Injection Anxiety and Pain in Men Using Intracavernosal Injection Therapy after Radical Pelvic Surgery

IntroductionIntracavernosal injection (ICI) therapy is a well‐recognized treatment strategy with high success rates for men with erectile dysfunction. Despite this, injection anxiety and pain related to injection are significant barriers to its use.AimsThis study aims to examine injection anxiety and injection pain in patients using ICI.MethodsMen starting ICI therapy post radical pelvic surgery completed questionnaires at initial visit, at each of the two ICI training sessions and at a 4‐month follow‐up visit.Main Outcome MeasuresInjection Anxiety Scale, Injection Pain Scale, Injection Reaction Inventory, and the Erectile Function Domain of the International Index of Erectile Function.ResultsAverage age of the 68 men was 60 ± 8 years. At 4 months, the self‐reported frequency of ICI use was: 29% <1/week, 26% 1/week, 40% 2/week, and 5% 3/week. Mean injection anxiety score at first injection was 5.7 ± 2.8 (range 0–10) and significantly decreased to a 4.1 ± 3 at 4 months (P < 0.001). At first injection, 65% reported high injection anxiety (≥5) and this significantly decreased to 42% (P = 0.003) at 4 months. Anxiety at first injection was negatively related to ICI frequency at 4 months (r = ?0.23, P = 0.08). Mean injection pain score at first injection was low (2.2 ± 1.8, range 0–10) and 59% rated injection pain ≤2. Injection pain remained consistent across time periods. At first injection, injection anxiety (assessed prior to injection) was related to injection pain (r = 0.21, P = 0.04) and subjects (n = 21) who reported high injection anxiety (≥5) across time points, reported an increase in injection pain scores from first injection to 4 months (2.7 vs. 3.7, P = 0.05).ConclusionsAlthough injection anxiety decreased with ICI use, mean injection anxiety remained at a moderate level (4.4) and 42% of men continued to report “high” injection anxiety at 4 months. While injection pain was low, injection anxiety and pain were related. These data suggest the need for a psychological intervention to help lower injection anxiety related to ICI. Nelson CJ, Hsiao W, Balk E, Narus J, Tal R, Bennett NE, and Mulhall JP. Injection anxiety and pain in men using intracavernosal injection therapy after radical pelvic surgery. J Sex Med 2013;10:2559–2565.     

Satisfaction profiles in men using intracavernosal injection therapy

IntroductionIntracavernosal injection therapy (ICI) is a well‐established second‐line therapy used in the treatment of erectile dysfunction (ED). Controversy exists as to whether oral phosphodiesterase type 5 inhibitors (PDE5i) or injection therapy lead to higher satisfaction.AimThis study addressed ICI satisfaction in a modern cohort of patients in the PDE5i era.MethodsPatients on ICI for at least 6 months were included in our study. Patients were administered the International Index of Erectile Function (IIEF) at the initial visit. On subsequent visits, patients were administered the IIEF and the Erection Hardness Scale (EHS).Main Outcome MeasuresStudy end points were change in baseline scores in the satisfaction domains (SD) of the IIEF, type of injection medication used, and predictors of satisfaction. Multiple logistic regressions were performed for predictors of satisfaction.ResultsOne hundred twenty‐two patients met inclusion criterion. Mean time to follow‐up was 25 ± 12 months (range 6–106 months). Sixty‐five percent of patients continued injections at the time of follow‐up. When SD scores were examined, intercourse SD scores increased from 4.8 ± 1.7 at baseline to 12.3 ± 3.1 (P < 0.01); overall SD scores increased from 4.1 ± 1.8 to 7.2 ± 2.0 (P < 0.05). On multivariate analysis, predictors of satisfaction included older age (odds ratio [OR] = 2.1), younger partner age (OR = 2.5), clinically significant increase in the erectile function domain score (OR = 3.1), and attainment of a “fully rigid” erection (EHS 4) (OR = 6.8).ConclusionsWe have evaluated satisfaction in a modern cohort of ICI patients. While dropout rates are significant, for those patients who continue to inject, we have found high levels of satisfaction using the IIEF, the gold standard for evaluation of erectile function. On multivariate analysis, we found that older age, younger partner age, and fully rigid erections were predictors of increased satisfaction. ICI remains a robust second‐line therapy in the treatment of ED even in the era of PDE5i. Hsiao W, Bennett N, Guhring P, Narus J, and Mulhall JP. Satisfaction profiles in men using intracavernosal injection therapy.     

An Evaluation of a Clinical Care Pathway for the Management of Men With Nonorganic Erectile Dysfunction

IntroductionThere exists little literature on the outcomes of the medical management of men with erectile dysfunction (ED) with no overt organic etiology.AimThis study was conducted to assess the outcomes of men with nonorganic ED treated medically.MethodsAll patients had normal hormone profiles and vascular assessment. All were given a trial of a phosphodiesterase type 5 inhibitor (PDE5i). If no improvement was experienced, intracavernosal injection (ICI) therapy was administered. All patients were encouraged to seek a consultation with a mental health professional.Main Outcome MeasurePatient demographics, medical comorbidities, hormone and hemodynamics assessments, and change in International Index of Erectile Function scores of patients were recorded.Results116 men with a mean age or 38 ± 19 (range 16?57) years were studied. 21% had mild ED, 47% had moderate ED, and 32% had severe ED. 21% had seen a psychiatrist. 81% of patients responded to PDE5i with a penetration hardness erection on follow-up (mean duration of 7 ± 3 months postcommencement of PDE5i). However, only 68% of these were capable of a consistently good response. The mean Erectile Function domain score on PDE5i for the entire group improved from 18 ± 11 to 22 ± 6 (P = .01), and for PDE5i responders it was 27 ± 4 (P < .001). 28% of men (22 PDE5i failures and 10 with a mixed response to PDE5i) attempted ICI, all obtaining consistently functional erections. At a mean time point of 11 ± 5 months, 83% of those responding to PDE5i had ceased using PDE5i due to a lack of need. 11% of those using ICI continued to use them 6 months after starting ICI; the remainder had been transitioned back to PDE5i. Of the 29 patients in the latter subgroup, 66% were no longer using PDE5i consistently due to a lack of need.Clinical ImplicationsNot all men with nonorganic ED respond to PDE5i initially and many of those who respond do so only intermittently; such patients are potentially curable, using erectogenic pharmacotherapy for erectile confidence restoration, most men are capable of being weaned from drug therapy.Strengths & LimitationsThe strengths of the study are the large number of patients and the use of serial validated instruments to assess erectile function outcomes. As a weakness, despite normal hormone and vascular assessments, the diagnosis of nonorganic ED is still a presumptive one.ConclusionMedical management of nonorganic ED utilizing the process of care model results in cure in a large proportion of such patients. The transient use of ICI in some patients permits successful PDE5i rechallenge.Jenkins LC, Hall M, Deveci S, et al. An Evaluation of a Clinical Care Pathway for the Management of Men With Nonorganic Erectile Dysfunction. J Sex Med 2019;16:1541–1546.     

Long Term Effectiveness and Safety of Intracavernosal Botulinum Toxin A as an Add-on Therapy to Phosphosdiesterase Type 5 Inhibitors or Prostaglandin E1 Injections for Erectile Dysfunction

BackgroundSome evidence suggests that intracavernosal botulinum toxin A (BTX-A IC) injections administered in addition to phosphodiesterase type 5 inhibitors (PDE5-Is) or prostaglandin E1 intracavernosal injections (PGE1 ICI) could effectively treat erectile dysfunction (ED) in non–responders, or insufficient responders to these pharmacologic treatments.AimTo determine the long-term effectiveness and safety of combined treatment involving a single injection of BTX-A IC as an add on therapy to PDE5-Is or PGE1-ICI for the treatment of ED of different etiologies.MethodsA retrospective, uncontrolled, single center study was conducted. Data from 123 consecutive patients with ED who were insufficient responders to PDE5-Is or PGE1-ICI and who received onabotulinumtoxinA 100 U, abobotulinumtoxinA 250 U or 500 U IC as an add on to their current pharmacologic treatment were analyzed. All analyses were exploratory. Qualitative data were compared using the Fisher's exact test. Univariate and multivariate analysis were performed using logistic regression with Odds Ratios (OR). Only variables with P < .05 in the univariate analysis were selected for multivariate analysis.ResultsThe minimally clinically important difference (relative to baseline severity of ED) in the International Index of Erectile Function-Erectile function domain (IIEF-EF) score was achieved in 50% of patients at 34 (27–42) days and in 41% at 5.9 (3.9 – 8.1) months following BTX-A IC in combination with PDE5-Is or PGE1 ICI. The severity of ED influenced response to BTX-A IC according to the multivariate analysis (OR = 0.3, IC(95%]) = (0.16 – 0.56). Neither being post prostatectomy nor the type of BTX-A affected the response. Effectiveness tended to decrease more over time with abobotulinumtoxinA 250 U than 500 U.The only side-effects were mild penile pain on injection (n = 1) and mild penile pain for 3 days following injection (n = 1); no systemic effects were reported.Clinical implicationsBTX-A IC (all types) administered as an add on to registered pharmacologic treatments improved erectile function for at least 6 months in 41% of patients with ED of varying etiologies, and was safe.Strengths & LimitationsA relatively large cohort of patients with ED was included, with a long follow-up period, however the study was retrospective, and uncontrolled.ConclusionThis study provides preliminary evidence that BTX-A IC administered as an add-on therapy for ED that is insufficiently responsive to standard therapy is effective for at least 6 months, and is safe. Randomized clinical trials are now needed to fully confirm these results.Giuliano F, Joussain C, Denys P, Long Term Effectiveness and Safety of Intracavernosal Botulinum Toxin A as an Add-on Therapy to Phosphosdiesterase Type 5 Inhibitors or Prostaglandin E1 Injections for Erectile Dysfunction. J Sex Med 2022;19:83–89.     

The Effect of Transendocardial Stem Cell Injection on Erectile Function in Men With Cardiomyopathy: Results From the TRIDENT,POSEIDON, and TAC-HFT Trials

BackgroundDespite limited human data, there is a growing interest in the use of stem cell therapy (SCT) for erectile dysfunction (ED).AimTo determine the effect of transendocardial stem cell injection on erectile function on men with cardiomyopathy and ED.MethodsWe used International Index of Erectile Function (IIEF) scores collected from men enrolled in 3 separate randomized controlled trials: Comparison of Allogeneic vs Autologous Bone Marrow–Derived Mesenchymal Stem Cells Delivered by Transendocardial Injection in Patients With Ischemic Cardiomyopathy (POSEIDON), Transendocardial Mesenchymal Stem Cells and Mononuclear Bone Marrow Cells for Ischemic Cardiomyopathy (TAC-HFT), and Dose Comparison Study of Allogeneic Mesenchymal Stem Cells in Patients With Ischemic Cardiomyopathy (TRIDENT). These trials recruited patients with ischemic cardiomyopathy and ejection fraction less than 50%. Inclusion and exclusion criteria were identical in all 3 trials. The primary intervention in these trials included transendocardial stem cell injection of stem cells or placebo via cardiac catheterization. The follow-up period was 1 year. IIEF data were collected at baseline and at multiple time points in each trial.OutcomesWe investigated erectile function over time based on cell dose, cell source (autologous vs allogenic), cell type (mesenchymal stem cells vs bone marrow mononuclear cells), and comparing men who received SCT with those who received placebo.ResultsA total of 36 men were identified with complete IIEF data. 8 men received placebo injection, and 28 received SCT. The median age was 66.5 years. Comorbidities were similar among all men. Analysis was performed on men with ED, defined by an IIEF-EF score of 24 or less. In the placebo and all-comer SCT group, the median IIEF-EF score was 5 [1–8] and 5 [1–15] at baseline and was 3.5 [3–5.8] and 7 [1–18] at 12 months (P > .05). When analyzed by cell dose, the IIEF-EF score in men who received 200 million cells increased significantly over 12 months (14 [4–23] to 20 [15–24.5], P = .014.) Similarly, an autologous cell source resulted in a similar increase from baseline to 12 months (14 [3.8–23.3] to 20 [12–22], P = .030).Clinical ImplicationsErectile function may improve after systemic delivery of SCT in men with ischemic cardiomyopathy and at least mild ED.Strengths & LimitationsThis post hoc analysis is the first to investigate the effect of SCT on erectile function using randomized, placebo-controlled data. Weaknesses include that ED was not a primary end point, and men were not originally recruited based on erectile function.ConclusionFuture trials on systemic delivery of SCT for ED should focus on high cell dose and autologous cell source, as these seem to provide the best response in men with at least mild ED.Ory J, Saltzman RG, Blachman-Braun R, et al. The Effect of Transendocardial Stem Cell Injection on Erectile Function in Men With Cardiomyopathy: Results From the TRIDENT, POSEIDON, and TAC-HFT Trials. J Sex Med 2020;17:695–701.     

Intracavernous injections of prostaglandin E1 for erectile dysfunction: patient satisfaction and quality of sex life on long-term treatment

IntroductionSince the availability of oral type 5 phosphodiesterase (PDE5) inhibitors for the treatment of erectile dysfunction (ED), patients’ views on the use of intracavernous injections (ICI) of prostaglandin E1 (PGE1) may have changed.AimTo assess the satisfaction of patients with long-term ICI.MethodsPatients with ED (>18 years old) who had used ICI of PGE1 for at least 3 months were asked to complete the “EASY” (Evaluation de l’Acceptation des injectionS dans la dYsfonction érectile) questionnaire.Main Outcome MeasuresOverall patient satisfaction with ICI, impact on quality of life, ease of use, satisfaction with the quality of erections, and perceived partner satisfaction.ResultsOverall, 596 questionnaires met our inclusion criteria. Mean patient age was 62.1 years, mean duration of ED was 61 months, and mean duration of ICI treatment was 35 months. Before using ICI, 43% of patients had taken at least one PDE5 inhibitor; 81% discontinued PDE5 for want of efficacy. The overall satisfaction rate with ICI was 78.3%. ICI met expectations each time in 78.6% of patients and at least half the time in 90% of patients; 86% were ready to recommend ICI to friends. Patients noted improvements in their sex life (70.1%), relationship with their partner (50%), quality of life (44.8%), and confidence in attempting sexual intercourse (80.3%). The mean number of injections was 4.4 per month. Most patients (81.1%) found the injections easy to use. The mean score for pain on injection was 2.09/10 and for pain on erection was 2.15/10. Three-quarters of patients (73.1%) thought that their partners were satisfied with ICI.ConclusionPatients on long-term ICI/PGE1 can recover a very satisfying sex life. ICI met patients’ expectations in terms of efficacy, ease of use, tolerance, and improved sex life. These results should encourage physicians and patients to use ICI when PDE5 fails, is not well tolerated, or is contraindicated. Alexandre B, Lemaire A, Desvaux P, and Amar E. Intracavernous injections of prostaglandin E1 for erectile dysfunction: Patient satisfaction and quality of sex life on long-term treatment.     

Measurement of penile curvature in Peyronie's disease patients: comparison of three methods

AimPeyronie’s disease (PD) may be treated in a medical or surgical fashion. Factors involved in the decision of which treatment to choose include duration of disease and magnitude of penile deformity. Curvature can be measured using at‐home photography (AHP), vacuum erection device (VED), or intracavernosal injection (ICI). This study was undertaken to determine the concordance between the three methods of deformity assessment. Patients were also questioned regarding the presence of erectile dysfunction (ED) based on self‐report and the International Index of Erectile Function.Materials and MethodsA total of 68 men presented to their urologist after taking penile photographs from three angles during maximal erectile rigidity. In the office, a VED was used to induce erection, and a goniometer was utilized to measure degree of curvature. ICI with trimix was then used to induce artificial erection, which was measured with a goniometer as well.ResultsThere was a statistically significant difference in self‐report curvature magnitude compared with measured ICI‐assisted curvature. Curvature profiles included dorsal plaques in 50 patients (73.5%), ventral plaques in 10 (15%), and lateral in eight (11%). Using ICI, the mean curvature measured was 42 degrees. Mean degree of curvature using VED was 33 degrees, while that of photography was 34 degrees. Photographic measurements differed most from ICI in men with concurrent ED (P < 0.01), while vacuum device measurements were most inaccurate in men with curvatures of >60 degrees.ConclusionsOur results show that the degree of curvature measured using vacuum‐assisted device and AHP is underestimated as compared with the gold standard ICI. We therefore recommend that ICI be used to most accurately determine degree of deformity. If ICI is not available, it is imperative that the same manner of measurement be used between all patients in a study group, as well as during serial evaluation in a trial. Ohebshalom M, Mulhall J, Guhring P, and Parker M. Measurement of penile curvature in Peyronie’s disease patients: Comparison of three methods. J Sex Med 2007;4:199–203.     

Effect of niacin on erectile function in men suffering erectile dysfunction and dyslipidemia

IntroductionDyslipidemia is closely related to erectile dysfunction (ED). Evidence has shown that the lipid‐lowering agent, 3‐hydroxy‐3‐methylglutaryl‐coenzyme A reductase inhibitor (statins), can improve erectile function. However, information about the potential role of another class of lipid‐lowering agent, niacin, is unknown.AimTo assess the effect of niacin alone on erectile function in patients suffering from both ED and dyslipidemia.MethodsA single center prospective randomized placebo‐controlled parallel‐group trial was conducted. One hundred sixty male patients with ED and dyslipidemia were randomized in a one‐to‐one ratio to receive up to 1,500 mg oral niacin daily or placebo for 12 weeks.Main Outcome MeasuresThe primary outcome measure was the improvement in erectile function as assessed by question 3 and question 4 of the International Index of Erectile Function (IIEF Q3 and Q4). Secondary outcome measurements included the total IIEF score, IIEF‐erectile function domain, and Sexual Health Inventory for Men (SHIM) score.ResultsFrom the overall analysis, the niacin group showed a significant increase in both IIEF‐Q3 scores (0.53 ± 1.18, P < 0.001) and IIEF‐Q4 scores (0.35 ± 1.17, P = 0.013) compared with baseline values. The placebo group also showed a significant increase in IIEF‐Q3 scores (0.30 ± 1.16, P = 0.040) but not IIEF‐Q4 scores (0.24 ± 1.13, P = 0.084). However, when patients were stratified according to the baseline severity of ED, the patients with moderate and severe ED who received niacin showed a significant improvement in IIEF‐Q3 scores (0.56 ± 0.96 [P = 0.037] and 1.03 ± 1.20 [P < 0.001], respectively) and IIEF‐Q4 scores (0.56 ± 1.03 [P = 0.048] and 0.84 ± 1.05 [P < 0.001], respectively] compared with baseline values, but not for the placebo group. The improvement in IIEF‐EF domain score for severe and moderate ED patients in the niacin group were 5.28 ± 5.94 (P < 0.001) and 3.31 ± 4.54 (P = 0.014) and in the placebo group were 2.65 ± 5.63 (P < 0.041) and 2.74 ± 5.59 (P = 0.027), respectively. There was no significant improvement in erectile function for patients with mild and mild‐to‐moderate ED for both groups. For patients not receiving statins treatment, there was a significant improvement in IIEF‐Q3 scores (0.47 ± 1.16 [P = 0.004]) for the niacin group, but not for the placebo group.ConclusionsNiacin alone can improve the erectile function in patients suffering from moderate to severe ED and dyslipidemia. Ng C‐F, Lee C‐P, Ho AL, and Lee VWY. Effect of niacin on erectile function in men suffering erectile dysfunction and dyslipidemia. J Sex Med 2011;8:2883–2893.     

Vardenafil restores erectile function to normal range in men with erectile dysfunction

IntroductionThe ability of oral phosphodiesterase type 5 (PDE5) inhibitor therapy to restore erectile function to normal is an important attribute to men with erectile dysfunction (ED).AimTo assess the ability of vardenafil to restore normal erectile function in men with general ED.MethodsIn two fixed‐dose, parallel‐group, double‐blind, placebo‐controlled, pivotal studies, patients received vardenafil (5, 10, or 20 mg) or placebo for 12/26 weeks.Main Outcome MeasureIn this retrospective analysis, the percentage of patients “returning to normal” erectile function at week 12 (as defined by scores ≥26 on erectile function domain of International Index of Erectile Function [IIEF‐EF]) was determined, with further stratification by baseline ED severity, etiology, age, and duration of ED.ResultsVardenafil 5, 10, and 20 mg returned 32%, 43%, and 49% of patients, respectively, to normal erectile function after 12 weeks, compared with 10% of patients receiving placebo (P < 0.0001). Return to normal IIEF‐EF domain scores was noted irrespective of severity, etiology, age, and duration of ED, and was observed even in challenging‐to‐treat subgroups. With vardenafil 20 mg, 39% of men with severe ED at baseline, 45–49% of men with ED of mixed or organic etiology, 35% of men aged ≥65 years, and 43% of men with ED of ≥3 years of duration returned to normal erectile function at week 12. Mean per‐patient SEP3 (question 3 on the Sexual Encounter Profile) success rates in patients achieving IIEF‐EF domain scores ≥26 ranged from 87% to 95%.ConclusionVardenafil improves the IIEF‐EF domain score to the normal range in a substantial proportion of men with ED. Padma‐Nathan H, Montorsi F, Giuliano F, Meuleman E, Auerbach S, Eardley I, McCullough A, Homering M, and Segerson T for the North American and European Vardenafil Study Group. Vardenafil restores erectile function to normal range in men with erectile dysfunction. J Sex Med 2007;4:152–161.     

Male Sexual Dysfunction in Unconsummated Marriage: Long‐Term Outcome in 417 Patients

IntroductionLittle research has been conducted about unconsummated marriage (UCM).AimTo report the long‐term outcome of male sexual dysfunction (MSD) in UCM.MethodsFrom 1997 to 2008, 417 couples presented to the author with UCM. The mean UCM duration ranged from 1 hour to 8 years. The median follow‐up was 78.5 months.Main Outcome MeasuresSelf‐reported MSD in UCM based upon clinical history taking.ResultsIn 177 cases, UCM was due to erectile dysfunction (ED) (86), premature ejaculation (PE) (89), performance anxiety (25), vaginismus (34), hypodesire disorder (6), not knowing the coital technique (8), men who have sex with men (MSM) (2), hypogonadism (1), request by bride to delay coitus (1), and thick hymen (1) (more than one factor involved in many cases). In the remaining 240 cases, UCM was due to being under social pressure to have a quick intercourse while relatives waited behind the door to confirm and celebrate coitus by checking a handkerchief that was placed beneath the bride to become bloody by hymen perforation. Intracavernosal injection (ICI) using papaverine ± phentholamine was used in 239 cases (57.3%); 221 (92.4%) responded. The eight cases who did not know the coital technique responded to sex education. Of the 50 men who were prescribed phosphodiesterase type 5 inhibitors, only 4 responded. Of the 26 men who received clomipramine (21) or fluoxetine (5) for PE, 2 and 1 responded, respectively. Fourteen grooms who did not respond to treatments later consummated spontaneously.No treatment was given to 94 grooms, including men with a diagnosis of psychotic disorder, men with learning difficulties, divorcing patients, and men in obligatory, loveless marriages. Ten untreated patients later consummated spontaneously. Of the 260 patients who consummated either with treatment (236) or spontaneously (24), 58 (22.3%) later presented with sexual complaints. The remaining 202 did well at a follow‐up. Of the 157 couples who did not respond to treatment or did not receive treatment, 62 were either divorced or divorcing.ConclusionWe strongly advise ICI as the first‐line treatment of UCM. Oral therapies of ED and PE, vacuum constriction devices (VCD), and hymenectomy are of limited value. No treatment is indicated in many cases. Most grooms do well sexually in a long‐term follow‐up. Zargooshi J. Male sexual dysfunction in unconsummated marriage: Long‐term outcome in 417 patients. J Sex Med **;**:**–**.     

Clinical Correlates of Erectile Dysfunction and Premature Ejaculation in Men with Couple Infertility

IntroductionThe frequency and the clinical characteristics of erectile dysfunction (ED) and premature ejaculation (PE) in infertile men have been poorly investigated.AimTo assess the prevalence of ED and PE and their clinical correlates in men seeking medical care for couple infertility.MethodsA consecutive series of 244 men (mean age 35.2 ± 7.8) with couple infertility was systematically evaluated. Erectile function was investigated with the International Index of Erectile Function‐15 erectile function domain (IIEF‐15‐EFD) whereas ejaculatory status with the PE diagnostic tool (PEDT).Main Outcome MeasuresAll patients underwent psychological (Middlesex Hospital Questionnaire [MHQ]), prostatitis symptoms (National Institutes of Health–chronic prostatitis symptom index [NIH‐CPSI]); hormonal, seminal, and interleukin 8 (sIL‐8; a surrogate marker of prostatitis) evaluation; along with scrotal and transrectal color Doppler ultrasound (CDU) assessment.ResultsED was found in 43 (17.8%) and PE in 38 (15.6%) subjects. After adjusting for age, IIEF‐15‐EFD score was negatively associated with depressive symptoms (MHQ‐D score), somatization (MHQ‐S score), NIH‐CPSI total, and quality of life subdomain score. In a logistic multivariate model, among all these variables, only depression was significantly associated with ED (adjusted odds ratio [OR] = 1.19 [1.02–1.39]; P < 0.05). PEDT score was positively associated with prostatitis symptoms and signs, such as sIL‐8 and prostate CDU abnormalities (including arterial prostatic peak systolic velocity, APPSV), phobic anxiety (MHQ‐P score), and calculated free testosterone (cFT). The association between PE and NIH‐CPSI score or APPSV was confirmed even after adjustment for age, MHQ‐P score and cFT (adjusted OR = 1.11 [1.05–1.17]; P < 0.0001 and 1.22 [1.03–1.44]; P = 0.02, for NIH‐CPSI score and APPSV, respectively).ConclusionsED and PE are reported by one in six infertile patients. ED is mainly associated with depressive symptoms, while PEDT score is positively associated with prostatitis symptoms and signs, phobic anxiety, and cFT. Lotti F, Corona G, Rastrelli G, Forti G, Jannini EA, and Maggi M. Clinical correlates of erectile dysfunction and premature ejaculation in men with couple infertility. J Sex Med **;**:**–**.     

Does a Positive Response to Spermatic Cord Block Predict Response to Microdenervation of the Spermatic Cord for Chronic Scrotal Content Pain?

IntroductionMicrodenervation of the spermatic cord (MDSC) has been demonstrated to be an effective treatment for men with intractable scrotal content pain.AimThis study evaluates the correlation between a positive response to a spermatic cord block with local anesthetic and the subsequent surgical outcome following MDSC.Main Outcome MeasuresPre- and post-cord block pain and pre- and post-MDSC pain.MethodsA retrospective review of 74 patients (77 testicular units) who underwent MDSC from 2006 to 2010 was performed. Pre- and post-spermatic cord block pain scores based on a 0–10 visual analog scale (VAS) were compared with pre- and post-MDSC pain scores. A positive response to the block was defined as greater than or equal to 50% temporary reduction of pain based on VAS.ResultsThe average patient age was 42 years with a mean follow-up of 10 months. The mean duration of symptoms before surgery was 69 months. Mean pre-cord block pain score was 8 with an 89% average decrease in pain following the block. Mean post-MDSC pain score was 2 with an average decrease of 73%. The level of temporary improvement from the cord block appeared to be a useful predictor of sustained improvement with MDSC (P = 0.05). Positive response to spermatic cord block was an independent predictor of MDSC response (P = 0.03).ConclusionsMen with chronic orchialgia who have a positive response to a spermatic cord block are likely to have durable and complete resolution of symptoms after undergoing MDSC. The amount of pain relief obtained after the cord block correlates with pain relief after undergoing a MDSC. Men with chronic orchialgia who desire surgical correction should undergo a preoperative spermatic cord block as part of their complete evaluation. The result of the cord block can help guide the practitioner and the patient toward definitive surgical management via MDSC. Benson JS, Abern MR, Larsen S, and Levine LA. Does a positive response to spermatic cord block predict response to microdenervation of the spermatic cord for chronic scrotal content pain? J Sex Med 2013;10:876–882.     

Pharmacotherapy for Erectile Dysfunction

IntroductionPharmacotherapy is the usual initial therapy for most men with erectile dysfunction.AimTo review the current data relating to the efficacy, tolerability and safety of drugs used in the treatment of men with erectile dysfunction.MethodsA critical review of the literature relating to the use of pharmacotherapeutic agents was undertaken by a committee of eight experts from five countries, building on prior reviews.Main Outcome MeasuresExpert opinion and recommendations were based on grading of evidence-based literature, internal committee dialogue, open presentation, and debate.ResultsAlmost all currently available evidence relates to sildenafil, tadalafil, and vardenafil. Phosphodiesterase type 5 (PDE5) inhibitors are first-line therapy for most men with erectile dysfunction who do not have a specific contraindication to their use. There is no evidence of significant differences in efficacy, safety, and tolerability between the PDE5 inhibitors and apomorphine. Intracavernosal injection therapy with alprostadil should be offered to patients as second line therapy for erectile dysfunction. Intraurethral alprostadil is a less effective treatment than intracavernosal alprostadil for the treatment of men with erectile dysfunction.ConclusionsPDE5 inhibitors are effective, safe, and well-tolerated therapies for the treatment of men with erectile dysfunction. Apomorphine, intracavernosal injection therapy with alprostadil, and intraurethral alprostadil are all effective and well-tolerated treatments for men with erectile dysfunction. We recommend some standardization of the assessment of psychosocial outcomes within clinical trials in the field of erectile dysfunction. Eardley I, Donatucci C, Corbin J, El-Meliegy A, Hatzimouratidis K, McVary K, Munarriz R, and Lee SW. Pharmacotherapy for erectile dysfunction.     

Erectile Dysfunction is a Modifiable Risk Factor for Major Depressive Disorder: Analysis of a Federated Research Network

BackgroundErectile dysfunction is one of many conditions associated with depression, but few studies exist to establish the risk of major depressive disorder (MDD) in the large population of men with erectile dysfunction, and it is unclear whether erectile dysfunction (ED) treatment is associated with decreased rates of MDD.AimWe determined the risk of major depressive disorder in men with erectile dysfunction and evaluated whether treatment of ED with phosphodiesterase-5 inhibitor or penile prosthesis is associated with a lower risk of developing major depressive disorder.MethodsWe reviewed a large, retrospective, cohort that utilized electronic health record data collected by the TriNetX Research Network, a global federated database that provides healthcare data for analysis. We performed multiple comparisons: men with ED against men without ED; men with ED treated with phosphodiesterase-5 inhibitors against untreated ED patients, and of men with ED who received penile prosthesis against those who did not. We assessed major depressive disorder (ICD-10-CM F32-F33) as a primary outcome and used propensity score matching to control for ethnicity, race, type 2 diabetes mellitus (E11), essential hypertension (I10), acute myocardial infarction (I21), chronic ischemic heart disease (I25), cerebral infarction (I63), overweight and obesity (E66), personal history of nicotine (Z87.891), hypogonadism (E29.1), and alcohol related disorders (F10).OutcomesWe assessed new diagnosis of major depressive disorder (F32-F33) within a 3-year time window following index event of ED diagnosis, visit to healthcare organization, or ED treatment with phosphodiesterase-5 inhibitor or penile prosthesis as the primary outcome.ResultsED was associated with major depressive disorder both before and after (OR 2.00, 95% CI 1.94–2.06) controlling for confounding variables through propensity score matching. Men who received ED therapies had lower rates of depression compared to those who did not, whether they were treated with phosphodiesterase-5 inhibitor (0.80, 0.77–0.83) or penile prosthesis (0.73, 0.60–0.89).Strengths and LimitationsStrengths include a large sample size and robust statistical techniques. Limitations include lack of detailed information regarding clinical severity and socioeconomic factors.Clinical ImplicationsOur findings indicate that clinicians should consider evaluating depressive symptoms among men with erectile dysfunction and counsel them regarding the risk of developing major depressive disorder.ConclusionsErectile dysfunction is associated with major depressive disorder, but treatment is associated with decreased rates of MDD.S Nackeeran, A Havanur, J Ory, et al. Erectile Dysfunction is a Modifiable Risk Factor for Major Depressive Disorder: Analysis of a Federated Research Network. J Sex Med 2021;18:2005–2011.     

Uric Acid Level and Erectile Dysfunction in Patients with Coronary Artery Disease

IntroductionErectile dysfunction (ED) is a frequent complaint of elderly subjects and is closely associated with endothelial dysfunction and cardiovascular disease (CVD). Uric acid is also associated with endothelial dysfunction, oxidative stress, and CVD, raising the hypothesis that an increased serum uric acid might predict ED in patients who are at risk for coronary artery disease (CAD).AimThis study aims to evaluate the association of serum uric acid levels with presence and severity of ED in patients presenting with chest pain of presumed cardiac origin.MethodsThis is a cross-sectional study of 312 adult male patients with suspected CAD who underwent exercise stress test (EST) for workup of chest pain and completed a sexual health inventory for men survey form to determine the presence and severity of ED. Routine serum biochemistry (and uric acid levels) were measured. Logistic regression analysis was used to assess risk factors for ED.Main Outcome MeasuresThe short version of the International Index of Erectile Function questionnaire diagnosed ED (cutoff score ≤ 21). Serum uric acid levels were determined. Patients with chest pain of suspected cardiac origin underwent an EST.ResultsOne hundred forty-nine of 312 (47.7%) male subjects had ED by survey criteria. Patients with ED were older and had more frequent CAD, hypertension, diabetes and impaired renal function, and also had significantly higher levels of uric acid, fibrinogen, glucose, C-reactive protein, triglycerides compared with patients without ED. Uric acid levels were associated with ED by univariate analysis (odds ratio = 1.36, P = 0.002); however, this association was not observed in multivariate analysis adjusted for estimated glomerular filtration rate.ConclusionSubjects presenting with chest pain of presumed cardiac origin are more likely to have ED if they have elevated uric acid levels. Solak Y, Akilli H, Kayrak M, Aribas A, Gaipov A, Turk S, Perez-Pozo SE, Covic A, McFann K, Johnson RJ, and Kanbay M. Uric Acid level and erectile dysfunction in patients with coronary artery disease. J Sex Med 2014;11:165–172.     

Long‐Term Changes of Sexual Function in Men with Obstructive Sleep Apnea after Initiation of Continuous Positive Airway Pressure

IntroductionObstructive sleep apnea (OSA), particularly intermittent nocturnal hypoxemia, is associated with erectile dysfunction (ED).AimWe investigated in patients with OSA whether continuous positive airway pressure (CPAP) therapy has a long‐term effect on sexual function, including ED, in the presence of other risk factors for ED.MethodsWithin a long‐term observational design, we reassessed 401 male patients who had been referred for polysomnography, with respect to erectile and overall sexual function. Mean ± standard deviation follow‐up time was 36.5 ± 3.7 months. Patients with moderate to severe ED were stratified according to the regular use of CPAP.Main Outcome MeasureChanges of sexual function were assessed by the 15‐item International Index of Erectile Function (IIEF‐15) questionnaire, including the domains erectile function (EF), intercourse satisfaction, orgasmic function (OF), sexual desire (SD), and overall satisfaction (OS).ResultsOf the 401 patients, 91 returned a valid IIEF‐15 questionnaire at follow‐up. Their baseline characteristics were not different from those of the total study group. OSA (apnea–hypopnea index >5/hour) had been diagnosed in 91.2% of patients. In patients with moderate to severe ED (EF domain <17), CPAP users (N = 21) experienced an improvement in overall sexual function (IIEF‐15 summary score; P = 0.014) compared with CPAP non‐users (N = 18), as well as in the subdomains OF (P = 0.012), SD (P = 0.007), and OS (P = 0.033). Similar results were obtained in patients with poor overall sexual dysfunction (IIEF‐15 summary score <44). In patients with moderate to severe ED and low mean nocturnal oxygen saturation (≤93%, median), also the EF subdomain improved in CPAP users vs. non‐users (P = 0.047).ConclusionsThese data indicate that long‐term CPAP treatment of OSA and the related intermittent hypoxia can improve or preserve sexual function in men with OSA and moderate to severe erectile or sexual dysfunction, suggesting a certain reversibility of OSA‐induced sexual dysfunctions. Budweiser S, Luigart R, Jörres RA, Kollert F, Kleemann Y, Wieland WF, Pfeifer M, and Arzt M. Long‐term changes of sexual function in men with obstructive sleep apnea after initiation of continuous positive airway pressure. J Sex Med **;**:**–**.     

Outcomes of crural ligation surgery for isolated crural venous leak

IntroductionVenous ligation surgery results for diffuse venous leak have been disappointing, although in isolated crural venous leak (ICVL) cases, efficacy for crural ligation surgery (CLS) has been demonstrated.AimThe purpose of this study was to present our experience with treatment of ICVL with CLS.MethodsAll patients underwent preoperative cavernosometry. Cavernosography (CG) or perineal compression (PC) was used to define the diagnosis of ICVL. If CG demonstrated ICVL or flow‐to‐maintain values normalized with PC, the patient was counseled regarding CLS. Baseline and postoperative erectile function (EF) was assessed by the International Index of Erectile Function (IIEF) questionnaire.Main Outcome MeasuresEF, using the EF domain (EFD) score of the IIEF, a domain with six questions with a maximum score of 30 and a minimum score of 6 in the sexually active male. All patients completed the questionnaire preoperatively and in a serial fashion after surgery at a time point after 12 months postoperatively.Results14 patients underwent CLS. Mean age was 29 ± 7 years. Also, 64% had primary erectile dysfunction. Mean baseline IIEF‐EF score was 18 ± 6. Furthermore, 71% of patients had failed phosphodiesterase type 5 (PDE5) inhibitors and 6/10 (60%) failed intracavernosal injections (ICI). Mean postoperative EFD score was 24 ± 3 representing a mean change of 6.5 points per patient. No patient needed ICI after CLS; however, 4/14 patients needed PDE5 inhibitors, all of whom had been using ICI preoperatively. In addition, 71% experienced unassisted sexual intercourse after CLS.ConclusionsIn a highly selected population of young men with ICVL, CLS cures 70% and improves EF in more than 90% of men. Surgical treatment of ICVL by CLS can be performed safely and with sufficient efficacy that larger and longer term studies should be undertaken. Flores S, Tal R, O’Brien K, and Mulhall JP. Outcomes of crural ligation surgery for isolated crural venous leak. J Sex Med **;**:**–**.     

Audiovisual Sexual Stimulation Improves Diagnostic Accuracy of Penile Doppler Ultrasound in Patients With Erectile Dysfunction

IntroductionAlthough penile Doppler ultrasound (PDU) is a useful tool in evaluating erectile dysfunction (ED), an optimal erectile response might be limited because of an increased sympathetic discharge. Audiovisual sexual stimulation (AVSS) has been suggested to help improving PDU performance.AimTo evaluate the use of AVSS as a tool to improve diagnostic accuracy of PDU studies.MethodsA total of 40 men (mean age: 61.8 ± 10.2 years) with ED were enrolled. PDU sessions were performed in a randomized fashion as follows: session A under intracavernous injection (ICI) alone and session B under ICI and AVSS with 7-day interval between sessions. Peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) were measured 5, 10, 15, and 20 minutes after ICI.Main Outcome MeasureComparisons between PSV, EDV, and RI values were performed with and without AVSS. Univariable and multivariable analyses including clinical and demographic parameters were performed to evaluate predictors of an abnormal PDU.Results23 patients performed the first session without AVSS, and 17 performed the first session with AVSS. EDV and RI were better in AVSS session (p = 0.022 and 0.019). PSV was not influenced by AVSS (p = 0.768). The proportion of patients whose diagnosis was changed because of the AVSS was 4 of 40 (10.0%, 95% confidence interval [CI]: 2.8–23.7%). Of 12 patients with venous leak observed on the PDU without AVSS, 3 turned into normal after AVSS (25.0%, 95% CI: 5.5–57.2%). Of 4 men with arterial insufficiency observed on the PDU on ICI alone, 1 became normal after AVSS (25.0%, 95% CI: 0.6–80.6%). International Index of Erectile Function-5 scores were lower in patients with abnormal PDU (6.3 ± 3.3 vs 12.0 ± 5.8, p=0.003). On multivariable analysis, DM and International Index of Erectile Function-5 scores were the only independent predictors of abnormal PDU studies.Clinical ImplicationsFalse diagnoses of venous leak during PDU with ICI could be a result of an increased adrenergic discharge during the examination. Routine AVSS may be helpful to avoid error in diagnosis.Strength & LimitationsThe study has randomized the use of AVSS in different session orders. Only one previously published study has used this strategy to control the accommodation effect in repeat studies, a common source of bias in the PDU literature. The main limitation is the absence of a rigidity assessment and a redosing protocol.ConclusionAdding AVSS during PDU improves ICI response and may help clinicians evaluate penile hemodynamics more accurately.Carneiro F, Nascimento B, Miranda EP, et al. Audiovisual Sexual Stimulation Improves Diagnostic Accuracy of Penile Doppler Ultrasound in Patients With Erectile Dysfunction. J Sex Med 2020;17:249–256.     

A Survey of Erectile Dysfunction in Taiwan: Use of the Erection Hardness Score and Quality of Erection Questionnaire

IntroductionThere are currently no studies in the Asia-Pacific region using the erection hardness score (EHS) and Quality of Erection Questionnaire (QEQ) to assess erectile dysfunction (ED).AimsTo provide up-to-date data on the prevalence of ED in Taiwanese men and to validate the EHS and QEQ in this population.MethodsA representative sample of 1,060 men aged ≥30 years completed a telephone interview. ED status was confirmed via direct questioning and using the abridged five-item version of the 15-item International Index of Erectile Function (IIEF-5). Responses regarding EHS, QEQ, marital and sexual satisfaction, and attitude to treatment were also recorded.Main Outcome MeasuresIIEF, EHS, and QEQ.ResultsThe prevalence of ED, as defined by IIEF-5, was 27% among all respondents and 29% among those aged ≥40 years. Although, the prevalence of ED increased with age, men of all ages tended to underestimate their erectile problems. Among men who indicated that they did not have ED, 25% were found to have mild to moderate ED according to the IIEF-5 assessment. An EHS ≤3, indicating the presence of ED, was reported in 26% of men. The EHS was consistent with the QEQ: When the EHS was 4, the satisfaction of each domain of QEQ ranged from 85% to 90%. The QEQ score correlated well with the IIEF-5 score and significantly affected both sexual and marital satisfaction (P < 0.005).ConclusionsThese data indicate that EHS is a simple, practical tool for clinical use. QEQ scores appear to be independently associated with sexual and marital satisfaction, and may be of value in the assessment and monitoring of ED patients. While ED is a common health problem in Taiwan and the prevalence of ED increases with age, affected men lack awareness regarding the presence of erectile problems and the importance of initiating timely and effective treatment. Hwang TIS, Tsai T-F, Lin Y-C, Chiang H-S, and Chang LS. A survey of erectile dysfunction in Taiwan: Use of the erection hardness score and quality of erection questionnaire.