The ‘effectiveness’ scale—therapeutic outcome of pharmacologic therapies for ED: an international consensus panel report

Despite availability of outcome measures and scales for assessing erectile dysfunction (ED) treatment efficacy, guidelines are not available for assessing broader therapeutic outcomes or defining treatment failure in ED. An International Consensus Advisory Panel was convened to develop guidelines, definitions and a new algorithm for evaluating treatment effectiveness in ED. These new guidelines are recommended for use in both research and clinical practice. A multidisciplinary, international panel, consisting of 11 senior researchers and clinicians, was convened to address pertinent issues concerning therapeutic outcome assessment for ED. The panel utilized a modified Delphi method of consensus development and proposed a new model for outcomes assessment. This model is inherently testable, using existing instruments and current methods of assessment. Following a comprehensive literature review and discussion, the Panel recommended adoption of a new treatment effectiveness conceptual framework or theoretical model for assessing therapeutic outcomes in ED. Treatment effectiveness is presumed to be a combined function of two other factors, treatment response and treatment satisfaction. Treatment response is based on the combined assessment of efficacy and tolerability, and treatment satisfaction on the combined assessment of patient and partner satisfaction. Taken together, these two domains define an overall domain of treatment effectiveness. This therapeutic index would be derived by independently assessing treatment efficacy and satisfaction by means of event logs, questionnaires or the more typical patient interview methods. In conclusion, the Ad Hoc Advisory Consensus Panel recommends adoption of a new framework or conceptual model for conducting ED outcome trials or clinical research. The concept of 'treatment effectiveness' is proposed as a new 'umbrella concept' or distal outcome to be evaluated.

Report of the American Foundation for Urologic Disease (AFUD) Thought Leader Panel for evaluation and treatment of priapism

PURPOSE

Patients with priapism often develop permanent erectile dysfunction and personal sexual distress. This report is intended to help educate the public by reviewing the varied definitions and classifications of priapism and limited literature reports of pathophysiology, diagnosis and treatment outcomes of priapism. The AUA priapism guidelines committee is responsible for creating consensus as to appropriate individual patient management of priapism by physicians.

MATERIALS AND METHODS

A multidisciplinary panel, consisting of 19 thought leaders in priapism, was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease to address pertinent issues concerning the role of the urologist, primary care providers and other health care professionals in the education of the public regarding management of men with priapism. The panel utilized a modified Delphi method and built upon the peer review literature on priapism.

RESULTS

The Thought Leader Panel recommended adoption of the definition of priapism as a pathological condition of a penile erection that persists beyond or is unrelated to sexual stimulation. Priapism is stressed to be an important medical condition that requires evaluation and may require emergency management. The classification system is categorized into ischemic and non-ischemic priapism. Essential elements of the ischemic classification are the inclusion of: (i) clinical characteristics of pain and rigidity; (ii) diagnostic characteristics of absence of cavernosal arterial blood flow; (iii) pathophysiological characteristics of a closed compartment syndrome; (iv) a time limit of 4 h prior to emergent medical care; and (v) a description of the potential consequences of delayed treatment. Essential elements of the non-ischemic classification are the inclusion of: (i) clinical characteristics of absence of pain and presence of partial rigidity; (ii) diagnostic and pathophysiological characteristics of unregulated cavernosal arterial inflow; and (iii) the need for evaluation but emphasizing the lack of a medical emergency. The panel recommended adoption of a rational management algorithm for the assessment and treatment of priapism where the cornerstone of initial assessment includes a careful clinical history, a focused physical examination and selected laboratory and/or radiologic tests. The panel recommended that specific criteria and clinical profiles requiring specialist referral should be identified. The panel further recommended that patient (and partner) needs and education concerning priapism should be addressed prior to therapeutic intervention, however only in the case of chronic management or post acute presentation evaluation should this delay intervention. Treatment goals to be discussed include management of the priapism with concomitant prevention of permanent and irreversible erectile dysfunction and associated psychosocial consequences. The panel recommended that when specific therapies for priapism are required, a step-care treatment approach based upon reversibility and invasiveness should be followed.

CONCLUSIONS

The Thought Leader Panel calls for research to expand our understanding of the prevalence and diagnosis of priapism and education to create awareness among the public of the potential urgency of this condition. Critical areas to be addressed include the multiple pathophysiologies of priapism as well as multi-institutional trials to objectively assess safety and efficacy in the various treatment modalities.

Chronic treatment with finasteride daily does not affect spermatogenesis or semen production in young men

PURPOSE

Finasteride, an oral type 2, 5alpha-reductase inhibitor, is used in 1 mg. daily doses for the treatment of male pattern hair loss. A dose of 5 mg. finasteride daily reduces ejaculate volume by approximately 25%, and reduces prostate volume by approximately 20% and serum prostate specific antigen (PSA) by approximately 50% in men with benign prostatic hyperplasia. To our knowledge no data exist on the effect of 1 mg. finasteride daily on ejaculate volume or other semen parameters, or on the prostate in young men. Therefore, we studied the potential effect and reversibility of effect of 1 mg. finasteride daily on spermatogenesis, semen production, the prostate and serum PSA in young men.

MATERIALS AND METHODS

In this double-blind, placebo controlled multicenter study 181 men 19 to 41 years old were randomized to receive 1 mg. finasteride or placebo for 48 weeks followed by a 60-week off-drug period. Of the 181 men 79 were included in a subset for the collection and analysis of sequential semen samples.

RESULTS

There were no significant effects of 1 mg. finasteride on sperm concentration, total sperm per ejaculate, sperm motility or morphology. Ejaculate volume in subjects on finasteride decreased 0.3 ml. (-11%) compared to a decrease of 0.2 ml. (-8%) for placebo, with a median between treatment group difference of -0.03 ml. (1%, 90% confidence interval -10.4 to 13.1, p = 0.915). There were significant but small decreases in prostate volume (-2.6%) and serum PSA (-0.2 ng./ml.) in the finasteride group, which reversed on discontinuation of the drug.

CONCLUSIONS

Treatment with 1 mg. finasteride daily for 48 weeks did not affect spermatogenesis or semen production in young men. The effects of 1 mg. finasteride daily on prostate volume and serum PSA in young men without benign prostatic hyperplasia were small and reversible on discontinuation of the drug.

Ex vivo expression of nitric oxide synthase isoforms (eNOS/iNOS) and calmodulin in human penile cavernosal cells

PURPOSE

Nitric oxide (NO) synthesized by nitric oxide synthase (NOS) is recognized as the central mediator of penile erection. This process appears to be mediated mainly by neuronal NOS (nNOS), which is localized to the nonadrenergic, noncholinergic innervation of the penis. However, the role of non-neuronal penile constituents (specifically the cavernosal smooth muscle), as well as other NOS isoforms in NO production in the human penis is not well understood. The present study evaluates the expression of non-neuronal (inducible and endothelial) isoforms of NOS in human penile cavernosal smooth muscle cells in culture.

MATERIALS AND METHODS

Primary culture was initiated with explants of human corpora cavernosa. For gene expression studies, total RNA was extracted from cavernosal cells and subjected to reverse transcriptase polymerase chain reaction (RT-PCR). For NADPH-diaphorase histochemistry, the cells were incubated with 1 mM beta-NADPH and 0.5 mM nitrobluetetrazolium at 37C for 3 hours. For indirect immunofluorescence and electron microscopy, cells were incubated overnight at 4C with specific primary (eNOS; calmodulin) and secondary antibodies. A conventional avidin biotin complex technique was used for electron microscopy.

RESULTS

The mRNA expression studies revealed that these cells express both endothelial (eNOS) and inducible (iNOS) forms. Localization studies showed positive signals for NADPH-diaphorase, eNOS, and calmodulin. The electron microscopic evaluation confirmed the localization of eNOS to the cytoplasm and small vesicles in the cells.

CONCLUSIONS

These findings support the hypothesis that human cavernosal smooth muscle cells express both endothelial and inducible forms of NOS, which may significantly contribute to NO production in the penile architecture during the erectile process.

Quantitative assessment of cytokines (GRO alpha and IL-10) in human seminal plasma during genitourinary inflammation

PROBLEM

Mechanisms involved in infertility due to genitourinary (GU) inflammation are unknown. The production of pro-inflammatory (GRO alpha) and anti-inflammatory (IL-10) cytokines in seminal plasma is monitored in this study.

METHOD

GRO alpha, IL-10, and granulocyte elastase were evaluated in semen from I) normal, II) infertile patients, and III) infertile patients with leukocytospermia.

RESULTS

GRO alpha in infertile patients with GU inflammation was 1.5-fold higher compared to group II and 2.5-fold higher compared to group I patients. The IL-10 was higher in group III than the other two groups. A positive correlation was observed between granulocyte elastase and GRO alpha in all groups. Group III patients exhibited poor sperm parameters.

CONCLUSIONS

A shift towards increased production of pro-inflammatory chemokine GRO alpha may have a potential role in male infertility associated with GU inflammation.

Effects of smoking on testicular function, semen quality and sperm fertilizing capacity

PURPOSE

The effects of smoking on testicular function and sperm physiology were studied.

MATERIALS AND METHODS

Left testicular biopsy was performed in 49 smokers and 28 nonsmokers. Seminal specimens from these men were analyzed.

RESULTS

Testosterone levels in the left testicular vein, left testicular androgen-binding protein secretion rate (in vitro), sperm motility, percentage of morphologically normal spermatozoa, sperm morphometric parameters and outcome of sperm function tests were significantly lower (p < 0.05) in smokers than in nonsmokers.

CONCLUSIONS

Morphological sperm abnormalities due to secretory dysfunction of the Leydig and Sertoli cells may be the cause of impaired sperm fertilizing capacity in smokers.

Time course of hydrogen peroxide induced changes in the lipid peroxidation of human sperm membranes

The present study evaluates the changes in sperm motility due to H202 induced membrane damage. Washed human sperm suspended in HAM's F-10 (20-30 x 10 6/ml) were incubated (37 degrees Celsius) with varying concentrations (0-0.05%) of H202 for up to 15 minutes. Sperm were analyzed for % motility, % viability, the ratio of cholesterol to phospholipids (C/PL), and the degree of lipid peroxidation (LPO). Motility was monitored manually and viability was evaluated by the Eosin Y staining method. Total lipids were extracted with chloroform:methanol (1:2) and used in colorimetric determination of cholesterol and phospholipid contents (mcmol/106 sperm). Lipid peroxidation was measured by the production of malondialdehyde (nmol MDA/108 sperm). The results (mean +or- SEM, n=8) indicate a dose a time-dependent effect on % motility during the 15 minute incubation period. In comparison to control (8 +or- 4%), samples incubated with 0.01% H202 exhibited a 25 +or- 3% decrease in % motility, while a complete loss of motility was observed with 0.05% H202. No significant differences in decrease in sperm viability were observed between control (211 +or- 4) and H202 (0.01%) treated samples (14 +or- 2%). An increase of (54 +or- 5%) in lipid peroxidation was observed with 0.01% H202, as compared with an 18 +or- 1% increase in control samples at 15 minutes. The C/PL ratio increased by 46 +or- 4% at 15 minutes in H202 treated samples while showing a 34.3% decrease in control samples. H202 inhibited sperm motility while increasing membrane LPO and C/PL, without altering sperm viability. It would appear that lipid peroxidation and alteration of sperm membrane composition lead to the loss of sperm motility.

The benefits of combining early radionuclide renal scintigraphy with routine bone scans in patients with prostate cancer

Based upon the rapid early renal excretion of bone imaging radiopharmaceuticals, we performed a prospective study to determine the use of combining renal evaluation with routine bone scans in 79 consecutive patients with prostate cancer. The radionuclide renal scintigraphy consisted of a 1-minute sequence of 2.5-second frames with a bolus injection of 99mtechnetium-methylene diphosphonate followed by a series of 2-minute images for 24 minutes. Whole body bone scans were performed after a 3-hour delay. All patients had at least 1 confirmatory study with excretory urography (62), ultrasonography (49) or computerized tomography (30). Results were interpreted independently and compared. Ten studies were normal. Radionuclide renal scintigraphy was able to identify 45 of 49 cortical abnormalities (90 per cent) with a false positive rate of 4 per cent. Accuracy of renal cyst detection was only 47 per cent (15 of 32 cases). All acutely obstructed kidneys were identified correctly by radionuclide renal scintigraphy (5 of 5 cases). Of 12 chronically obstructed kidneys 8 (67 per cent) were identified correctly. The 4 missed kidneys were small and nonfunctioning, and they were diagnosed correctly as such but obstruction as the etiology of nonfunction was unidentifiable by radionuclide renal scintigraphy. The false positive rate of obstructive diagnosis by radionuclide renal scintigraphy was 24 per cent (4 of 17 cases). These findings demonstrate that renal evaluation combined with routine bone scanning is an effective screening procedure for renal complications of prostate cancer; no significant abnormalities were missed. The procedure is entirely free of morbidity and does not add to the radiation dose from the bone scan. Furthermore, it is cost-effective, since it avoids the routine need for 2 separate procedures at followup of patients with prostate cancer.