Behavior-Related Erectile Dysfunction: A Systematic Review and Meta-Analysis

BackgroundErectile dysfunction (ED) is a common problem among men across the world. It is usually multifactorial in origin. Behavioral factors can be related to the development of ED and related to many other chronic diseases. It impacts not only the sexual function but also the psychology and their overall quality of life.AimTo determine the association of the behavior factors in relation to ED and to identify the risk and protective factors.MethodA systematic review search based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis was conducted. The primary databases PubMed, PlosOne, Oxford Academic, SCOPUS, and Ovid were accessed using specific keyword searches. Quality of articles was assessed by using Newcastle-Ottawa Assessment Scale according to the study design.OutcomeEvaluation of the relationship between behavioral factors and ED.Results24 studies were identified from the 5 databases which met the predetermined criteria. Overall, the study population include adult male age between 18 and 80 years. The sample size of the studies ranges from 101 to the largest sample size of 51,329. Smoking, alcohol, and drugs usage are found to be risk factors for ED. Meanwhile, dietary intake, physical activity, and intimacy are the protective factors for ED.Clinical ImplicationThe findings from this review may aid clinicians to aim for early detection of ED by screening their risk factors and providing early treatment. This can also be used to promote awareness to the community on the sexual health and factors that can affect their sexual function.Strength & LimitationThis study looks at all types of behavioral factors that may affect ED; however, there was a substantial heterogeneity detected across the selected study factors. Furthermore, the lack of PROSPERO registration is also a limitation in this study.ConclusionOverall, smoking, dietary intake, alcohol consumption, drugs, and physical activities are modifiable risk factors for ED in men. Therefore, it is crucial to promote healthy lifestyle and empower men to prevent ED and early detection of ED for early treatment.Sivaratnam L, Selimin DS, Abd Ghani SR, et al. Behavior-Related Erectile Dysfunction: A Systematic Review and Meta-Analysis. J Sex Med 2021;18:121–143.     

Erectile Dysfunction and Depression: A Systematic Review and Meta-Analysis

Background

Some studies have reported that exposure to depression increases the risk of erectile dysfunction (ED), whereas others have observed no association. Moreover, additional studies have reported that exposure to ED increases the risk of depression.

Association Between Psoriasis and Erectile Dysfunction: A Meta-Analysis

Background

Several studies have shown a relationship between psoriasis and erectile dysfunction (ED), but a meta-analysis of the data has not been performed.

Association Between HIV Infection and Prevalence of Erectile Dysfunction: A Systematic Review and Meta-Analysis

BackgroundThe prevalence of erectile dysfunction (ED) in men positive for HIV has been reported to exceed the baseline of the general population. However, no meta-analysis or conclusive review has investigated whether individuals with HIV infection have a significantly higher prevalence of ED.AimTo explore the exact association between HIV infection and the prevalence of ED.MethodsThe PubMed, Embase, Medline, and Cochrane Library databases were searched to identify studies concerning the association between HIV infection and the prevalence of ED that were published up to December 2016. Manual searches also were performed. Relative risks and corresponding 95% confidence intervals were used to estimate the strength of association between HIV infection and the prevalence of ED. The methodologic quality of the included cohort studies was assessed through the Newcastle-Ottawa Scale. The cross-sectional study quality methodology checklist was used to assess the quality of cross-sectional studies. Sensitivity analyses were conducted to assess potential bias. This study was conducted according to the guidelines for Meta-Analyses and Systematic Reviews of Observational Studies (MOOSE).OutcomesThe strength of association between HIV infection and the prevalence of ED was evaluated using summarized unadjusted pooled relative risks and 95% confidence intervals.ResultsTwo cohort studies and three cross-sectional studies involving 4,252 participants were included. Mean age of patients ranged from 35.2 to 52 years in the included studies. Based on the random-effects model, analyses of all studies showed that HIV infection was significantly associated with an increased prevalence of ED (relative risk = 2.32, 95% confidence interval = 1.52–3.55, P < .001). There was significant heterogeneity among included studies (I² = 84%, P < .001). Estimates of total effects were generally consistent with the sensitivity.Clinical ImplicationsIndividuals with HIV infection had a significantly increased prevalence of ED, which suggests that ED should be of concern to clinicians when managing men with HIV infection.Strengths and LimitationsA strength of this study is that it is the first meta-analysis to explore the relation between HIV infection and the prevalence of ED. A limitation is that all included studies were observational studies, which can induce recall bias or selection bias.ConclusionEvidence from the observational studies suggested that individuals with HIV infection had a significantly increased prevalence of ED despite significant heterogeneity. More research is warranted to clarify the relation between HIV infection and the prevalence of ED.Luo L, Deng T, Zhao S, et al. Association Between HIV Infection and Prevalence of Erectile Dysfunction: A Systematic Review and Meta-Analysis. J Sex Med 2017;14:1125–1132.     

Association Between Opioid Use and Risk of Erectile Dysfunction: A Systematic Review and Meta-Analysis

BackgroundOpioid analgesics have been widely used to relieve chronic pain conditions; however, a connection between opioid analgesic administration and increased susceptibility to erectile dysfunction (ED) has been hypothesized.AimTo evaluate whether opioid use was a risk factor for ED in a systematic review and meta-analysis.MethodsThe PubMed, Cochrane Library, and Embase databases were searched to identify eligible studies concerning opioid use and risk of ED from inception to April 2017. The association between opioid use and risk of ED was summarized using the relative risk with 95% CI. Sensitivity analyses were conducted to assess potential bias. The Begg and Egger tests were used for publication bias analysis. The GRADE evidence profile tool was used to assess the quality of the evidence.OutcomesThe overall combined risk estimates for the effect of opioid use on ED were calculated using a random-effects model.ResultsThis meta-analysis included 8,829 men (mean age = 41.6 years) from 10 studies, 2,456 of whom received opioid management (duration of intervention = 4 months to 9.5 years). Pooled results demonstrated that the use of opioids was significantly associated with an increased risk of ED (relative risk = 1.96, 95% CI = 1.66–2.32, P < .001). Estimates of the total effects were generally consistent in the sensitivity analysis. No evidence of publication bias was observed. The overall quality of evidence was rated as low.Clinical ImplicationsWe found that men with opioid use had a significantly increased prevalence of ED, which suggests that patients and clinicians should be aware of the potential role played by opioid administration in the development of ED.Strengths and LimitationsThis is the first meta-analysis performed to describe the relation between opioid use and ED risk based on all available epidemiologic studies. However, the direction of causality between opioid use and risk of ED should be interpreted with caution because most included studies used a cross-sectional design.ConclusionEvidence from the included observational studies indicated that men with opioid use had a significantly increased risk of ED. Further randomized controlled trials are still needed to confirm this relation.Zhao S, Deng T, Luo L, et al. Association Between Opioid Use and Risk of Erectile Dysfunction: A Systematic Review and Meta-Analysis. J Sex Med 2017;14:1209–1219.     

Effects of Low-Intensity Extracorporeal Shockwave Therapy on Erectile Dysfunction: A Systematic Review and Meta-Analysis

IntroductionLow-intensity extracorporeal shock wave therapy (Li-ESWT) has been proposed as an effective non-invasive treatment option for erectile dysfunction (ED).AimTo use systematic review and meta-analysis to assess the efficacy of Li-ESWT by comparing change in erectile function as assessed by the erectile function domain of the International Index of Erectile Function (IIEF-EF) in men undergoing Li-ESWT vs sham therapy for the treatment of ED.MethodsSystematic search was conducted of MEDLINE, EMBASE, and ClinicalTrials.gov for randomized controlled trials that were published in peer-reviewed journals or presented in abstract form of Li-ESWT used for the treatment of ED from January 2010 through March 2016. Randomized controlled trials were eligible for inclusion if they were published in the peer-reviewed literature and assessed erectile function outcomes using the IIEF-EF score. Estimates were pooled using random-effects meta-analysis.Main Outcome MeasuresChange in IIEF-EF score after treatment with Li-ESWT in patients treated with active treatment vs sham Li-ESWT probes.ResultsData were extracted from seven trials involving 602 participants. The average age was 60.7 years and the average follow-up was 19.8 weeks. There was a statistically significant improvement in pooled change in IIEF-EF score from baseline to follow-up in men undergoing Li-ESWT vs those undergoing sham therapy (6.40 points; 95% CI = 1.78–11.02; I² = 98.7%; P < .0001 vs 1.65 points; 95% CI = 0.92–2.39; I² = 64.6%; P < .0001; between-group difference, P = .047). Significant between-group differences were found for total treatment shocks received by patients (P < .0001).ConclusionIn this meta-analysis of seven randomized controlled trials, treatment of ED with Li-ESWT resulted in a significant increase in IIEF-EF scores.     

An Analysis of Popular Online Erectile Dysfunction Supplements

IntroductionErectile dysfunction supplements (ED-Ss) are featured on online marketplaces like Amazon.com, with dedicated pages and claims that they naturally treat ED. However, their efficacy and safety are largely unknown, limiting the ability to counsel patients regarding their use.AimTo evaluate the highest rated and most frequently reviewed ED-Ss on Amazon.com to facilitate patient counseling regarding marketing myths, ingredient profiles, and evidence for product efficacy and safety.MethodsThe Amazon marketplace was queried using the key term “erectile dysfunction” with default search settings and ranking items based on relevance. The top 6 ED-S products identified on September 29, 2018, were reviewed based on price, ratings, reviews, manufacturer, and ingredients. Consumer reviews were categorized using subtopics within the International Index of Erectile Function (IIEF) questionnaire to better understand ED-S efficacy and then reanalyzed following filtration of untrustworthy comments using ReviewMeta.com, a proprietary Amazon review analysis software.OutcomesQuantitative and qualitative evaluation of ED-S products sold on Amazon.com.ResultsThe top 6 ED-Ss had an average of 2,121 ± 1,282 reviews and a mean rating of 3.92 ± 0.42 stars. A total of 21 ingredients were identified in these ED-Ss. Ginseng, horny goat weed, L-arginine, and tongkat ali were the most popular ingredients included in the analyzed products. Our literature review identified 413 studies involving the 21 identified ingredients, of which 59 (16%) involved human subjects. Among these 69 human studies, only 12 (17%) investigated supplement ingredients individually and reported improvement in ED. Analysis of top-ranked customer reviews from the first 2 pages of reviews for each supplement revealed differences in IIEF scores before and after ReviewMeta.com filtration. After filtration, we observed a 77% decrease in reviews reporting improved erection strength, an 83% decrease in reviews reporting improved ability to maintain erection, a 90% decrease in reviews reporting increased sexual satisfaction, an 88% decrease in reviews reporting increased enjoyment with intercourse, and an 89% decrease in reviews reporting increased erection confidence.Strengths & LimitationsStudy strengths include a novel approach to ascertaining consumers’ perceptions and satisfaction with ED-Ss and practical summary information that clinicians can provide to patients. Limitations include selection bias, the small number of supplements analyzed, and the proprietary nature of the Amazon review analysis software.ConclusionsOur investigation revealed that human studies evaluating the efficacy of ED-S ingredients are limited and have yielded no definitive findings of the effects on ED. Patients considering ED-S use should receive appropriate counseling, given the prevalence of disingenuous reviews and the ready availability of Food and Drug Administration–approved drug therapies.Balasubramanian A, Thirumavalavan N, Srivatsav A, et al. An Analysis of Popular Online Erectile Dysfunction Supplements. J Sex Med 2019;16:843–852.     

The Natural History of Erectile Dysfunction After Prostatic Radiotherapy: A Systematic Review and Meta-Analysis

BackgroundErectile dysfunction (ED) after treatment for prostate cancer with radiotherapy (RT) is well known, and pooled estimates of ED after RT will provide more accurate patient education.AimTo systematically evaluate the natural history of ED in men with previous erectile function after prostate RT and to determine clinical factors associated with ED.MethodsWe performed a review of the PubMed and Medline, Embase, Cochrane Library, and Web of Science databases in April 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Identified reports included a measurement of ED before and after prostate RT. Two hundred seventy-eight abstracts were screened and 105 publications met the criteria for inclusion. Only men with known erectile function before RT were included in the analysis.OutcomeED after RT of the prostate.ResultsIn total, 17,057 men underwent brachytherapy (65%), 8,166 men underwent external-beam RT (31%), and 1,046 men underwent both (4%). Seven common instruments were used to measure ED, including 23 different cutoffs for ED. The Sexual Health Inventory for Men (SHIM) was used in 31 studies (30%). Pooled estimates of SHIM-confirmed ED (score <10–17) suggested the prevalence of ED after RT is 34% of men (95% CI = 0.29–0.39) at 1 year and 57% (95% CI = 0.53–0.61) at 5.5 years. Compared with brachytherapy, studies of the two types of radiation increased the proportion of new-onset ED found by 12.3% of studies (95% CI = 2.3–22.4). For every 10% who were lost to follow-up, the proportion of ED reported increased by 2.3% (95% CI = 0.03–4.7).Clinical ImplicationsED is common regardless of RT modality and increases during each year of follow-up. Using the SHIM, ED is found in approximately 50% patients at 5 years.Strengths and LimitationsThe strengths of this systematic review include strict inclusion criteria of studies that measured baseline erectile function, no evidence for large effect size bias, and a large number of studies, which allow for modeling techniques. However, all data included in this analysis were observational, which leaves the possibility that residual confounding factors increase the rates of ED.ConclusionDefinitions and measurements of ED after RT vary considerably in published series and could account for variability in the prevalence of reported ED. Loss to follow-up in studies could bias the results to overestimate ED.Gaither TW, Awad MA, Osterberg EC, et al. The Natural History of Erectile Dysfunction After Prostatic Radiotherapy: A Systematic Review and Meta-Analysis. J Sex Med 2017;14:1071–1078.     

Erectile Dysfunction Predicts Cardiovascular Events as an Independent Risk Factor: A Systematic Review and Meta-Analysis

IntroductionPrevious studies demonstrating that erectile dysfunction (ED) predicts the risk of further cardiovascular events (CV) events are insufficient to make recommendations for cardiologists, diabetologists, urologists, and more, and the association between CV events and ED degree is unclear.AimTo assess whether ED was a risk factor for CV events in a comprehensive literature review and meta-analysis.MethodsPubMed, EMBASE, the Cochrane Library, Medline, and the Web of Science were searched for eligible studies. The protocol for this meta-analysis is available from PROSPERO (CRD42018086138).Main Outcome MeasuresThe main outcomes included cardiovascular disease (CVD), coronary heart disease (CHD), stroke, and all-cause mortality. Subgroup and sensitivity analyses were conducted to detect potential bias.Results25 eligible studies involving 154,794 individuals were included in our meta-analysis. Compared with those of men without ED, the CVD risk of ED patients was significantly increased by 43% (relative risk [RR] =1.43; P < .001), CHD was increased by 59% (RR = 1.59; P < .001), stroke was increased by 34% (RR = 1.34; P < .001), and all-cause mortality was increased by 33% (RR = 1.33; P < .001). Older individuals with ED (≥55 years), those with ED of a shorter duration (<7 years), and those with higher rates of diabetes (≥20%) and smoking (≥40%) were more prone to develop CVD. Additionally, severe ED was proven to predict higher CVD and all-cause mortality risk. The standardized model proposed here can be properly applied for screening early CV events.Clinical ImplicationsThe evidence prompts the diligent observation of at-risk men and reinforces the importance of early treatment to prevent CV events.Strengths & LimitationsLarger sample sizes from recent prospective cohort studies were included to provide more up-to-date, reliable, and comprehensive results. Moreover, the results were robust regarding consistency across sensitivity and subgroup analyses and remained consistent; even pre-excluded retrospective or cross-sectional studies were included. We constructed a standardized model that addresses the study’s innovations and implications for the first time. However, not all included studies were randomized controlled trials, which might downgrade this evidence.ConclusionsRisk of total CVD, CHD, stroke, and all-cause mortality was significantly increased in populations with ED, and severe ED is of particular concern. The evidence suggests the need for diligent observation of at-risk men and reinforces the importance of early treatment to prevent CV events.Zhao B, Hong Z, Wei Y, et al. Erectile Dysfunction Predicts Cardiovascular Events as an Independent Risk Factor: A Systematic Review and Meta-Analysis. J Sex Med 2019;16:1005–1017.     

Altered Penile Caveolin Expression in Diabetes: Potential Role in Erectile Dysfunction

BackgroundThe pathophysiology of increased severity of erectile dysfunction in men with diabetes and their poor response to oral pharmacotherapy are unclear. Defective vascular endothelium and consequent impairment in the formation and action of nitric oxide (NO) are implicated as potential mechanisms. Endothelial NO synthase, critical for NO generation, is localized to caveolae, plasma membrane lipid rafts enriched in structural proteins, and caveolins. Type 2 diabetes mellitus (T2DM)-induced changes in caveolin expression are recognized to play a role in cardiovascular dysfunction.AimsTo evaluate DM-related changes to male erectile tissue in a mouse model that closely resembles human T2DM and study the specific role of caveolins in penile blood flow and microvascular perfusion using mice lacking caveolin (Cav)-1 or Cav-3.MethodsWe used wild-type C57BL6 (control) and Cav-1 and Cav-3 knockout (KO) male mice. T2DM was induced by streptozotocin followed by a high-fat diet for 4 months. Penile expressions of Cav-1, Cav-3, and endothelial NO synthase were determined by western blot, and phosphodiesterase type 5 activity was measured using [³H] cyclic guanosine monophosphate as a substrate. For hemodynamic studies, Cav-1 and Cav-3 KO mice were anesthetized, and penile blood flow (peak systolic velocity and end-diastolic velocity; millimeters per second) was determined using a high-frequency and high-resolution digital imaging color Doppler system. Penile tissue microcirculatory blood perfusion (arbitrary perfusion units) was measured using a novel PeriCam PSI system.OutcomesPenile erectile tissues were harvested for histologic studies to assess Cav-1, Cav-3, and endothelial NO synthase expression, phosphodiesterase type 5 activity, and blood flow, and perfusion measurements were assessed for hemodynamic studies before and after an intracavernosal injection of prostaglandin E₁ (50 ng).ResultsIn T2DM mice, decreased Cav-1 and Cav-3 penile protein expression and increased phosphodiesterase type 5 activity were observed. Decreased response to prostaglandin E₁ in peak systolic velocity (33 ± 4 mm/s in Cav-1 KO mice vs 62 ± 5 mm/s in control mice) and perfusion (146 ± 12 AU in Cav-1 KO mice vs 256 ± 12 AU in control mice) was observed. Hemodynamic changes in Cav-3 KO mice were insignificant.Clinical TranslationOur findings provide novel mechanistic insights into erectile dysfunction severity and poor pharmacotherapy that could have potential application to patients with T2DM.Strengths and LimitationsUse of KO mice and novel hemodynamic techniques are the strengths. A limitation is the lack of direct evaluation of penile hemodynamics in T2DM mice.ConclusionAltered penile Cav-1 expression in T2DM mice and impaired penile hemodynamics in Cav-1 KO mice suggests a regulatory role for Cav-1 in DM-related erectile dysfunction.Parikh J, Zemljic-Harpf A, Fu J, et al. Altered Penile Caveolin Expression in Diabetes: Potential Role in Erectile Dysfunction. J Sex Med 2017;14:1177–1186.     

Erectile Dysfunction and Premature Ejaculation in Homosexual and Heterosexual Men: A Systematic Review and Meta-Analysis of Comparative Studies

Introduction

Comparative studies on differences in sexual function outcomes between homosexual and heterosexual men are sparse and inconclusive.

High Prevalence of Erectile Dysfunction in Diabetic Men With Depressive Symptoms: A Meta-Analysis

Background

Erectile dysfunction (ED) may be common among diabetic men with depressive symptoms (DS), but its prevalence is still debated.

Prevalence of Erectile Dysfunction in Patients With End-Stage Renal Disease: A Systematic Review and Meta-Analysis

BackgroundErectile dysfunction (ED) is an under-recognized clinical entity in men with end-stage renal disease (ESRD), and studies on renal transplant recipients, patients on dialysis, and patients starting dialysis report different prevalence rates and severity of ED among these groups.AimTo determine the prevalence and severity of ED in patients with ESRD, assessed with the International Index of Erectile Function-15 and International Index of Erectile Function-5.MethodsWe performed a systematic review and meta-analysis of observational studies assessing the prevalence of ED in ESRD individuals. (PROSPERO ID: CRD42020182680). Records were identified by search in MEDLINE, Scopus, and CENTRAL databases and sources of gray literature until July 2020. We conducted a random-effects meta-analysis of proportions (double arcsine transformation).OutcomesWe included 94 studies with 110 patient group entries and a total of 10,320 ESRD male individuals with a mean age of 48.8 ± 14.25 years.ResultsOverall, 7,253 patients experienced ED. We estimated an overall pooled ED prevalence of 71% (95% CI: 67–74%, I² = 92%). In the subgroup analyses, the pooled prevalence was 59% (95% CI: 53–64%, I² = 92%) among renal transplant recipients, 79% (95% CI: 75–82%, I² = 86%) in patients on hemodialysis, 71% (95% CI: 58–83%, I² = 86%) in patients on peritoneal dialysis, and 82% (95% CI: 75–88%, I² = 0%) in patients with ESRD starting dialysis. The prevalence of the severity of ED was also estimated. Further assessment of heterogeneity was conducted via sensitivity analysis, cumulative meta-analysis, and meta-regression of significant risk factors.Clinical translationDespite its high prevalence in patients with ESRD, ED constitutes an underestimated and taboo subject in this group. Therefore, arousing clinical concern among healthcare providers involved in ESRD management is more than necessary to screen and treat ED in patients receiving renal replacement therapy.Strengths & LimitationsWe estimated ED solely for ESRD, included the largest number of patients compared with previous studies and estimated ED prevalence as per severity and renal replacement therapy subgroups. Contrary, because we restricted our eligibility criteria to the International Index of Erectile Function, some studies assessing ED prevalence with other validated tools were not included in this meta-analysis. Moreover, the levels of heterogeneity among studies remained high after sensitivity and meta-regression analyses, and for some moderators, the results of the meta-regression might have been underpowered.ConclusionsED is highly prevalent in patients with ESRD irrespective of the type of renal replacement therapy, thereby warranting clinical attention.Pyrgidis N, Mykoniatis I, Nigdelis MP, et al. Prevalence of Erectile Dysfunction in Patients With End-Stage Renal Disease: A Systematic Review and Meta-Analysis. J Sex Med 2021;18:113–120.     

Role of Nanotechnology in Erectile Dysfunction Treatment

IntroductionThe biological importance of nanotechnology-based delivery vehicles for in vivo tissue regeneration is gaining acceptance by the medical community; however, its relevance and incorporation into the treatment of sexual dysfunction are evolving and have not been well evaluated.AimTo provide scientific evidence examining the use of state-of-the-art nanotechnology-based delivery methodology in the treatment of erectile dysfunction (ED) in animal models and in patients.MethodsThis review assessed the current basic science literature examining the role of nanotechnology-based delivery vehicles in the development of potential ED therapies.ResultsThere are four primary areas where nanotechnology has been applied for ED treatment: (i) topical delivery of drugs for on-demand erectile function, (ii) injectable gels into the penis to prevent morphologic changes after prostatectomy, (iii) hydrogels to promote cavernous nerve regeneration or neuroprotection, and (iv) encapsulation of drugs to increase erectile function (primarily of phosphodiesterase type 5 inhibitors).ConclusionBasic science studies provide evidence for a significant and evolving role for nanotechnology in the development of therapies for ED and suggest that properly administered nano-based therapies might be advantageous for treating male sexual dysfunction.     

The Basic Science Behind Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction: A Systematic Scoping Review of Pre-Clinical Studies

Introduction

Despite recent promising clinical results, the underlying mechanism of action of low-intensity extracorporeal shockwave therapy (Li-ESWT) for erectile dysfunction (ED) is mostly unclear and currently under investigation.

Quality of Clinical Practice Guidelines for the Diagnosis and Treatment of Erectile Dysfunction: A Systematic Review

IntroductionClinical practice guidelines (CPGs) guide the diagnosis and treatment of erectile dysfunction using different methodologies. Nonetheless, the quality of published CPGs is unknown.AimTo evaluate the quality of CPGs for diagnosis and treatment of patients with erectile dysfunction.MethodsThe Medline, Embase, and LILACS databases were searched using structured strategies. The evidence was complemented by searches on websites of scientific societies and guideline developers. The CPG quality was assessed using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument.Main Outcome MeasureThe outcome measure included the quality of CPGs in accordance with the AGREE II instrument score.Results17 guidelines met the selection criteria. 15 had recommendations for diagnosis, 16, had recommendations for treatment, and 1 included a follow-up. Most of the guidelines were developed in Europe (35.3%) and North America (29.4%), 2 were prepared by specialized groups (11.7%), and 1 was funded by public resources. The most common development method was the panel of experts (9 guides, 52.9%). 5 guidelines were of high quality as per the methodological rigor, as follows: Cancer Care Ontario 2016 (76.5%), European Urology Association 2018 (65.6%), American Urological Association 2018 (62.5%), American College of Physicians (62.5%), and Japanese Society for Sexual Medicine (60.4%). There was a significant relationship (P = .043) between the methodological quality of the guidelines and the funding source.Clinical ImplicationsBy knowing the quality of the clinical practice guidelines, users can make more objective decisions about their use, which has an impact on patient care.Strength & LimitationsHigh-quality CPGs frequently used in health-care practice were identified. Solely CPGs in Spanish, English, and Portuguese were included, which generates selection bias in the results.ConclusionsThe number of CPGs for erectile dysfunction developed using international standards that meet the AGREE II quality criteria is low. Scientific societies have a strong interest in developing guidelines on this topic, whereas the participation of governmental organizations is limited.Sandoval-Salinas C, Saffon JP, Corredor HA. Quality of Clinical Practice Guidelines for the Diagnosis and Treatment of Erectile Dysfunction: A Systematic Review. J Sex Med 2020;17:678–687.     

Role of Serum High-Sensitivity C-Reactive Protein as a Predictor of Therapeutic Response to Tadalafil in Patients With Erectile Dysfunction: A Prospective Observational Study

IntroductionHigh-sensitivity C-reactive protein (hs-CRP), a marker of inflammation, is known to be elevated in patients with erectile dysfunction (ED). However, its role in predicting therapeutic response to phosphodiesterase-5 inhibitors is incompletely understood.AimThe aim of this study was to understand the relationship among hs-CRP, mechanism of ED, and therapeutic response of ED to tadalafil, a phosphodiesterase-5 inhibitor.MethodsA total of 282 men (mean age 36.6 ± 12.0 years) with ED were included. All subjects underwent detailed evaluation, including estimation of a 6-item abbreviated version of the International Index of Erectile Function (IIEF-6) score, penile Doppler studies, and measurement of hs-CRP. IIEF-6 scoring and hs-CRP measurement were repeated after 6 weeks of tadalafil therapy (10 mg/day). The patients were categorized into vasculogenic and nonvasculogenic ED groups based on penile Doppler findings.Main Outcome MeasureThe main outcome measure was the therapeutic response to tadalafil, in relation to the mechanism of ED and hs-CRP levels.ResultsVasculogenic ED was much less common (23.8% of the subjects) than non-vasculogenic ED. Subjects with vasculogenic ED were older, had higher prevalence of cardiovascular risk factors, had more severe (mean IIEF-6 score 9.2 ± 4.6 vs 14.8 ± 4.7; P < .001) and longer duration ED, and responded less favorably to therapy (response rate 10.4% vs 75.0%; P < .001). Those showing improvement with tadalafil had lower hs-CRP at baseline (median 1.5 mg/L [interquartile range 0.9?2.3] vs 2.0 mg/L [interquartile range 1.1?3.1; P = .034]) and had proportionately greater reduction in its level. However, on multivariate analysis, only shorter duration of ED (P = .008), non-vasculogenic origin (P = .025), and higher IIEF-6 score at baseline (P = .013) were independent predictors of response to treatment.Clinical ImplicationsSerum hs-CRP is elevated in patients who are less likely to respond to vasodilator therapy but does not have an independent predictive value for this purpose.Strengths & LimitationsThis is the largest study to evaluate the relationship among the mechanism of ED, serum hs-CRP level, and therapeutic response of ED to tadalafil. All patients underwent a penile Doppler study to characterize the type of ED. The limitations were nonrandomized nature of the study and nearly 22% dropout rate.ConclusionSerum hs-CRP level is higher in vasculogenic ED compared with non-vasculogenic ED, and is associated with poorer response to tadalafil therapy. However, this association is not independent of underlying risk factors and mechanism of ED.Jamaluddin, Bansal M, Srivastava GK, et al. Role of Serum High-Sensitivity C-Reactive Protein as a Predictor of Therapeutic Response to Tadalafil in Patients With Erectile Dysfunction: A Prospective Observational Study. J Sex Med 2019;16:1912–1921.     

A Systematic Review of Pelvic Floor Muscle Training for Erectile Dysfunction After Prostatectomy and Recommendations to Guide Further Research

BackgroundErectile dysfunction is one potential complication after radical prostatectomy; often pelvic floor muscle training is offered as an intervention to improve quality of life and erectile function post-operatively.AimTo provide a summary of current evidence regarding the effectiveness of pelvic floor muscle training in the management of erectile dysfunction after radical prostatectomy and provide recommendations for future research.MethodsAn electronic search was conducted for relevant research studies using PubMed, EMBASE, CINAHL, Medline, and PEDro. Quality of selected trials was assessed by 2 independent reviewers using the Modified Downs and Black Checklist; disagreements were resolved by consensus.Main Outcome MeasureThe main outcome measure is the International Index of Erectile function (IIEF-5).Results9 studies of various study design were included in this review. Most studies demonstrated improvements in erectile dysfunction with pelvic floor muscle training; however, lack of methodological rigor for several studies and variability among training protocols limited interpretation of results.Clinical ImplicationsFurther well powered and rigorously designed randomized controlled trials are needed to investigate the effect of pelvic floor muscle training on erectile dysfunction after radical prostatectomy.Strengths & LimitationsThis review employed a systematic method of appraising the available evidence for pelvic floor muscle training for erectile dysfunction after radical prostatectomy. Limited high-quality articles were identified and few conclusions could be drawn from the existing evidence.ConclusionFuture high-quality randomized controlled trials should include strategies to improve adherence to exercise, clearly describe exercise protocols, and integrate new evidence for verbal cues and biofeedback for muscles involved in erection.Wong C, Louie DR, Beach C. A Systematic Review of Pelvic Floor Muscle Training for Erectile Dysfunction After Prostatectomy and Recommendations to Guide Further Research. J Sex Med 2020;17:737–748.     

Enriching the Interpretation of the Erectile Dysfunction Inventory of Treatment Satisfaction: Characterizing Success in Treatment Satisfaction

Background

Patient-reported outcomes, such as the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) index, are essential for successful evaluation and treatment of patients with erectile dysfunction.

Management of Antipsychotic-Related Sexual Dysfunction: Systematic Review

IntroductionSexual dysfunction is one of the most frequently occurring side-effects of antipsychotic medication, impacting both quality of life and adherence to treatment. Despite this, limited evidence-based guidance on treatment options is available.AimTo synthesize and analyze the evidence on management of antipsychotic-related sexual dysfunction, specifically taking note of the more recently developed antipsychotics that have been incorporated in studies over the past decade.MethodsEMBASE, Medline, and PsychINFO databases were searched using search terms related to sexual or erectile dysfunction, treatments, and antipsychotics. 2 reviewers independently assessed papers for the inclusion criteria for randomized controlled trials (RCTs) of treatments for antipsychotic-related sexual dysfunction, including adjunctive medications and a switch of antipsychotic. Studies were excluded if participants did not have recorded sexual dysfunction at baseline.Main Outcome MeasureThe primary outcome measure was any change in sexual function.Results6 RCTs were identified, all of which investigated different interventions; hence, it was not possible to synthesize the data quantitatively. Results were overall limited by small sample size, brief treatment duration, and the potential for bias. 2 studies, one assessing adjunctive sildenafil and the other adjunctive aripiprazole, reported a reduction in antipsychotic-related sexual dysfunction.Clinical ImplicationsDue to the lack of high-quality data, no clinical recommendations can be made.Strengths & LimitationsA comprehensive search strategy was used with an extensive number of relevant search terms including “erectile dysfunction” and newer antipsychotics such as aripiprazole. In light of evidence that prolactin is not a reliable marker for sexual dysfunction, this review focused its inclusion criteria on participants presenting with sexual dysfunction rather than with hyperprolactinemia, which should give its recommendations more validity. However, only 6 RCTs were identified, and results were overall limited by small sample size, brief treatment duration, and the potential for bias.ConclusionOur findings highlight the paucity of high-quality research in this area, and conjecture that it may be difficult to recruit participants with antipsychotic-related sexual dysfunction. Future research may be necessary to unlock and address these difficulties. Furthermore, fully powered future studies should focus on the management of sexual dysfunction rather than the surrogate marker of hyperprolactinemia.Allen K, Baban A, Munjiza J, et al. Management of Antipsychotic-Related Sexual Dysfunction: Systematic Review. J Sex Med 2019;16:1978–1987.