Korean Society for Sexual Medicine and Andrology (KSSMA) Guideline on Erectile Dysfunction

Management of Male Infertility with Coexisting Sexual Dysfunction: A Consensus Statement and Clinical Recommendations from the Asia-Pacific Society of Sexual Medicine (APSSM) and the Asian Society of Men's Health and Aging (ASMHA)

Male infertility (MI) and male sexual dysfunction (MSD) can often coexist together due to various interplay factors such as psychosexual, sociocultural and relationship dynamics. The presence of each form of MSD can adversely impact male reproduction and treatment strategies will need to be individualized based on patients' factors, local expertise, and geographical socioeconomic status. The Asia Pacific Society of Sexual Medicine (APSSM) and the Asian Society of Men's Health and Aging (ASMHA) aim to provide a consensus statement and practical set of clinical recommendations based on current evidence to guide clinicians in the management of MI and MSD within the Asia-Pacific (AP) region. A comprehensive, narrative review of the literature was performed to identify the various forms of MSD and their association with MI. MEDLINE and EMBASE databases were searched for the following English language articles under the following terms: "low libido", "erectile dysfunction", "ejaculatory dysfunction", "premature ejaculation", "retrograde ejaculation", "delayed ejaculation", "anejaculation", and "orgasmic dysfunction" between January 2001 to June 2022 with emphasis on published guidelines endorsed by various organizations. This APSSM consensus committee panel evaluated and provided evidence-based recommendations on MI and clinically relevant MSD areas using a modified Delphi method by the panel and specific emphasis on locoregional socio-economic-cultural issues relevant to the AP region. While variations exist in treatment strategies for managing MI and MSD due to geographical expertise, locoregional resources, and sociocultural factors, the panel agreed that comprehensive fertility evaluation with a multidisciplinary management approach to each MSD domain is recommended. It is important to address individual MI issues with an emphasis on improving spermatogenesis and facilitating reproductive avenues while at the same time, managing various MSD conditions with evidence-based treatments. All therapeutic options should be discussed and implemented based on the patient's individual needs, beliefs and preferences while incorporating locoregional expertise and available resources.

Consensus of Experts on the Treatment of Sexual Dysfunction after Surgery for Prostate Cancer in Taiwan

According to the Taiwan Cancer Report, in 2018, prostate cancer was one of the top five cancers reported in men. Each year, many patients with prostate cancer undergo radical prostatectomy (RP) therapy. One of the most common RP complications is erectile dysfunction (ED). Although consensus guidelines for the management of sexual dysfunction after prostate cancer surgery have been developed for many Western and Asian countries, no such clinical practice guidelines have been developed for Taiwan. The consensus opinions expressed in this article were discussed by numerous experienced physicians in Taiwan, based on both existing international guidelines and their individual experiences with clinical trials and providing advice to clinical physicians on how to inform patients of the risk of ED prior to surgery. This review also discusses how recovery and rehabilitation may be affected by socioeconomic status, the existence of an intimate relationship, comorbidities, or the need for cancer adjuvant therapy and how to determine rehabilitation goals and provide appropriate treatments to assist in the recovery of both short- and long-term sexual function.

Application of dual-energy CT angiography in diagnosis of arterial erectile dysfunction: new scanning technology, new scanning area

OBJECTIVES

To explore the value of dual-energy computed tomography (DE-CT) angiography in diagnosis of arteriogenic erectile dysfunction (ED) patients and feasibility of new scanning area that excludes the testis.

MATERIALS AND METHODS

Ninety-three patients suspected of suffering arterial ED and 40 health volunteers underwent penile duplex Doppler ultrasound and DE-CT angiography (DE-CTA). The scanning range of DE-CTA covered whole arterial system of pelvis and testis was excluded. Two blinded investigators independently evaluated the arterial system that supplies the penis.

RESULTS

Finally, 1596 segments were evaluated and 470 segments were judged to be abnormal. The distribution was: 2 (0.4%) in common iliac artery, 7 (1.5%) in internal iliac artery, 82 (17.5%) in internal pudendal artery, 89 (18.9%) in penile artery, 120 (25.5%) in dorsal artery, and 170 (36.2%) in cavernosal artery. The specificity, sensitivity, positive predictive value, and negative predictive value of DE-CTA in diagnostic were 86.02%, 87.50%, 94.12%, and 72.92%. Besides, the new scan area allowed for effective evaluation of the arteries while excluding the testis.

CONCLUSION

DE-CTA can provide unbiased, safe evaluation of the vascular status of the penile bed in patients with ED.

Management of male sexual dysfunction after cancer treatment

BACKGROUND

With an increase in the number of cancer survivors each year, male sexual dysfunction becomes an important topic for discussion between patients and providers who treat cancer. The aim of this article is to review types and mechanisms of sexual dysfunction after cancer therapy and discuss treatment options.

METHODS

Contemporary concepts regarding male sexual dysfunction after cancer treatment are reviewed and translated for clinical utility.

FINDINGS

To optimize recovery of erectile capacity after erectile dysfunction causing cancer treatments, a penile rehabilitation protocol involving phosphodiesterase inhibitors, vacuum erection device, intra corporal injections, or a combination is likely to provide some degree of clinically significant benefit. Treating hypogonadism post cancer treatment depends on the type of cancer that has been treated and patient comorbidities. Anejaculation after cancer treatments is typically not successfully or reliably treated due to the mechanism and severity of sympathetic nerve injury. Semen cryopreservation prior to cancer treatments that may injure nerve fibers essential for the ejaculatory response is highly recommended.

CONCLUSION

Management of post cancer treatment sexual dysfunction requires identification of this problem and referral to a specialist if necessary. There are several management options available that can greatly enhance quality of life in this often overlooked aspect of post cancer treatment care.

An Intervention Study on Children's Healthy Joint Attention Skills Based on a Mixed Instructional Approach of DTT and PRT

Joint attention is an important element that influences children's early development of communication and sociality, and joint attention is more often than not the earliest incipient of their prosocial behavior. Joint attention skills are one of the core deficits of children with autism, and identifying and remediating the core problems of autism is a popular area of interest, with joint attention being the focus of attention. The aim of this study was to investigate whether the combined orientation model of Discrete Trial Teaching (DTT) and Pivotal Response Training (PRT) could improve the joint attention skills of children with autism. This study used a cross-behavioral multitest design in a single-subject study with two preschool children with autism as subjects, with the independent variable being joint attention teaching and the dependent variable being the three joint attention skills (eye gaze, following directions, and active display). After the instructional intervention, children with autism showed a significant increase in the correctness of "eye alternation," "following directions," and "moving displays."

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.

Optimizing Aging Male Symptom Questionnaire Through Genetic Algorithms Based Machine Learning Techniques

Purpose

Genetic algorithm (GA) is a machine learning optimization strategy where sample strategies compete for fitness to evolve an optimum solution. This study evolves the Aging Male Symptoms (AMS) with GA to better identify late onset hypogonadism (LOH) with serum testosterone.

Materials and Methods

GA was trained on a training set of standard AMS questionnaire on a nationwide LOH epidemiology study. Random matrices of selectors for particular items were generated. Each generation of was evolved through a fitness function determined by sensitivity. Threshold to determine positive serum testosterone level for LOH was randomized for each competing strategy. After 2,000 runs, with each run producing the best result out of a set of 3,000 randomly generated sets evolved through 300 generations, the best AMS selection matrix was then applied to a separately enrolled validation set to compare outcomes.

Results

Predictability for serum testosterone levels dropped markedly above 3.5 ng/mL during pilot training. Limiting the training to testosterone thresholds between 2.5 and 3.5 ng/mL the GA 93 different strategies. Only a selection of 5 items, determining for a threshold of 20 points and determining for a serum testosterone level of 3.16 ng/mL, showed robust reproducibility within the internal validation set. Applying these conditions to the independent validation set showed sensitivity improved from 0.66 to 0.77, with a specificity of 0.07 to 0.19, respectively.

Conclusions

GA method of selecting questionnaires improved AMS questionnaire significantly. This method can be easily applied to other questionnaires that do not correlate with physiological markers.

Neuroimaging biomarkers of psychogenic erectile dysfunction: protocol for a systematic review

INTRODUCTION

Erectile dysfunction (ED) is the most common male sexual disorder that severely impacts the sexual performance and quality of life of men. As the main subtype of ED, psychogenic ED (pED) has been demonstrated to be a genitourinary disease and also associated with alterations in both brain structure and function. However, the scattered neuroimaging evidence from individual studies has not yet been integrated, and the central pathological alterations associated with pED remain unclear. The objective of this systematic review is to integrate and assess the evidence of the impact of pED on brain structure and function.

METHODS AND ANALYSIS

Five databases (PubMed, EMBASE, Web of Science, China Biology Medicine Database and China National Knowledge Infrastructure (CNKI)) will be systematically searched from inception to 1 October 2019 (the anticipated completion date of this review), with language restricted to English and Chinese. Studies focusing on the structural or functional alterations in patients with pED will be retrieved. The study selection process will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline and quality assessment will be conducted with a customised checklist. After data extraction, a qualitative review will be performed to synthesise the structural and functional brain alterations as well as the correlations between the altered cerebral structures and functions and the clinical characteristics of patients with pED. If the collected data make it feasible, an activation likelihood estimation meta-analysis will also be launched.

ETHICS AND DISSEMINATION

Ethical approval is not required as primary data will not be collected. This review will be published in a peer-reviewed journal and presented at conferences.

PROSPERO REGISTRATION NUMBER

CRD42019117206.

Postmicturition Dribble Is Associated with Erectile Dysfunction in Middle-Aged and Older Men with Lower Urinary Tract Symptoms

PURPOSE

Lower urinary tract symptoms (LUTS) are correlated with erectile dysfunction (ED), but research on whether postmicturition dribble (PMD) is related to ED is limited. We assessed the correlation between PMD and ED in middle-aged and older Korean men with LUTS.

MATERIALS AND METHODS

In our prospective, cross-sectional, observational, multicenter study, we enrolled 205 men (age >40 years) with LUTS. LUTS and ED were assessed using the International Prostate Symptom Score (IPSS) and International Index of Erectile Function-5 (IIEF-5), respectively. PMD was assessed using the Hallym PostMicturition Dribble Questionnaire, Question 1, and the PMD volume was calculated in a paper test. Age, prostate volume, serum prostate-specific antigen, maximum urinary flow rate, and postvoid residual urine were also evaluated.

RESULTS

There were significant differences in the total and voiding IPSS between men with and without ED (p=0.042 and 0.043, respectively). The Hallym PostMicturition Dribble Questionnaire 1 score was inversely well correlated with the IIEF-5 score (r=-0.388, p<0.001). Also, the PMD volume was inversely correlated with the IIEF-5 score (r=-0.138, p=0.042). ED prevalence increased as the Hallym PostMicturition Dribble Questionnaire 1 score increased (p=0.002). Further, incorporating the Hallym PostMicturition Dribble Questionnaire 1 into the IPSS tended to increase the predictive accuracy of LUTS by 4.2% in ED patients (p=0.082).

CONCLUSIONS

PMD was significantly correlated with ED and reinforced the relationship between LUTS and ED in middle-aged and older men. PMD might be an important component of the association between LUTS and ED.

Diagnostic value of four-dimensional CT angiography in arterial erectile dysfunction using 320-detector row dynamic volume CT

The present study aims to evaluate the diagnostic value of four-dimensional CT angiography (4D-CTA) in the diagnosis of arterial erectile dysfunction (ED) using 320-detector row dynamic volume CT. Arterial ED patients attributed to arterial insufficiency were enrolled. To induce penile erection, an intracavernous injection (ICI) of corpus cavernosum with a vasoactive drug was administered. Patients were assigned into the erection hardness score (EHS) 1/2 group or EHS 3/4 group. Color duplex Doppler ultrasound (CDDU) was used to analyze blood flow spectrum. Each patient was examined using 4D-CTA. Receiver operating characteristic (ROC) curve was plotted to evaluate the diagnostic value of 4D-CTA in arterial ED. According to Irwin Goldstein, the EHS 3/4 group (n=38) had a shorter course of ED and low proportion with history of hypertension, hyperlipidemia, and diabetes than the EHS 1/2 group (n=35). The peak systolic velocity (PSV), end diastolic velocity (EDV), and resistant index (RI) in the EHS 3/4 group were lower than those of the EHS 1/2 group. 4D-CTA showed there were a total of 35 cases in the EHS 1/2 group (two cases missed) and 38 cases in the EHS 3/4 group (seven cases misdiagnosed). Using 4D-CTA to diagnose arterial ED, the area under the ROC curve yielded a value of 0.879, with a specificity of 93.9% and a sensitivity of 82.5%. These findings indicated that 4D-CTA using 320-detector row dynamic volume CT is a promising and reliable utility in diagnosing arterial ED.

A Randomized, Placebo-Controlled, Double-Blind, Multi-Center Therapeutic Confirmatory Study to Evaluate the Safety and Efficacy of Avanafil in Korean Patients with Erectile Dysfunction

A multi-center, randomized, double-blind, placebo-controlled study was conducted with 158 subjects who were randomized to placebo or avanafil 50, 100, and 200 mg on demand for 8 weeks to evaluate the safety, tolerability, and efficacy of avanafil in the treatment of erectile dysfunction (ED) in Korean men. The primary outcome was the erectile function (EF) domain score of the International Index of Erectile Function (IIEF) questionnaire. Secondary outcomes included changes in the scores of IIEF questions 3 and 4 (IIEF Q3, Q4) from baseline, changes in all domain scores in the IIEF from baseline, Sexual Encounter Profile questions 2-5 (SEP2-5), the Global Efficacy Assessment Question (GEAQ), and the number of subjects whose EF domain score at the 8th week visit was ≥ 26. After 8 weeks of treatment, the dose groups except avanafil 50 mg scored significantly higher on the IIEF-EF domain from baseline than the placebo group. The changes from baseline in the avanafil group in IIEF Q3 (all doses) and Q4 (200 mg alone) were higher than the placebo group. The differences between avanafil and placebo groups were significant in SEP2 (100 and 200 mg) and SEP3-5 (200 mg). The differences in the GEAQ "Yes" response were also significant in the avanafil 100 and 200 mg groups. Regarding the ratio of normal EF at the end of the study, avanafil 200 mg differed significantly from the placebo. Most treatment-associated adverse events were mild and resolved spontaneously. This is a clinical trial study and was registered at www.ClinicalTrials.gov (Identifier: NCT02477436).

Intracavernous delivery of clonal mesenchymal stem cells rescues erectile function in the streptozotocin-induced diabetic mouse

The major hurdle for the clinical application of stem cell therapy is the heterogeneous nature of the isolated cells, which may cause different treatment outcomes. The aim of this study was to examine the effectiveness of mouse clonal bone marrow-derived stem cells (BMSCs) obtained from a single colony by using subfractionation culturing method for erectile function in diabetic animals. Twelve-week-old C57BL/6J mice were divided into four groups: controls, diabetic mice, and diabetic mice treated with a single intracavernous injection of PBS (20 μL) or clonal BMSCs (3 × 10(5) cells/20 μL). Clonal BMSCs were isolated from 5-week-old C3H mice. Two weeks after treatment, erectile function was measured by electrical stimulation of the cavernous nerve. The penis was stained with antibodies to PECAM-1, smooth muscle α-actin, neuronal nitric oxide synthase (nNOS), neurofilament, and phosphorylated endothelial NOS (phospho-eNOS). We also performed Western blot for phospho-eNOS, and eNOS in the corpus cavernosum tissue. Local delivery of clonal BMSCs significantly restored cavernous endothelial and smooth muscle cell contents, and penile nNOS and neurofilament contents, and induced eNOS phosphorylation (Ser1177) in diabetic mice. Intracavernous injection of clonal BMSCs induced significant recovery of erectile function, which reached 80-90% of the control values. Clonal BMSCs successfully restored erectile function through dual angiogenic and neurotrophic effects in diabetic mice. The homogenous nature of clonal mesenchymal stem cells may allow their clinical applications and open a new avenue through which to treat diabetic erectile dysfunction.

Development of a comprehensive spectral library of sildenafil and related active analogues using LC-QTOF-MS and its application for screening counterfeit pharmaceuticals

The abuse or misuse of forged erectile-dysfunction drugs, containing phosphodiesterase type 5 inhibitors (e.g. sildenafil), is a serious issue globally. Therefore, the detection of sildenafil and related active analogues in counterfeit pharmaceuticals or the differentiation between counterfeit and authentic drugs has been performed with a variety of analytical techniques. Recently, a liquid chromatography-hybrid quadrupole time-of-flight mass spectrometry (LC-QTOF-MS)-based in-house library, consisting of accurate mass ion fragmentation information and retention times, was effectively applied to screen a large number of compounds in field of forensic toxicology. However, a comprehensive LC-QTOF-MS spectral library of sildenafil and related active analogues has not yet been reported. In the present study, a spectral library of 40 compounds of sildenafil and related analogues was developed with accurate mass spectra and retention times using LC-QTOF-MS, and applied to screen nine marketed counterfeit products. The in-house library successfully identified sildenafil, dimethylsildenafil, hydroxyhomosildenafil, demethylhongdenafil, pseudovardenafil and vardenafil in the samples. Our LC-QTOF-MS-based spectral library search is considered a powerful approach for identifying sildenafil and related active analogues in counterfeit pharmaceuticals.

Sexual function and stress level of male partners of infertile couples during the fertile period

OBJECTIVES

To evaluate the sexual function and stress level during timed intercourse (TI) of male partners of infertile couples.

PATIENTS AND METHODS

The study included 236 male partners of couples with >1 year of infertility who sought medical care or an evaluation of couple infertility. Besides infertility evaluation, all men were asked to complete the five-item version of the International Index of Erectile Function (IIEF-5) for evaluation of sexual function, and stresses related to infertility and TI were measured using 10-division visual analogue scales (VAS).

RESULTS

Stress levels for sexual function were higher during fertile than non-fertile periods in109 of the 236 (46.2%) male partners, with 122 (51.7%) reporting no difference in stress during fertile and non-fertile periods. The mean (sd) VAS score of sexual relationship stress was significantly higher during fertile than non-fertile periods, at 3.4 (2.6) vs 2.1 (2.2) (P < 0.001). Of the 236 men, 21 (8.9%) reported more than mild-to-moderate erectile dysfunction (ED; IIEF-5 score ≤16) and 99 (42%) reported mild ED (IIEF-5 score 17-21).

CONCLUSION

Male partners of infertile couples experience significantly higher TI-related stresses during the fertile period compared with the non-fertile period. Sexual dysfunction is also common in male partners of infertile couples. Medical personnel dealing with infertile couples should be aware of these potential problems in male partners and provide appropriate counselling.

Sympathetic skin response in patients with vascular erectile dysfunction

PURPOSE

We aimed to investigate the utility of sympathetic skin response (SSR) test for evaluating vasculogenic erectile dysfunction (ED) which is the most common type of impotence.

MATERIALS AND METHODS

Men in the age group of 28 to 60 years and suffering from vasculogenic ED, as confirmed by a papaverin test and color Doppler sonography, at least for 6 months referred from our university urology department were included. We used the International Index of Erectile Function (IIEF-5) for grading severity of dysfunction and recorded the SSR of every patient from the median, tibial, and dorsal nerves of the penis. One-way analysis of variance (ANOVA), independent t-test and Pearson's correlation coefficient were used for comparing quantitative variables, and Fisher's Exact test was used for comparing qualitative variables. The Mann-Whitney U Test and the Kruskal-Wallis test were performed for analysis of data that were not normally distributed. A p value of less than 0.05 was considered significant.

RESULTS

Forty-two patients were recruited for the study. We found a strong statistical relationship between the IIEF score and the pathologic SSR registered from every mentioned nerve. Patients with abnormal SSR had more severe ED according to IIEF score (p<0.001). In addition, the IIEF score had a significantcorrelation with diabetes mellitus and cardiovascular disease (t-test; p<0.05).

CONCLUSIONS

Our results confirmed the presence of autonomic dysfunction in patients with vasculogenic impotence via an SSR test. We suggest evaluating the efficacy of the SSR test in patients with vascular impotence for treatment response monitoring in future studies.