Canadian Urological Association guideline: Erectile dysfunction

Risk of major adverse cardiovascular events in rural vs urban settings among patients with erectile dysfunction: a propensity-weighted retrospective cohort study of 430 621 men

BACKGROUND

The relationship between erectile dysfunction (ED) and cardiovascular (CV) events has been postulated, with ED being characterized as a potential harbinger of CV disease. Location of residence is another important consideration, as the impact of rural residence has been associated with worse health outcomes.

AIM

To investigate whether men from rural settings with ED are associated with a higher risk of major adverse CV events (MACEs).

METHODS

A propensity-weighted retrospective cohort study was conducted with provincial health administrative databases. ED was defined as having at least 2 ED prescriptions filled within 1 year. MACE was defined as the first hospitalization for an episode of acute myocardial infarction, heart failure, or stroke that resulted in a hospital visit >24 hours. We classified study groups into ED urban, ED rural, no ED urban, and no ED rural. A multiple logistic regression model was used to determine the propensity score. Stabilized inverse propensity treatment weighting was then applied to the propensity score.

OUTCOMES

A Cox proportional hazard model was used to examine our primary outcome of time to a MACE.

RESULTS

The median time to a MACE was 2731, 2635, 2441, and 2508 days for ED urban (n = 32 341), ED rural (n = 18 025), no ED rural (n = 146 358), and no ED urban (n = 233 897), respectively. The cohort with ED had a higher proportion of a MACE at 8.94% (n = 4503), as opposed to 4.58% (n = 17 416) for the group without ED. As compared with no ED urban, no ED rural was associated with higher risks of a MACE in stabilized time-varying comodels based on inverse probability treatment weighting (hazard ratio, 1.06-1.08). ED rural was associated with significantly higher risks of a MACE vs no ED rural, with the strength of the effect estimates increasing over time (hazard ratio, 1.10-1.74).

CLINICAL IMPLICATIONS

Findings highlight the need for physicians treating patients with ED to address CV risk factors for primary and secondary prevention of CV diseases.

STRENGTHS AND LIMITATIONS

This is the most extensive retrospective study demonstrating that ED is an independent risk factor for MACE. Due to limitations in data, we were unable to assess certain comorbidities, including obesity and smoking.

CONCLUSIONS

Our study confirms that ED is an independent risk factor for MACE. Rural men had a higher risk of MACE, with an even higher risk among those who reside rurally and are diagnosed with ED.

Analysis of vacuum negative pressure therapy and traditional Chinese medicine lavage in combination with tadalafil for vascular erectile dysfunction

This study investigates the clinical effects of the novel Traditional Chinese Medicine (TCM) topical wash used in combination with negative pressure irrigation and tadalafil for the treatment of vascular erectile dysfunction. Eighty-seven patients with vascular erectile dysfunction were divided into an observation group and a control group. The observation group was administered negative pressure irrigation (TCM) in combination with oral tadalafil for four weeks, and the control group was administered oral tadalafil for four weeks. The observation group included 21 patients with arterial erectile dysfunction and 22 with intravenous erectile dysfunction. After treatment, IIEF-5, EHS, GAD scores, PSV, EDV and RI in observation group were improved compared with those before treatment (P = 0.000, 0.000, 0.000, L0.000/R0.000, L0.000/R0.000, L0.003/R0.000). Erectile function (IIEF-5, EHS) was significantly improved compared with the control group (P = 0.008, 0.002). In the observation group, there were 21 cases of arterial erectile dysfunction and 22 cases of intravenous erectile dysfunction. After treatment, PSV of arterial ED improved significantly (P = L0.000/R0.000), but EDV did not decrease significantly (P = L0.084/R 0.098). In patients with venous ED, PSV increased (P = L0.026/R0.032) and EDV decreased significantly (P = L0.000/R0.000). These findings suggest that TCM negative pressure lavage combined with tadalafil improves the blood supply of the penile artery, relaxes smooth muscle, and improves the closing mechanism of venous vessels in patients with vascular erectile dysfunction, ultimately improving the erectile function.

Periodontitis as a risk factor for organic erectile dysfunction: A case-control study in a sub-Saharan population

Background

This study investigated the association between periodontitis and organic erectile dysfunction (ED) in a sub-Saharan population.

Methods

This multicenter analytical study lasted from April to September 2021. A total of 114 patients (38 cases and 76 controls) were recruited and matched on age, diabetes, and smoking status. Medical history and ED were recorded, as well as the plaque index, bleeding index, maximum interdental clinical attachment loss (CALmax), maximum probing depth, clinically detectable furcation involv ement, number of teeth in the mouth, number of teeth lost for periodontal reasons, and tooth mobility. The analysis was performed with SPSS 20.0 with a significance threshold set at 5%.

Results

The two study groups were comparable regarding sociodemographic characteristics. Periodontitis was present in 76.31% of cases and 75% of controls without a significant difference (P=0.878). Logistic regression showed a significant association between high blood pressure and ED with an OR=4.78 (95% CI: 1.80‒12.70). Periodontitis was not associated with ED (OR=1.52, 95% CI: 0.55‒4.16); however, severe periodontitis was significantly associated with severe ED (OR=1.44, 95% CI: 1.11‒1.85, and OR=1.68, 95% CI: 1.15‒2.44, respectively for CALmax and tooth loss).

Conclusion

Within the limits of this study, periodontitis was not associated with organic ED. However, the severity of periodontal disease significantly increased in patients with organic ED.

Survey of the quality and origins of websites on penile low-intensity shockwave therapy in Canada

INTRODUCTION

The aim of this study was to establish the quality of patient-facing websites advertising low-intensity shockwave therapy (LISWT) for erectile dysfunction (ED) and Peyronie's disease (PD) patients in Canada.

METHODS

Canadian websites offering LIWST for ED or PD were identified using online web searches. The characteristics of these websites were reviewed, along with examining the presence of HONCode certification, assigning a brief DISCERN score (a tool designed to evaluate health information online) and readability scores. We also examined the LIWST technology advertised, as well as benefits of LIWST cited by the websites.

RESULTS

Twenty-five unique websites linked to 46 clinics were identified and reviewed. Twenty-four percent of websites were run by a urologist. Other specialties offering LISWT included general practitioners, anesthesiologists, naturopaths, nurse practitioners, physiotherapists, and registered massage therapists. Twenty-four percent of the websites advertised the use of a focused shockwave generator. Forty percent of the websites had peer-reviewed references. The average brief DISCERN score was 14 (standard deviation 3.4). There was no association between the physician-or non-physician-led websites and the use of peer-reviewed references, readability scores, the number of clinic locations, or higher brief discern scores.

CONCLUSIONS

LISWT is readily advertised online for ED and PD patients in Canada; however, only a minority use a focused shockwave generator. There is a wide diversity of practitioners offering LISWT. Websites offering LISWT are generally of poor quality and do not provide adequate information for patients to make educated treatment decisions.

A fragility index analysis of clinical trials evaluating low-intensity extracorporeal shockwave therapy for erectile dysfunction

Erectile dysfunction is a common sexual dysfunction that affects a significant proportion of men. Low-intensity extracorporeal shockwave therapy has been evaluated in multiple clinical trials as a therapeutic option for men with erectile dysfunction. The robustness of these clinical trials is not well defined, as the trials are hindered by inconsistent treatment protocols, small study arm size and short follow-up intervals. The fragility index is a statistical analysis which is used to evaluate the robustness of clinical trials. It is calculated by evaluating the minimum number of patients in a given trial arm that would be required to have an alternative outcome to alter the statistical significance of the results. The lowest fragility index in statistically significant trials is 1, meaning that if just one participant experienced an alternate outcome, the results would no longer achieve statistical significance. The upper limit is determined by the number of participants in a given arm of the trial. Herein, a scoping review of clinical trials evaluating the efficacy of low-intensity extracorporeal shockwave therapy in erectile dysfunction to determine the fragility index of trials with clinically significant results. We hypothesized that the fragility index would be low, indicating the results are less robust and generalizable.

Altered regional brain activity and functional connectivity in resting-state brain networks associated with psychological erectile dysfunction

Introduction

Erectile dysfunction (ED), especially psychological ED (pED), is usually accompanied with psychological factors, which are related to abnormal activity in brain regions involved in sexual behavior. However, the mechanisms underlying functional changes in the brain of pED are still unclear. The present study aimed to explore the abnormalities of brain function, as well as their relationships with sexual behavior and emotion in pED patients.

Materials and methods

Resting state functional magnetic resonance imaging (rs-fMRI) data were collected from 31 pED patients to 31 healthy controls (HCs). The values of amplitude of fractional amplitude of low-frequency fluctuation (fALFF) and functional connectivity (FC) were calculated and compared between groups. In addition, the associations between abnormal brain regions and clinical features were evaluated by Pearson correlation analyses.

Results

Compared to HCs, pED patients demonstrated decreased fALFF values in the left medial superior frontal gyrus (had decreased FC values with the left dorsolateral superior frontal gyrus), the left lingual gyrus (had decreased FC values with the left parahippocamal gyrus and insula), the left putamen (had decreased FC values with the right caudate) and the right putamen (had decreased FC values with the left putamen and the right caudate). The fALFF values of the left medial superior frontal gyrus were negatively correlated with the fifth item scores of International Index of Erectile Function (IIEF-5). Negative relationships were found between fALFF values of the left putamen and the second item scores of Arizona Sexual Scale (ASEX). FC values between the right putamen and caudate were negatively related to the state scores of State-Trait Anxiety Inventory (STAI-S).

Conclusion

Altered brain function were found in the medial superior frontal gyrus and caudate-putamen of pED patients, which were associated with sexual function and psychological condition. These findings provided new insights into the central pathological mechanisms of pED.

Does Testosterone Salvage PDE5i Non-Responders? A Scoping Review

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.

Atlas of 35 patient reported outcome measures (PROMs) in andrology: a comprehensive overview of literature

INTRODUCTION

Disorders of male sexual health and functioning are complex and can have significant deleterious effects on patients psychological wellbeing and interpersonal relationships. It is well recognised that clinicians have an overall poor understanding of the true effect that disease has on their patients and self-reported patient-reported outcome measures (PROMs) aim to better communicate these issues. PROMs are generally welcomed by patients and their use in this highly sensitive area of clinical practice is well recognised. An atlas of available PROMs for key conditions in andrology is presented in this article.

METHODS

A comprehensive search of world literature was conducted from the inception of databases to June 2022, to identify male-specific PROMs relevant to four key andrological disorders: hypogonadism, erectile dysfunction, penile curvature and disorders of ejaculation. Each tool was evaluated in narrative format.

RESULTS

35 PROMs were identified. 6 were designed for the assessment of hypogonadism, 18 for erectile dysfunction, one for penile curvature and 10 for ejaculatory disorders. In general, PROMs were brief, self-administered and user-friendly. There was sufficient scope and variety in all categories (apart from penile curvature) to give the clinician flexibility in tool selection and find an appropriate tool for different scenarios.

CONCLUSION

A number of PROMs exist within andrology that can be utilised in both research and clinical settings. PROMs enable subjective evaluation of difficult-to-assess aspects of the patient experience.

Psychosocial risk factors of erectile dysfunction among heterosexual men living with HIV

ABSTRACTThe risk of erectile dysfunction (ED) is significantly higher in men living with HIV (MLWH). Despite the adverse effects of ED on quality of life for MLWH, there is a lack of research on the psychosocial factors that may influence ED, especially among heterosexual MLWH. According to a recent systematic review, findings on the psychosocial risk factors of ED in past studies have been largely conflicting or inconclusive. To bridge this gap, we analyzed psychosocial and other correlates of ED among a sample of 317 primarily Black and Latino heterosexual adult MLWH in New York City. Data collection involved quantitative surveys administered using a combination of computer-assisted personal interview and audio computer-assisted self-interview techniques. After adjusting for age and general health, the relative risk of ED among heterosexual men living with HIV was associated with higher HIV-related stigma, anxiety, depression, and negative HIV-coping; greater social support was associated with a lower risk of ED. In addition, the data were consistent with the potential effects of childhood emotional, physical, and sexual abuse and structural discrimination on the risk of ED. Overall, our research findings help provide a better understanding of the psychosocial factors associated with ED among heterosexual MLWH.

Ageing male (part 2): Management of functional hypogonadism in older men, a patient-centric holistic approach

The diagnosis of functional hypogonadism should prompt a thorough assessment and optimization of general health, including lifestyle changes, weight reduction, care of comorbidities and cessation of offending medications, some of which can lead to meaningful gains in endogenous testosterone (T) concentrations. Having excluded or addressed reversible causes and contra-indications, patients with functional hypogonadism can be offered a trial of testosterone replacement therapy (TRT) after full discussion on the anticipated benefits and potential risks. T treatment improves libido but may be less effective for erectile dysfunction (ED). T treatment can also have modest positive effects on insulin resistance, bone strength, some measures of physical strength, and mild depressive symptoms but the clinical significance of these relatively short-term improvements remain uncertain in terms of longer-term patient-important outcomes. Initiation of TRT is a joint decision between patient and clinician since longer-term benefits and risks have not been adequately defined.

Assessment of the intracavernosal injection platelet-rich plasma in addition to daily oral tadalafil intake in diabetic patients with erectile dysfunction non-responding to on-demand oral PDE5 inhibitors

This study aimed to evaluate the effectiveness of ICI of platelet-rich plasma (PRP) in addition to daily oral tadalafil intake in diabetic erectile dysfunction (ED) patients non-responding to PDE5 inhibitors. Overall, 48 patients complaining of ED non-responding to on-demand PDE5 inhibitors were allocated into 2 equal groups, diabetics and non-diabetics that were given a daily dose of 5 mg tadalafil plus vardenafil 20 mg on demand during the study besides being subjected to 3 doses of ICI of PRP, 4 weeks apart. Responses to on-demand PDE5 inhibitors, International index of erectile function-5 (IIEF-5) score, erection hardness scores (EHS) and pharmaco-dynamic duplex studies were assessed. After PRP injections, 33% and 50% of cases were satisfied with on-demand PDE5 inhibitors, respectively, whereas 41% and 66% of them showed improved EHS response. Compared with baseline scores, the mean IIEF-5 scores were significantly improved after PRP therapy in the diabetic ED group (12.1 vs. 8.04, p = 0.003) as well as in the non-diabetic ED group (14.8 vs. 10.2, p = 0.001) linked to pharmaco-penile duplex readings. Both good and fair diabetic control exhibited significant responses to ICI therapy of PRP compared with bad controlled cases. The significant improvement included; the IIEF-5 score increase (86.7%, 126% vs. 16.1%), improved EHS as well as penile duplex readings. Baseline HbA1C demonstrated a significant negative correlation with IIEF-5 score before (p = 0.019) and after PRP therapy (p = 0.002) respectively. It could be concluded that ICI of PRP could be an effective therapy for treating ED patients non-responding to on-demand oral PDE5 treatment.

Accurate and time‐saving, two‐step intracavernosal injection procedure to diagnose psychological erectile dysfunction

Background

The recognition of the erectile dysfunction pathogenesis is essential to identify the appropriate erectile dysfunction management. As vascular erectile dysfunction could be a manifestation of a systemic arterial damage, the watershed in the erectile dysfunction diagnostic framework is the discrimination between psychological erectile dysfunction and vascular erectile dysfunction. However, reliable tools to directly diagnose psychological erectile dysfunction are currently lacking.

Objective

To identify which parameters could predict psychological erectile dysfunction. Moreover, we suggest a new intracavernosal injection procedure to optimize the erectile dysfunction diagnostic workup.

Materials and methods

A retrospective, real‐world analysis was carried out including all men who underwent intracavernosal injection procedure at the Modena Andrology Unit from 2018 to 2021. A first intracavernosal injection procedure with 5 µg of prostaglandin E‐1 (PGE‐1) was performed. In the absence of a full drug‐induced erection (immediate or delayed), an echo‐color Doppler penile evaluation after administration of PGE‐1 10 µg was conducted, measuring intracavernosal blood flows, to document a possible vascular etiology. Hormonal evaluations were performed.

Results

Out of 179 enrolled patients, 70.4% showed psychological erectile dysfunction, 21.7% vascular erectile dysfunction, and 7.8% hormonal genesis. Multinomial logistic regression analysis identified absence of cardiovascular disease (p = 0.017), presence of spontaneous morning erections (p = 0.018), and normal penile erections with masturbation (p = 0.035) as predictors of psychological erectile dysfunction. Clinically, normal intracavernosal injection test response was detected in 86 patients and abnormal response in 93 subjects. Among the latter, 54 patients experienced a delayed response. The combination of intracavernosal injection test with late penile erections evaluation was able to diagnose psychological erectile dysfunction (sensitivity 97%, specificity 100%), avoiding unnecessary retesting.

Discussion

We propose a two‐step intracavernosal injection procedure that allows to recognize psychological erectile dysfunction with a high sensitivity/specificity, saving costs and time, and limiting adverse events. Moreover, the presence of spontaneous morning erections and valid penile erections after masturbation could guide the diagnostic workup, indirectly identifying those patients deserving of a deeper evaluation of vascular health.

Technological Advancements for Treating Erectile Dysfunction and Peyronie's Disease

Over the past decade, there have been several advancements in the technologies available to treatment erectile dysfunction and Peyronie's disease. Vacuum erection devices, penile traction devices, low-intensity extracorporeal shockwave therapy, and penile prosthesis surgery have evolved and are changing the way we treat men's health. Although significant improvements have been made, further work is needed to standardize treatment, create universal algorithms for technological applications, and simply their use.