussing sexuality with aging adults may reveal underlying illness and facilitate future help-seeking behaviours. We suggest that primary care physicians have a responsibility to routinely initiate such discussions in clinical practice.
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Affiliation(s)
| | - Morgan Slater
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, ON
| | - Charlie Guiang
- Faculty of Medicine, University of Toronto, Toronto, ON
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, ON
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The Efficacy of Tadalafil Daily vs on Demand in the Treatment of Erectile Dysfunction: A Systematic Review and Meta-analysis. Urology 2017; 112:6-11. [PMID: 28882778 DOI: 10.1016/j.urology.2017.08.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/12/2017] [Accepted: 08/18/2017] [Indexed: 11/23/2022]
Abstract
We present a review comparing the use of tadalafil daily vs on-demand for erectile dysfunction. We examined randomized controlled trials and observational studies that examined the use of tadalafil for at least 8 weeks of follow-up with the primary outcome of International Index for Erectile Dysfunction-Erectile Function domain. Eight studies that examined the desired dosing regimens were identified. Of these, 6 studies included the primary end point of 12 weeks. Those patients taking tadalafil daily for 12 weeks scored on average 1.82 points higher in International Index for Erectile Dysfunction-Erectile Function domain scores, although the difference may not be clinically significant (Fig. 1).
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Neuroprotective and Nerve Regenerative Approaches for Treatment of Erectile Dysfunction after Cavernous Nerve Injury. Int J Mol Sci 2017; 18:ijms18081794. [PMID: 28820434 PMCID: PMC5578182 DOI: 10.3390/ijms18081794] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 01/02/2023] Open
Abstract
Erectile dysfunction (ED) is a significant cause of reduced quality of life in men and their partners. Cavernous nerve injury (CNI) during pelvic surgery results in ED in greater than 50% of patients, regardless of additional patient factors. ED related to CNI is difficult to treat and typically poorly responsive to first- and second-line therapeutic options. Recently, a significant amount of research has been devoted to exploring neuroprotective and neuroregenerative approaches to salvage erectile function in patients with CNI. In addition, therapeutic options such as neuregulins, immunophilin ligands, gene therapy, stem cell therapy and novel surgical strategies, have shown benefit in pre-clinical, and limited clinical studies. In the era of personalized medicine, these new therapeutic technologies will be the future of ED treatment and are described in this review.
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Di Francesco S, Tenaglia RL. Mediterranean diet and erectile dysfunction: a current perspective. Cent European J Urol 2017; 70:185-187. [PMID: 28721287 PMCID: PMC5510347 DOI: 10.5173/ceju.2017.1356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 04/15/2017] [Accepted: 04/18/2017] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION In this current perspective we analyzed the role of Mediterranean diet (MedDiet) in sexual function and particularly in erectile dysfunction (ED), according to the latest scientific evidence. MATERIAL AND METHODS We conducted a systematic search of relevant full-length papers identified during the time period from 1 January 2010 to the present. RESULTS Published studies showed that adherence to a MedDiet contributes to preventing ED through an improved lipid and glucose metabolism, increased antioxidant defenses, and increased arginine levels which could raise nitric oxide activity. CONCLUSIONS Our findings suggest that the encouragement of a healthy lifestyle, such as MedDiet promotion, could be an attractive dietary approach to prevent ED and preserve sexual function.
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Affiliation(s)
- Simona Di Francesco
- G. D'Annunzio University of Chieti-Pescara, Department of Medical and Oral Sciences and Biotechnologies, Chieti, Italy
| | - Raffaele Lanfranco Tenaglia
- G. D'Annunzio University of Chieti-Pescara, Department of Medical and Oral Sciences and Biotechnologies, Chieti, Italy
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In vitro and in vivo investigation of natural compounds from seed extract of Mucuna pruriens lacking l-DOPA for the treatment of erectile dysfunction. ASIAN PAC J TROP MED 2017; 10:238-252. [PMID: 28442107 DOI: 10.1016/j.apjtm.2017.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/06/2017] [Accepted: 02/27/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To investigate the biological effects of the Mucuna pruriens (M. pruriens) seed extracts that lacked l-DOPA, which was formerly reported as the active ingredient, on erectile dysfunction (ED) both in vitro and in vivo. METHODS Seed of M. pruriens plant that cultivated in Mae Taeng District, Chiang Mai Province, Thailand, was collected. Component of its seeds were extracted and isolated into 2 fractions using methanol, polar and nonpolar. Each fraction was investigated for phytochemicals using gas chromatography and mass spectroscopy and was screened for biological activity in vitro using three different cell lines. The most biological active fraction was used to treat both streptozotocin (STZ)-induced diabetes mellitus-erectile dysfunction (DM-ED) male Wistar rats and normal rats (n = 6 per groups) to compare the effect on sexual behavior parameters, including number of intromission, mounting and ejaculation, with that of rats given Sildenafil by individually pairing with their female counterparts. Penile tissues and serums were collected to determine histological structure, related gene expression and biomolecules. RESULTS The phytochemicals of the polar fraction were possibly catechol and its derivatives plus polyphenols, whereas the nonpolar fraction consisted of lipid derivatives. l-DOPA was not detected in either of the extracts. The polar fraction was able to up-regulate the expression of ED-related genes including eNOS and nNOS in vitro which subsequently promotes nitric oxide production and maintains intracellular cyclic guanosine monophosphate levels. When administrated to DM-ED rats, the polar extract significantly improved all sexual behavior parameters in DM-ED rats compared to untreated group (18.3 ± 1.8 to 10.8 ± 2.9 for intromission, 9.8 ± 2.2 to 5.7 ± 1.3 for mounting, and 1.8 ± 0.6 to 0.2 ± 0.4 for ejaculation). That effect might due to the ability of the extract to stimulate the expression of eNOS and nNOS which results in nitric oxide production and subsequently maintains cyclic guanosine monophosphate levels in penile tissue. Moreover, this extract may also prevent penile tissue deterioration due to diabetes. CONCLUSIONS The polar extract of M. pruriens seed can be used for ED therapy, especially in patients with metabolic diseases including diabetes. The action of the extract might be due to catechol and its derivatives and polyphenols.
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Turkay R, Inci E, Yenice MG, Tugcu V. Shear wave elastography: Can it be a new radiologic approach for the diagnosis of erectile dysfunction? ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2017; 25:150-155. [PMID: 29410690 DOI: 10.1177/1742271x17697512] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/02/2017] [Indexed: 01/12/2023]
Abstract
Introduction Erectile dysfunction (ED) is a common health problem among males, and radiology has limited use in its diagnosis and treatment. Shear wave elastography (SWE) is a new sonographic technique. In this study, we examined the significance of SWE in the diagnosis of ED. Methods The study included a total number of 70 participants. The mean age of the participants was 54.14 ± 8.03 years (range: 39 and 71 years old). We composed two groups. Group 1 had 35 patients who presented to the urology clinic in our hospital complaining of ED, and had a score of 17 or lower from the International Index of Erectile Function (IIEF) questionnaire. Group 2 consisted of 35 healthy volunteers who did not have ED. SWE measurements were performed from corpus cavernosum penis in both groups, and the results were noted. Differences between the groups were evaluated statistically. Results The difference between the mean SWE measurements of two groups (Group 1: 20.94 ± 6.23 kPa and group 2: 24.63 ± 7.58 kPa) was found to be statistically significant (p = 0.027; p < 0.05). For a cut-off value of 17.1 kPa, the SWE method has specificity, sensitivity, positive predictive value, and negative predictive value regarding diagnosis of ED as 94.29%, 34.29%, 85.71%, and 58.93%, respectively. The mean age of the groups did not show a statistically significant difference (p = 0.287; p > 0.05). Conclusions Due to its high specificity and positive predictive value, SWE can offer useful data in the radiologic evaluation of ED cases.
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Campbell J, Alzubaidi R. Understanding the cellular basis and pathophysiology of Peyronie's disease to optimize treatment for erectile dysfunction. Transl Androl Urol 2017; 6:46-59. [PMID: 28217450 PMCID: PMC5313310 DOI: 10.21037/tau.2016.11.01] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Erectile dysfunction (ED) is a common condition that significantly impacts a man’s physical and psychological well-being. ED is often associated with Peyronie’s disease (PD), which is an abnormal curvature of the penis. Delayed treatment of or surgical invention for PD often results in ED and therefore unsatisfied patients. The pathophysiology of PD is incompletely understood, but has been studied extensively and based on our current understanding of PD physiology, many medical treatment options have been proposed. In this paper, we will review what is known about the pathophysiology of PD and the medical treatment options that have been trialed as a result. More investigations in regards to the basic science of PD need to be carried out in order to elucidate the exact mechanisms of the fibrosis, and propose new, more successful treatment options which should be implemented prior to the onset of ED.
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Affiliation(s)
- Jeffrey Campbell
- London Health Sciences Centre and St. Joseph's Health Care, Western University, London, Ontario, Canada
| | - Raidh Alzubaidi
- London Health Sciences Centre and St. Joseph's Health Care, Western University, London, Ontario, Canada
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Mandava S, Ganganna B, Hwang J, Jang Y, Hwang J, Samala M, Kim KB, Park H, Lee JH, Baek SY, Lee J. Synthesis and Structure Revision of Dimeric Tadalafil Analogue Adulterants in Dietary Supplements. Chem Pharm Bull (Tokyo) 2017; 65:498-503. [DOI: 10.1248/cpb.c17-00034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
| | | | | | | | - Jiho Hwang
- College of Pharmacy, Kangwon National University
| | | | - Ki-Bbeum Kim
- College of Pharmacy, Kangwon National University
| | - Haeil Park
- College of Pharmacy, Kangwon National University
| | - Ji Hyun Lee
- Advanced Analysis Team, Toxicological Evalauation and Research Department, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety
| | - Sun Young Baek
- Advanced Analysis Team, Toxicological Evalauation and Research Department, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety
| | - Jongkook Lee
- College of Pharmacy, Kangwon National University
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Choi HK, Jung JA, Shon J, Bahng MY, Cho DY, Yeo CW, Kim EY, Shin JG. The Effect of Age on the Pharmacokinetics of Udenafil in Healthy Subjects. J Clin Pharmacol 2016; 56:1372-1377. [PMID: 27006150 DOI: 10.1002/jcph.739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/17/2016] [Indexed: 11/07/2022]
Abstract
Udenafil, a cyclic guanosine monophosphate-specific phosphodiesterase type 5 inhibitor, has been developed to treat erectile dysfunction. We evaluated the effect of age on the pharmacokinetics and tolerability of udenafil. A single-center, open-label, parallel-group phase 1 study was conducted in healthy adult subjects who took a single oral dose of udenafil (100 mg). The pharmacokinetics and tolerability of udenafil were compared between 12 healthy young men (21-27 years) and 12 healthy elderly men (65-78 years). Serial blood and urine samples were collected for up to 60 and 48 hours after dosing. The plasma concentrations of udenafil and its major metabolite, DA-8164, were analyzed using a validated liquid chromatography-tandem mass spectrometry method. The mean Cmax of udenafil tended to be slightly less (214.0 vs 292.8 μg/L) in the elderly compared with the young (GMR, 68.9; 95% CI, 48.9-97.1); however, the AUC did not differ between the groups (1858.8 vs 2100.6 μg·h/L; GMR, 84.6; 95% CI, 66.1-108.4). The mean t1/2 was prolonged by approximately 5 hours in the elderly (P < .05). The clearance and metabolic AUC ratio did not differ between the elderly and young. In terms of tolerability, all adverse events were mild, and all subjects recovered without additional therapy. The systemic exposure of elderly subjects to udenafil appears to be comparable to or slightly less than that of young healthy subjects. Based on our pharmacokinetic comparisons, udenafil dose adjustment is unlikely to be required in the elderly population.
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Affiliation(s)
- Hyang-Ki Choi
- Department of Pharmacology, Inje University College of Medicine, Busan Jin-gu, Busan, Republic of Korea
| | - Jin Ah Jung
- Department of Pharmacology, Inje University College of Medicine, Busan Jin-gu, Busan, Republic of Korea.,Department of Clinical Pharmacology, Inje University Busan Paik Hospital, Busan Jin-gu, Busan, Republic of Korea
| | - Jihong Shon
- Department of Pharmacology, Inje University College of Medicine, Busan Jin-gu, Busan, Republic of Korea.,Department of Clinical Pharmacology, Inje University Busan Paik Hospital, Busan Jin-gu, Busan, Republic of Korea
| | - Mi Young Bahng
- Dong-A ST Co., Ltd, Dong Dae Moon-gu, Seoul, Republic of Korea
| | - Doo-Yeoun Cho
- Department of Clinical Pharmacology and Therapeutics, CHA Bundang Medical Center, CHA University, Bundang-gu, Seongnam, Republic of Korea
| | - Chang Woo Yeo
- Department of Pharmacology, Inje University College of Medicine, Busan Jin-gu, Busan, Republic of Korea.,Department of Clinical Pharmacology, Inje University Busan Paik Hospital, Busan Jin-gu, Busan, Republic of Korea
| | - Eun-Young Kim
- Department of Pharmacology, Inje University College of Medicine, Busan Jin-gu, Busan, Republic of Korea.,Department of Clinical Pharmacology, Inje University Busan Paik Hospital, Busan Jin-gu, Busan, Republic of Korea
| | - Jae-Gook Shin
- Department of Pharmacology, Inje University College of Medicine, Busan Jin-gu, Busan, Republic of Korea. .,Department of Clinical Pharmacology, Inje University Busan Paik Hospital, Busan Jin-gu, Busan, Republic of Korea.
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45
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Maasoumi R, Mokarami H, Nazifi M, Stallones L, Taban A, Yazdani Aval M, Samimi K. Psychometric Properties of the Persian Translation of the Sexual Quality of Life-Male Questionnaire. Am J Mens Health 2016; 11:564-572. [PMID: 26856758 DOI: 10.1177/1557988316629641] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Sexual dysfunction has been demonstrated to be related to a poor quality of life. These dysfunctions are especially prevalent among men. This cross-sectional study aimed to investigate the psychometric properties of the Persian translation of the Sexual Quality of Life-Male (SQOL-M), translated and adapted to measure sexual quality of life among Iranian men. Forward-backward procedures were applied in translating the original SQOL-M into Persian, and then the psychometric properties of the Persian translation of the SQOL-M were studied. A total of 181 participants (23-60 years old) were included in the study. Validity was assessed by construct validity using confirmatory factor analysis, convergent validity, and content validity. The international index of erectile function (IIEF) and the work ability index were used to study the convergent validity. Reliability was evaluated through internal consistency and test-retest reliability analyses. The results from confirmatory factor analysis confirmed a one-factor solution for the Persian version of the SQOL-M. Content validity of the translated measure was endorsed by 10 specialists. Pearson correlations indicated that work ability index score, dimensions of the IIEF, and the IIEF total score were positively correlated with the Persian version of the SQOL-M ( p < .001). Reliability evaluation indicated a high internal consistency and test-retest reliability. The Cronbach's alpha coefficient and intraclass correlation coefficients were .96 and .95, respectively. Results indicated that the Persian version of the SQOL-M has good to excellent psychometric properties and can be used to assess the sexual quality of life among Iranian men.
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Affiliation(s)
| | | | | | | | | | | | - Kazem Samimi
- 6 Birjand University of Medical Sciences, Birjand, Iran
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46
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Kovac JR. A critical analysis of the 2014 CUA guidelines for erectile dysfunction: Is there more that can be done? Can Urol Assoc J 2015; 9:30-1. [PMID: 25737751 DOI: 10.5489/cuaj.2731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Jason R Kovac
- Urology of Indiana, Male Reproductive Endocrinology and Surgery, Carmel, IN
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