Efficacy and safety of tadalafil for erectile dysfunction in patients with multiple sclerosis

INTRODUCTION

Data are sparse concerning the effects of phosphodiesterase type 5 (PDE5) inhibitors for erectile dysfunction (ED) in subjects with multiple sclerosis (MS).

AIM

To evaluate the efficacy and safety of tadalafil use in subjects with ED because of MS.

METHODS

Ninety-six MS patients with ED after a 4-week treatment-free period were given tadalafil 10 mg. All patients were re-evaluated after 4 weeks. Those with a score lower than 26 on the International Index of Erectile Function (IIEF-15) and with less than 75% of total successful sexual attempts assessed by the Sexual Encounter Profile Questions 2 and 3 (SEP2-3) had their dosage of tadalafil increased to 20 mg, whereas responding subjects continued with 10 mg. Subsequently, all patients had a final follow-up visit after 8 weeks.

MAIN OUTCOME MEASURES

SEP2-3, IIEF-15 questionnaire. The Life Satisfaction Checklist (LSC) questionnaire composed of eight questions was used prior to starting tadalafil and at the end of the 12-week treatment.

RESULTS

Ninety-two subjects completed the study. Seventy-two responded, 30 of whom used 10 mg. Two subjects discontinued the therapy because of moderate side effects: one suffered from headache and one from tachycardia. Responding patients reached a significant statistical improvement in all follow-ups compared with baseline on the erectile domain and overall sexual satisfaction scores of the IIEF-15 using the Wilcoxon test P < 0.01. Furthermore, they showed statistical improvement through the Wilcoxon test P < 0.01 on the sexual life, family life, and partner relationship questions of the LSC compared with baseline.

CONCLUSION

Tadalafil is an effective and safe treatment for males with MS suffering from ED. Further studies are needed on MS patients to evaluate the efficacy and safety of long-term use, and to detect predictable parameters for the success of PDE5 inhibitors.

Ten years of phosphodiesterase type 5 inhibitors in spinal cord injured patients

INTRODUCTION

The majority of men with spinal cord injury (SCI) require chronic treatment for erectile dysfunction (ED), but most of them, prior to taking phosphodiesterase type 5 (PDE5) inhibitors, stopped therapy due to side-effects or low compliance rate.

AIM

Analysis of literature on oral PDE5 inhibitors in individuals with SCI and ED in order to evaluate how much their release changed the management of ED in SCI subjects and what remains to be seen of their potential or limits.

MAIN OUTCOME MEASURES

Questionnaires on sexual function.

METHODS

18 internationally published clinical studies that enrolled SCI males treated with at least one of the PDE5 inhibitors were analyzed.

RESULTS

The small numbers of papers with large and diverse outcome measures did not consent a meta-analysis of treatment results. 705 used sildenafil, 305 vardenafil and 224 tadalafil. Median age was less than 40 years. Only 1 study excluded tetraplegic individuals. For measures of ED evaluated, 11 out of 13 studies reported a significant statistical improvement with PDE5 inhibitors versus placebo or erectile baseline (P < 0.01, or p < 0.005). The most frequent predicable factor for the therapeutic success of PDE5 inhibitors was upper motoneuron lesion. Statistical impact on ejaculation success rates was shown in at least one paper for all PDE5 inhibitors (p < 0.05). Overall, 15 patients, (7 using sildenafil), discontinued the therapies due to drawbacks. Only 1 sildenafil study reported a follow-up maximum of 24 months.

CONCLUSIONS

Literature suggests that all oral PDE5 inhibitors represent a safe and effective treatment option for ED caused by SCI. Further research is needed on head-to-head comparative trials and SCI patient preference for these drugs; their impact on ejaculation and orgasm function, their early use after SCI for increasing the recovery rate of a spontaneous erection, and their effectiveness and tolerability in the long-term are still to be investigated.

Vardenafil Improves Urodynamic Parameters in Men With Spinal Cord Injury: Results From a Single Dose, Pilot Study

PURPOSE

We assessed urodynamic changes after vardenafil administration in spinal cord injured male patients on oxybutynin treatment.

MATERIALS AND METHODS

We performed a single center, randomized, double-blind, placebo controlled trial in 25 patients with spinal cord injury who had erectile dysfunction and micturition disorders. A baseline urodynamic test was performed as well as a second urodynamic test 1 to 3 hours after the administration of 20 mg vardenafil and placebo in 15 and 10 cases, respectively. In all patients standard oral oxybutynin administration was not discontinued. Statistical assessment included the 3 urodynamic parameters maximum detrusor pressure during voiding, maximum cystometric capacity and detrusor overactivity volume.

RESULTS

Placebo administration did not affect urodynamic parameters. After vardenafil administration maximum detrusor pressure was significantly decreased (59.3 vs 52.1 cm H(2)O, p <0.001) and maximum cystometric capacity considerably improved (233.5 vs 272 ml, p <0.001). The most dramatic variations were observed for detrusor overactivity volume (174 vs 218 ml, p <0.0001). In 7 patients with American Spinal Injury Association classification A and spinal cord injury above T6 we observed the most significant improvement in the evaluated urodynamic items, including maximum detrusor pressure 57 vs 52 cm H(2)O (p = 0.039), maximum cystometric capacity 253 vs 296 ml (p = 0.004) and detrusor overactivity volume 177 vs 229 ml (p = 0.003).

CONCLUSIONS

This trial demonstrates that in spinal cord injured patients a single 20 mg vardenafil administration achieved a significant decrease in maximum detrusor pressure, an improvement in maximum cystometric capacity and a remarkable increase in detrusor overactivity volume value.

Neurogenic detrusor overactivity treated with english botulinum toxin a: 8-year experience of one single centre

OBJECTIVE

Determine long-term effect of English botulinum neurotoxin type A (BoNTA; Dysport) for refractory neurogenic detrusor overactivity (NDO) for possible reduction of BoNTA efficacy after repeated injections.

METHODS

Between 1999 and 2005, 199 patients with spinal cord lesions with refractory NDO were treated with Dysport. All patients underwent a clinical examination, urinalysis, and videourodynamic study at baseline and at 3, 6, and 12 mo after each treatment, as well as a visual analogue scale (VAS) assessment and a bladder diary checked for 1 wk before each visit. We used 1000, 750, 500 IU BoNTA at the beginning of our experience, and thereafter we mainly used 750 IU. Outcome measures included frequency of urge urinary incontinence (Incontinence Episode Frequency [IEF] test); urodynamic parameters including maximum cystometric bladder capacity (MCBC), reflex volume (RV), bladder compliance (BC); number of pads/condoms; antimuscarinic drug consumption; short- and long-term side-effects; and quality of life measured with VAS.

RESULTS

No statistically significant differences were found in efficacy duration with the three Dysport doses (p=0.5274). The difference between the intervals of injections was not statistically significant (p=0.2659). MCBC, RV, and BC improved significantly after treatment compared with baseline values (p<0.001) and there were no statistically significant differences after each retreatment or regarding Dysport dose (p>0.05). There was a significant improvement in patient satisfaction after each retreatment as expressed on the VAS (p<0.001). There was a significant reduction in IEF score and pads/condoms use in the first 4 wk after each treatment (p<0.0001).

CONCLUSION

After repeated injections the effect of BoNTA remained constant.

Female Sexual Dysfunction and Hormonal Status in Spinal Cord Injured (SCI) Patients

To investigate a possible correlation between sexual hormonal status and the presence of female sexual dysfunction (FSD) using the Female Sexual Function Index (FSFI) in females with spinal cord injuries (SCI), we selected 39 SCI fertile-aged women. At visit 1, we assessed the presence of FSD using the FSFI, and all individuals were submitted to a blood hormone evaluation on the third day of their menstrual cycle. The levels of serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), thyroid-stimulating hormone (TSH), cortisol, dehydroepiandrosterone sulphate (DHEA-S), androstenedione, 17[alpha]-hydroxyprogesterone; total and free testosterone, 17beta-estradiol, inhibin, sex hormone-binding globulin (SHBG), and thyroid hormones (fT3 and fT4) were checked. Progesterone was measured on the 20th to 21st day after the menstrual cycle. In patients with amenorrhea, we tested all the hormones using 1 random blood test. After a 3-month period, the tests were repeated. Overall, 23/39 (58.9%) patients continued to manifest at least one sexual dysfunction. These patients reached a median score of 19.52. All but 6 patients (15.3%) consistently showed hormonal values within the normal range. Of the 6 patients with abnormal hormonal alterations, 5 showed at least one sexual dysfunction, 2 had low levels of total testosterone, 1 had a low level of free testosterone, 1 suffered from hypothyroidism, 1 presented with low levels of cortisol, and 1 showed hypoprogesterone. There was no significant correlation between abnormal hormonal status and the presence of a specific sexual dysfunction, as assessed with the FSFI.

Sexuality in patients with spinal cord injuries due to attempted suicide

OBJECTIVE

To evaluate the specific characteristics of sexuality in spinal cord injury (SCI) patients resulting from attempted suicide pre- and post-SCI.

METHODS

From March 1998 to March 2005, n=27 were compared with a SCI group with similar characteristics. In March 2006, all patients completed a final sexual check-up. Using our database we reviewed their sexuality path.

RESULTS

Suicide group (SG): Examination of personal/clinical history revealed in three how sexuality represented a possible co-factor for suicidal tendencies: one female reported a history of sexual abuse, two were homosexual (one gay and one lesbian). Five reported sexual dysfunctions. Nine females consistently showed via the Female Sexual Function Index (FSFI) at least one sexual disorder in all follow-ups; six females were in a stable relationship pre-SCI, seven during the final check-up; eight males in the SG presented erectile dysfunction using the International Index of Erectile Function (IIEF5); and eight were in a stable relationship pre-SCI and seven during the final visit. Control group (CG): Pre-SCI only one male presented erectile dysfunction. Seven females consistently showed sexual disorders. 11 females and 11 males were in stable relationships pre-SCI, respectively, 10 and 11 at the final check-up. In women the overall sexual satisfaction is statistically significant, correlated to the duration of the relationship P<0.05. Nine patients showed erectile dysfunction in the final follow-up.

CONCLUSIONS

The SG showed a higher percentage of sexual dysfunction pre-SCI compared with CG, and they presented constant difficulty in establishing a stable relationship causing both an obstacle in the initial sexual rehabilitation and in achieving a satisfactory overall sexual life.

Evaluation of tamoxifen and anastrozole in the prevention of gynecomastia and breast pain induced by bicalutamide monotherapy of prostate cancer

PURPOSE

To determine whether tamoxifen or anastrozole prevents gynecomastia and breast pain caused by bicalutamide (150 mg) without compromising efficacy, safety, or sexual functioning.

PATIENTS AND METHODS

A double-blind, placebo-controlled trial was performed in patients with localized, locally advanced, or biochemically recurrent prostate cancer. Patients (N = 114) were randomly assigned to either bicalutamide (150 mg/d) plus placebo or in combination with tamoxifen (20 mg/d) or anastrozole (1 mg/d) for 48 weeks. Gynecomastia, breast pain, prostate-specific antigen (PSA), sexual functioning, and serum levels of hormones were assessed.

RESULTS

Gynecomastia developed in 73% of patients in the bicalutamide group, 10% of patients in the bicalutamide-tamoxifen group, and 51% of patients in the bicalutamide-anastrozole group (P < .001); breast pain developed in 39%, 6%, and 27% of patients, respectively (P = .006). Baseline PSA level decreased by > or = 50% in 97%, 97%, and 83% of patients in the bicalutamide, bicalutamide-tamoxifen, and bicalutamide-anastrozole groups, respectively (P = .07); and adverse events were reported in 37%, 35%, and 69% of patients, respectively (P = .004). There were no major differences among treatments in sexual functioning parameters from baseline to month 6. Elevated testosterone levels occurred in each group; however, free testosterone levels remained unchanged in the bicalutamide-tamoxifen group because of increased sex hormone-binding globulin levels.

CONCLUSION

Anastrozole did not significantly reduce the incidence of bicalutamide-induced gynecomastia and breast pain. In contrast, tamoxifen was effective, without increasing adverse events, at least in the short-term follow-up. These data support the need for a larger study to determine any effect on mortality.

Role of bladder neck preservation in urinary continence following radical retropubic prostatectomy

OBJECTIVE

To report our experience of the influence of bladder neck preservation on patient continence.

MATERIAL AND METHODS

Radical retropubic prostatectomy with bladder neck preservation was performed in 131 patients (age range 48-73 years; mean 64.5 years). Urinary continence was evaluated using a validated questionnaire at follow-up visits and telephone interviews. All patients reporting incontinence were studied using a pad test and urodynamics.

RESULTS

After a mean follow-up period of 21.7 months (range 4-47 months), 115 patients were continent (87%) and 16 incontinent. According to the International Continence Society criteria, three had severe, three moderate and 10 mild incontinence. Urodynamics revealed sphincter deficiency in 15 cases, which was associated with decreased bladder compliance in four, while decreased compliance was the only abnormality in one. Continence was recovered 0-27 months after surgery (mean 3.2 months): 40% of men were continent within the first month and 74% within the third. Histopathology revealed positive margins in 30/131 patients (22%), but exclusively at the bladder neck level in only seven (5%), and two also had positive nodes. Six patients (4.5%) presented bladder neck stenosis requiring transurethral incision. No statistically significant differences were found between the ages of continent and incontinent men or between the time to continence recovery with two different techniques of retropubic hemostasis; however, use of a nerve-sparing technique significantly reduced the time to continence recovery.

CONCLUSIONS

Bladder neck preservation during radical retropubic prostatectomy does not improve the long-term results of urinary continence but does contribute substantially to its earlier recovery, thus improving the quality of life. With proper patient selection the risk of positive margins at the bladder neck level only is reasonably low.

[Alternative treatment of benign prostatic hypertrophy]

In our study we propose to find an alternative to surgery management of IPB usable in DH regime with current instrumentation or with new technology from physics. We retrospectively reviewed techniques commonly mentioned in the literature to value benefits about cost, comfort, outcomes, and, at the same time, we stress disadvantages regarding each of these. TUI is economical, can be done in a few minutes, involves minimum bleeding, but can't be utilized in III lobe prostate and it doesn't provide material for histological tests. TUBT, feasible with light patient sedation, provides not satisfying results. Hyperthermia is necessary in selected cases. TULIP must be effected in anesthesia, needs complicated and expensive instrumentation, and it isn't practicable in III lobe prostate. Urethral stent application is expensive and not satisfactory in large size and III lobe prostate. The outcomes we obtained with TUI are similar to TUR; TUBT obtains good symptomatological results only in 20% of cases at 12 months. Hyperthermia and TULIP obtain an improvement in urinary flow rate from 20 to 60% and 50% respectively. Stent application provides good results. We think that the most modern, effective and economical alternative to the surgery of prostate adenoma is endoscopic surgery in TUI model.