Management of premature ejaculation: a clinical guideline from the Italian Society of Andrology and Sexual Medicine (SIAMS)

Premature ejaculation (PE) is the most prevalent male sexual dysfunction, and the most recently defined. PE is often mistakenly considered a purely psychosexological symptom by patients: the lacking awareness in regards to the pathophysiology and treatments often lead to resignation from the patients' side, making PE the most underdiagnosed sexual complaint. However, an ever-growing body of evidence supporting several organic factors has been developed in the last decades and several definitions have been suggested to encompass all defining features of PE. In the present document by the Italian Society of Andrology and Sexual Medicine (SIAMS), we propose 33 recommendations concerning the definition, pathophysiology, treatment and management of PE aimed to improve patient care. These evidence-based clinical guidelines provide the necessary up-to-date guidance in the context of PE secondary to organic and psychosexological conditions, such as prostate inflammation, endocrine disorders, and other sexual dysfunctions, and suggest how to associate pharmacotherapies and cognitive-behavioral therapy in a couple-centered approach. New therapeutic options, as well as combination and off-label treatments, are also described.

Testosterone therapy: where do the latest guidelines agree and differ?

PURPOSE OF REVIEW

The incidence of testosterone deficiency and number of men on testosterone therapy (TTh) has increased significantly over the past 3 decades. This rise has been accompanied by controversies surrounding the indications and possible adverse effects of therapy. To better inform prescribing habits among providers, many major medical associations have devised guidelines regarding the diagnosis and management of testosterone deficiency. While these guidelines agree in many areas, there are some key differences that should be identified. This review will explore the similarities, differences, and rationale for these guidelines.

RECENT FINDINGS

Over the past 7 years, much attention has been devoted to the implications of TTh on cardiac health. All reviewed guidelines include dedicated sections discussing these implications and the society's position on prescribing testosterone considering recent findings, however, differ on specific contraindications to TTh and when to initiate therapy after a cardiovascular event. In addition, the American College of Physicians released its first guideline earlier this year which may impact prescribing habits among primary care physicians.

SUMMARY

The differences between testosterone deficiency guidelines may indicate gaps in our knowledge of testosterone deficiency and focuses of future research efforts. Prescribers should be aware of these differences and discuss all treatment options with their patients.

[Disease-syndrome combination in integrated traditional Chinese and Western medicine in andrology: Confusions and countermeasures in studies]

Researches on the mechanisms underlying the therapeutic effects of the disease-syndrome combination approach in integrated traditional Chinese and Western medicine are becoming a hot spot in andrology, but many recent studies of this kind have failed to explain the connotation of integrated traditional Chinese and Western medicine in andrology. Related existing problems include repeated researches into the same indexes of action mechanisms of different therapeutic principles of traditional Chinese medicine (TCM), Chinese herbal compound and special prescriptions, studies focusing on individual diseases but ignoring symptoms, immature syndrome models for studies of mechanisms, and too much attention to uncertain or immature target mechanisms. The stress should be placed on the action mechanisms of Chinese herbal compound and special prescriptions on male diseases and, what is more important, on the clarification of the essential principles of differentiation and treatment of TCM syndromes. In the recent years, proteomics, genomics, transcriptomics and metabolomics have shed some light upon researches into the mechanisms underlying the therapeutic effects of the disease-syndrome combination approach in integrated traditional Chinese and Western medicine in andrology. An insight into the TCM syndrome, a macroscopic inductive analysis, and a comprehension of such microcosmic aspects as the gene, protein, metabolism and metagenome may contribute to some breakthroughs and new ideas in the studies of disease-syndrome combination in integrated traditional Chinese and Western medicine in andrology.

[Traditional Chinese Medicine promotes the development of andrology]

Andrology is an ancient branch of science which has gained a new development in the recent years and therefore has both traditional and modern characteristics. On the one hand, andrology keeps benefiting from the achievements of modern medicine and, on the other hand, it relies on the support of the theories of Traditional Chinese Medicine (TCM). An integration of Chinese and Western medical principles may further facilitate the development of andrology. TCM may contribute to the development of andrology by giving full play to its advantage as a psychosomatic medicine, enriching treatment strategies for male diseases with comprehensive TCM therapies, integrating the advantages of Western medicine to improve clinical efficacy, and normalizing the use of patent TCM drugs.

[Organ-sparing surgery in andrology]

Penile and testicular tumors, especially those of the malignant nature, usually require radical excision, which alters the organ image, affects sexual and urinary functions, and consequently undermines the self-confidence and quality of life of the patient. Recent studies show that organ-sparing surgery can be an alternative to radical excision for superficial tumors and small masses. Penis-sparing surgery (PSS) has been indicated for superficial penile cancer, such as Tis and T1a lesions, and testis-sparing surgery (TSS) is feasible for benign small bilateral or solitary testicular masses (TIN). Long-term follow-ups after PSS or TSS show that the patients may retain a satisfactory appearance of the organ as well as desirable sexual and reproductive functions.

Robotic assisted andrological surgery

The introduction of the operative microscope for andrological surgery in the 1970s provided enhanced magnification and accuracy, unparalleled to any previous visual loop or magnification techniques. This technology revolutionized techniques for microsurgery in andrology. Today, we may be on the verge of a second such revolution by the incorporation of robotic assisted platforms for microsurgery in andrology. Robotic assisted microsurgery is being utilized to a greater degree in andrology and a number of other microsurgical fields, such as ophthalmology, hand surgery, plastics and reconstructive surgery. The potential advantages of robotic assisted platforms include elimination of tremor, improved stability, surgeon ergonomics, scalability of motion, multi-input visual interphases with up to three simultaneous visual views, enhanced magnification, and the ability to manipulate three surgical instruments and cameras simultaneously. This review paper begins with the historical development of robotic microsurgery. It then provides an in-depth presentation of the technique and outcomes of common robotic microsurgical andrological procedures, such as vasectomy reversal, subinguinal varicocelectomy, targeted spermatic cord denervation (for chronic orchialgia) and robotic assisted microsurgical testicular sperm extraction (microTESE).

What does the clinician need from an andrology laboratory?

What does the clinician need from an andrology laboratory? The andrology laboratory is vital for the accurate diagnosis and treatment of male factor infertility, which is contributory in 50% of infertile couples. While there are some diagnostic tests of limited clinical utility, many tests can be useful in specific clinical settings. In this chapter, we will review the basic interpretation of the semen analysis, testing for sperm vitality and motion, inflammation, semen antioxidant capacity, sperm DNA damage, antisperm antibodies, post ejaculate urine analysis as well as other functional testing. Several clinical vignettes are presented for real-life examples of interpretation of the role of the andrology laboratory in clinical infertility.

Andrology - reproductive years and beyond

BACKGROUND

In recent years, significant advances have been made in our knowledge of the role of testosterone in male fertility and sexual function. In addition, new microsurgical techniques have improved outcomes in testicular biopsy for sperm retrieval, varicocoele treatment and vasectomy reversal.

OBJECTIVE

This article provides an update on the assessment and treatment of male infertility, and the role of testosterone replacement therapy and erectile dysfunction.

DISCUSSION

The evaluation of male infertility requires comprehensive history taking and a focused examination. Investigations that help form the basis for important treatment decisions include semen analysis and hormone testing. Further specialist assessment may be required to determine the need for genetic testing. There is increased evidence for the role of microsurgery in sperm retrieval, varicocelectomy and vasectomy reversal in men seeking paternity. Testosterone plays a role in both spermatogenesis and sexual functioning in a man. While testosterone replacement therapy can restore erections in androgen deficient men and treat other conditions related to hypogonadism, it can also result in male infertility.

[Erectile dysfunction: conservative treatment and new approaches]

Recent societal evolutions have enabled more and more men to talk about erectile dysfunction (ED). There is a strong association between ED and cardiovascular disease and ED should now be considered as an early clinical evidence of vascular disorder. Inhibitors of the PDE-5 have revolutionized the treatment of ED. The three currently drugs (sildenafil, vardenafil and tadalafil) available as first-line therapeutic option, are well tolerated and highly effective in improving erectile function. All the potential cardiac and vascular effects of PDE-5 inhibitors have recently been reviewed. Despite the fact that million patients with ED worldwide have been successfully treated with one of these PDE5 inhibitors, some men are always difficult to treat. Several new PDE-5 inhibitors have recently been developed and are now being investigated in trials. However 30% of patients need alternative therapies and intracavernous injections are the most successful second-line treatment. Some of new therapeutic approaches are currently under investigation such as gene transfer therapy and stem cells therapy, melanocortin activators or extracorporeal shockwave therapy. Such approaches are still at an early stage but remain exciting new targets in difficult to treat patients.

Revised guidelines for human embryology and andrology laboratories

These guidelines provide clinicians with specific guidance on laboratory procedures to ensure that their programs' practice reflects current recommendations.

[RNA interference and its application in andrology research]

RNA interference (RNAi), induced by double-strand RNA homologous to the silenced gene, is a process of post-transcriptional gene silencing in animals and plants. It plays an important role in fighting viral infection, inhibiting transposon activity and down-regulating the expression of the endogenous gene. As a focus of current biomedical research, RNAi has been applied to the studies of erectile dysfunction (ED), prostate cancer and spermatogenesis. This paper summarizes the mechanisms of RNAi, the latest progress in its researches and its application in andrology studies.

Andrology

Andrology is part of dermatology in Germany, as it arose from dermatology as a subspecialty. Accordingly training in andrology is part of the curriculum for specialty certification in dermatology. All dermatologists are required to "have experience in the diagnosis of andrologic disorders and their subsequent treatment". The specialty of andrology deals with male infertility problems including questions regarding fertility prophylaxis, contraception, erectile dysfunction, disturbance in libido, ejaculation and copulation, and primary and secondary hypogonadism, as well as male aging and diseases of the male breast. Evaluation and treatment of the partner may also be necessary. Ejaculate analysis is the most important laboratory tool and each dermatologist must be qualified in its performance.

Hyaluronic acid binding ability of human sperm reflects cellular maturity and fertilizing potential: selection of sperm for intracytoplasmic sperm injection

PURPOSE OF REVIEW

The current concepts of sperm biochemical markers and the central role of the HspA2 chaperone protein, a measure of sperm cellular maturity and fertilizing potential, are reviewed.

RECENT FINDINGS

Because HspA2 is a component of the synaptonemal complex, low HspA2 levels and increased frequency of chromosomal aneuploidies are related in diminished maturity sperm. We also suggest a relationship between HspA2 expression in elongating spermatids and events of late spermiogenesis, such as cytoplasmic extrusion and plasma membrane remodeling that aid the formation of the zona pellucida binding and hyaluronic acid binding sites. The presence of hyaluronic acid receptor on the plasma membrane of mature sperm, coupled with hyaluronic acid coated glass or plastic surfaces, facilitates testing of sperm function and selection of single mature sperm for intracytoplasmic sperm injection. The frequencies of sperm with chromosomal disomy are reduced approximately fourfold to fivefold in hyaluronic acid selected sperm compared with semen sperm, comparable to the increase in such abnormalities in intracytoplasmic sperm injection offspring. Hyaluronic acid binding also excludes immature sperm with cytoplasmic extrusion, persistent histones, and DNA chain breaks.

SUMMARY

Hyaluronic acid mediated sperm selection is a novel technique that is comparable to sperm zona pellucida binding. Hyaluronic acid selected sperm will also alleviate the risks related to intracytoplasmic sperm injection fertilization with sperm of diminished maturity that currently cause worldwide concern.

[Study on psychiatric disorders and defensive process assessed by the "defense style questionnaire" in sterile males SAMPLE consulting in andrology]

BACKGROUND

The literature about artificial insemination and the associated psychological, psychiatric and sexual disorders is relatively rich. But the majority of these studies is made in gynaecology, with a feminine approach of the disorder. There are very few works led in andrology. This justified the investigation of new trails in order to understand better the clinical context of the sterile man. We undertake a study about the psychiatric disorders among sterile men and about the defense styles. These are a clinical entity recently introduced in the quantitative psychopathology research. The defense style questionnaire (DSQ) is a psychometric scale used in common practice in order to measure the defense styles.

OBJECTIVES

We made this study in order to examine the psychiatric state of a sterile males sample consulting in andrology; to assess the defense style by means of the Bond and al DSQ-88 ; to look into a difference between the defensive process according to their clinical situation of azoospermic males or as the oligoazoospermic males and finally, to reveal a correlation between the psychiatric disorders developed in this sample of sterile males and the defensive process they used.

METHOD

There were 42 people (22 azoospermic males and 20 oligoazoospermic males) aged between 23 and 49 years old in the analysed sample. These have been selected at the surgery of andrology at the RUHC of Lille, depending on their arrival order for 6 months. There was no significant difference between the two groups as far as the age and the education standard are concerned. The selection criteria were medical and somatic. Our sample population were divided into two groups: azoospermia (no spermatozoon found in the semen analysis) and oligoasthenospermia (decrease of the number and the mobility of the spermatozoa and an increase of the percentage of atypical forms). The method first consisted in the DSQ, followed by the analysis of the psychiatric state according to the DSM IV, a hetero questionnaire to collect some general information about infertility and a self questionnaire about the sexual, conjugal and social effects of infertility. The DSQ and the interviews took place in the andrology department with the same investigator trained for this job.

RESULTS

We found in our sample 26.2% of psychiatric disorders according to the DSM IV with a significant over-representation of generalized anxious disorder and somatization disorder. The comparison between azoospermic males and oligoazoospermic males patients showed the absence of significative difference as far as psychiatric morbidity rate and the use of defense styles are concerned.

DISCUSSION

Our sample defended himself in accordance with modalities similar to the general population and used defense mechanisms preferentially belonging to the mature defense style, such as humor, repression and anticipation. The psychiatric pathology was significantly correlated to the preferential use of withdrawal, consumption, reaction formation and lack of humor use. We also confirm in our study the fact that the subjects using especially neurotic defense styles are more likely to develop a psychiatric disorder than the others. Our male sample is a waiting population and threatened by failure. The situation of wait creates anxiety. We also know that infertility is one of the most stressful situations a couple might face. However, our study did not enable us to know the precise relations between generalized anxious disorder and infertility, especially whether the generalized anxious disorder preceded this pathology or not. The over-representation of a somatization disorder only allows us to acknowledge its existence. We can also deduce from that a possible link between infertility and psychic disorder, even if no research permitted to affirm to date the existence of interrelations linking infertility and psychic life. On the whole, this population was suffering despite 73.8% of the patients had no confirmed psychiatric disorder. It is the reason why a liaison psychiatry more inserted into highly specialized teams is interesting, especially because it includes a medical and psychological approach of such disorders. The defense mechanisms preferentially used by this population were humor, repression and anticipation. Humor can only be considered as a defense mechanism when it is applied to oneself. The population who has no psychiatric disorder more uses humor. Does humor protect against the development of a psychiatric pathology, as certain authors proved it ? On the other hand, is repression really protective? It didn't interfere in our study about the development of a psychiatric pathology. So we can suppose that repression was protective for our whole sample, but we can not prove it. However, we wonder if this mechanism works after the failure of an artificial insemination is announced. In which measure such a stress can be repressed out of the conscience field? As for anticipation, it is used by our population who is for the most part in good health. But the question is to know if our sample really envisaged all the different possible solutions or only the success of artificial insemination. As some other works, we confirm that the, psychiatric, people significantly use the neurotic style. Our psychiatric patients used less humor and more consumption, withdrawal and reaction formation than the sane people. Consumption is rarely considered as a defense mechanism by some other authors. And yet, consumption and the existence of psychiatric disorders were very closely linked. This association is found again with anxiety in other studies. The correlation between psychiatric disorder and withdrawal was veryimportant too. The DSM lV defines withdrawal as an apathetic withdrawal. It is not an apathetic withdrawal in our population because the average scores for the ,, activity >, defense mechanism remained high. In our sample, the use of this defense mechanism would encourage the expression of psychiatric troubles. The reaction formation quoted by Freud and Bergeret are both valorised in our society. What kinds of reaction formations use these men ? Are they pathological ? Our study can not answer to these questions. However, the DSQ items examining the reaction formation present its "socially promoted" aspect and forget the pathological one. It has been showed that the evaluation of the defense modalities in a certain type of population can allow the emergence of specific defense mechanisms. This can be considered as predictive factors of development of a mental pathology. The evaluation of specific mental defenses could permit to define vulnerability and affinity for given affections instead of simple personality traits or profiles. Most part of the works shows results in favour of the capacity of DSQ to assess the different defense mechanisms according to the diagnosis groups. But the insufficient numbers of studies moderate on the whole the hypothesis of the existence of specific defense mechanisms--protective factors and factors of vulnerability--linked to a given psychiatric disorder.

CONCLUSION

There is not a difference of psychological effect in terms of degree of sterility. On the other hand, the existence of over-represented psychiatric disorders with sterile males compared with a control group force Consultation-Liaison psychiatrists and andrologists would be able to understand the pain beyond the need of acting by the artificial insemination. In our opinion, this justifies the fact that the patients should have the opportunity of expressing, in the department where they are treated, all the feelings inherent to their personal and conjugal drama as part of a specialized treatment. Our study confirms the difficulty to know whether some defense mechanisms are vulnerability factors for a certain psychiatric disorder or whether the defense mechanisms are an epiphenomenon of a particular psychiatric disorder. This is the reason why a lot of authors having worked with DSQ agree to conclude that additional prospective studies, which would permit to make a link between the defense mechanisms anda certain psychiatric pathology, are necessary. In the case we study, it is important to explore the defensive modalities before the infertility diagnosis and after the birth of a child, with a more important sample population. A better knowledge of the defensive modalities of such a population, used in a psychotherapeutic context could help to prevent the appearance of psychiatric disorders or, if not, to anticipate them.

Is quality assurance in semen analysis still really necessary? A view from the andrology laboratory

Quality assurance (QA) is a fundamental part of laboratory medicine, of which internal and external QA (proficiency testing) is an important part. In a recent debate article published in Human Reproduction, it was argued that it was no longer necessary for semen analysis to be subject to QA, primarily because it is now being performed robustly and there is little evidence that it has any real clinical value. In response to this argument, it is suggested here that although there may have been some improvements in the training of laboratory scientists, recent studies have shown that the techniques of semen analysis are still poorly implemented at many locations. Moreover, as the impact of the introduction of QA into the andrology laboratory begins to take effect, there are a growing number of studies showing that the results of semen analysis do correlate well with natural conception and some assisted reproductive technologies. However, since the processes of QA are central to the principles of total quality management, which in turn underpins the process of laboratory accreditation, QA needs to remain in the andrology (and embryology) laboratory so that they can achieve the same accredited status as medical laboratories in other disciplines.

Intracytoplasmic sperm injection: a novel selection method for sperm with normal frequency of chromosomal aneuploidies

OBJECTIVE

To test a newly invented intracytoplasmic sperm injection (ICSI) sperm selection method based on sperm hyaluronic acid (HA) binding.

DESIGN

Comparison of chromosomal disomy and diploidy frequencies in sperm arising from semen and in HA-bound sperm.

SETTING

Academic andrology laboratory.

PATIENT(S)

Men presenting for semen analysis.

INTERVENTION(S)

Washed sperm fractions of 32 semen samples were applied to Petri dishes or glass slides coated with immobilized HA. The unbound sperm were rinsed gently, and the HA-bound sperm were removed with an ICSI pipette. The control sperm population was the unselected sperm. Both HA-selected and unselected sperm were treated with fluorescence in situ hybridization with centromeric probes for the X, Y, and 17 chromosomes.

MAIN OUTCOME MEASURE(S)

Chromosomal disomy and diploidy frequencies.

RESULT(S)

In the HA-bound sperm (495-2,079 per man, 41,670 in all) compared with unselected sperm (4,770 per man, 162,210 in all), the chromosomal disomy frequencies were reduced to 0.16% from 0.52%, diploidy to 0.09% from 0.51%, and sex chromosome disomy to 0.05% from 0.27% (a 5.4-fold reduction vs. 4-fold respective increase in ICSI offspring).

CONCLUSION(S)

The HA sperm selection method for ICSI, which is based on a relationship between sperm receptors for zona pellucida and HA, will likely reduce the potential genetic complications and adverse public health effects of ICSI.

Lack of compliance by UK andrology laboratories with World Health Organization recommendations for sperm morphology assessment

BACKGROUND

Sperm morphology is known to correlate with the probability of conception both in vitro and in vivo, but the assessment of sperm morphology in the laboratory remains problematic. The 4th edition (1999) of the World Health Organization (WHO) Laboratory Manual has attempted to improve matters by giving rigorous recommendations regarding sperm morphology assessment. However, it is unknown how well these recommendations have been implemented in practice.

METHODS

A survey of the methods used to undertake the assessment of sperm morphology during semen analysis was undertaken in 37 laboratories in the UK.

RESULTS

In total, only two laboratories (5%) were compliant with all current WHO guidelines regarding morphology assessment, including methods of staining and observation, classifying and sampling methods, and the participation in internal and external quality control programmes.

CONCLUSION

These results illustrate an urgent need for education and training initiatives to encourage laboratories to become compliant with current WHO guidelines for sperm morphology assessment.

[Topic selection and design for andrological researches in Chinese traditional medicine]

The past decade was witnessed a rapid development of andrology in Chinese Traditional Medicine (ACTM) and a steady growth of the contingent of clinicians and researchers in this domain. Now we are challenged to a very important task of how to raise the clinical and research levels to a new height. Topic selection in the researches on ACTM showed be accurate, scientific and practical, and the research design should follow the principles of multi-centering, randomization, controlling and blind trials. This article also discusses the characteristics and evaluation of the researches on ACTM.

Comparison of two techniques to evaluate the acrosomal status of zona pellucida bound sperm in humans

In this work, we have compared two procedures that evaluate the acrosomal status of human sperm bound to the human zona pellucida. Motile sperm, selected by a Percoll gradient, were capacitated by incubation at 37 degrees C, 5% CO2, for 4.5 h, at 20 x 10(6) cells ml(-1). Then, the sperm were incubated with nonviable human oocytes for 10 min at 37 degrees C, 5% CO2. The oocytes with bound sperm were transferred to 500 microl phosphate-buffered saline (PBS) and washed to remove loosely bound sperm. The oocytes were then processed according to the procedures of Cross et al. (1986) or Liu & Baker (1996). In the Cross's procedure, the sperm were labelled while they were bound to the zona. In the Liu's procedure, the sperm were first dislodged from the zona into a droplet of PBS and labelled in there. Both procedures gave equivalent percentages of acrosome-reacted sperm. However, the total number of zona-bound sperm available for assessment with the procedure of Liu & Baker was greater than that of Cross et al. We suggest to use the former procedure to evaluate the acrosomal status of zona-bound sperm in humans. Moreover, this procedure also provided information about sperm ability to bind to the zona pellucida.