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Introduction: Natesto®, testosterone nasal gel (TNG) is an intranasal testosterone therapy (TTh) used to restore testosterone levels and improve symptoms of hypogonadism. Treatment requires application two (bid) or three (tid) times daily. The Treatment Satisfaction Questionnaire for Medication (TSQM) and a Patient Preference and Use (PPU) questionnaire were used to obtain patient feedback on the use of TNG and compare it to experience with topical TTh. Methods: The study enrolled 24 TTh-naive (TThN) and 93 TThexperienced (TThE) hypogonadal men. Treatment lasted up to 120 days, with titration at day 90 to determine the most appropriate dose for restoration of testosterone levels (11 mg bid or tid). Patient satisfaction and symptom changes were measured at days 0, 30, 60, 90, and 120. The PPU questionnaire was performed at study entry and study completion. Results: Symptoms improved from baseline (30.6) to day 90 (35.1) (p<0.0001; +15%), consistent with testosterone replacement. TNG increased scores for effectiveness (+20%), convenience (+30%), and global satisfaction (+3%) as compared to their previous topical TTh. TThE patients reported ease of use, convenience, efficacy/effectiveness, and travel friendliness as "likes" of TNG therapy. Overall, 67.2% of patients agreed or strongly agreed that they preferred TNG over topical TTh and 59% sought a prescription to continue treatment with TNG. Conclusions: Patients switching from topical TTh to TNG reported significant improvements in symptoms and patient satisfaction compared to their previous topical TTh. Patients also reported a significant improvement in convenience with TNG despite two to three times daily application. Preference, satisfaction, and convenience may translate to better treatment compliance. [ABSTRACT FROM AUTHOR]

Introduction: Natesto®, testosterone nasal gel (TNG), is a testosterone therapy (TTh) indicated for adult male hypogonadism.1 This study allowed titration decisions to be based on physicians' assessment of patient symptoms. Methods: Hypogonadal males on active topical testosterone therapy (TThE) or naive to any form of testosterone therapy (TThN) were treated with 22 mg TNG daily (11 mg twice daily) for 90 days. Titration was determined by the physician at day 90 wherein the dose was increased to 33 mg daily if symptoms were not properly managed. Total testosterone (TT) levels were collected at day 90 and 120 and the quantitative Androgen Deficiency in the Aging Male (qADAM) symptom questionnaire was administered on days 0, 30, 60, 90, and 120. Results: At study endpoint, 77.0% of all patients were in the normal TT range. Mean qADAM scores increased from 30.8 at baseline to 35.5 (6.6) at day 90. Physician assessments resulted in 37% patients being up-titrated for an additional 30 days, however, qADAM scores did not change significantly at the higher dose. Conclusions: The majority of patients achieved the normal range of testosterone with TNG when physicians based their titration decision on an assessment of symptoms. Sexual function and energy-related symptoms were predictive of improvements resulting from treatment. These symptoms were the most relevant indicators for physicians in making decisions relating to titration. [ABSTRACT FROM AUTHOR]

Introduction Controversy exists as to whether erectile response to phosphodiesterase type 5 inhibitors is compromised in men with low total testosterone (TT) levels. This is amplified by reports of improved response to phosphodiesterase type 5 inhibitor therapy after coadministration of testosterone replacement therapy in hypogonadal men unresponsive to phosphodiesterase type 5 inhibitors. Aim To determine whether TT and luteinizing hormone levels influence efficacy of tadalafil for erectile dysfunction in men with concomitant lower urinary tract symptoms and benign prostatic hyperplasia. Methods This integrated analysis included 1,075 men randomized to once-daily tadalafil 5 mg (n = 540) or placebo (n = 535) for 12 weeks in three prospective clinical trials who had not received concomitant testosterone replacement therapy. Subjects were categorized at baseline by low vs normal TT levels (n = 1,049; <300 vs ≥300 ng/dL) and normal vs high luteinizing hormone levels (n = 1,058; ≤9.4 vs >9.4 mIU/mL). Treatment-group differences in International Index of Erectile Function (IIEF) by hormone subgroups were assessed using analysis of covariance. Main Outcome Measures Changes in IIEF erectile function domain and other domain scores. Results The overall study population was comprised primarily of white men (>86%) with a mean age range of 64 to 70 years. Median baseline TT level in the integrated population was 355 ng/dL; levels were lower than 300 ng/dL (cutoff for normal) in 32.4% of men. Men with low TT levels reported diabetes (21.8%), cardiovascular disease (54.1%), and hypertension (49.1%) numerically more often than men with normal TT levels (10.6%, 43.2%, and 36.7%, respectively). Low TT and high luteinizing hormone levels were associated with numerically, but not statistically significantly, lower 12-week IIEF domain scores compared with those with normal levels. Changes in most 12-week IIEF domain scores showed that tadalafil was significantly more effective than placebo ( P < .02). Conclusion Low TT levels at baseline did not negatively influence response to tadalafil in men of advancing age with concomitant lower urinary tract symptoms and benign prostatic hyperplasia and erectile dysfunction. [ABSTRACT FROM AUTHOR]

Introduction Various factors play a role in the development of erectile dysfunction (ED). Aim To provide a descriptive comparison of erectile function response for tadalafil on-demand (PRN) and once-daily (OAD) dosing regimens in patients with common comorbid conditions, treatments, or risk factors that can be considered when treating ED. Methods In total, 17 PRN and 4 OAD placebo-controlled studies were included in the integrated database in these pooled analyses. Data were analyzed from patients treated with placebo, tadalafil 10 mg (low dose), and 20 mg (high dose) for the PRN studies and placebo, tadalafil 2.5 mg (low dose), and 5 mg (high dose) for the OAD studies. Main Outcome Measures The effects of tadalafil were measured using the International Index of Erectile Function administered from baseline to week 12. A descriptive comparison of the efficacy of tadalafil PRN vs OAD was examined in the clinical populations. Results Baseline characteristics of 4,354 men were comparable between the PRN and OAD groups, with differences seen only in the variables of race, body mass index (BMI) of at least 30 kg/m 2 , and alcohol use. Tadalafil was efficacious at improving erectile function for all clinical populations, except for the low-dose OAD group, which demonstrated a weaker effect vs placebo than the high-dose OAD group, and the low- and high-dose PRN groups vs placebo for patients with BMI of at least 30 kg/m 2 for patients without a cardiovascular disorder, smokers, patients with ED duration shorter than 1 year, and patients without previous phosphodiesterase type 5 inhibitor use. Tadalafil was efficacious for patients with or without diabetes mellitus, arterial hypertension, hyperlipidemia, and alcohol use at baseline. Conclusion Tadalafil OAD and PRN regimens showed efficacy in patients with ED. No clinical populations of patients with ED seemed to benefit overwhelmingly from one dose regimen over the other. [ABSTRACT FROM AUTHOR]

Introduction and Aim The multicenter, randomized, double-blind, double-dummy, placebo-controlled REACTT trial suggested that treatment with tadalafil once daily (OaD) started early after bilateral nerve-sparing radical prostatectomy (nsRP) for prostate cancer may contribute to erectile function (EF)-recovery, which was predefined as achieving an International Index of Erectile Function (IIEF)-EF score ≥22. Here, we report descriptive post-hoc analyses, using the more strict definition for EF-recovery of returning back to the pre-surgery IIEF-EF-level (“back-to-baseline analysis”). Methods REACTT included 422 men <68 years with adenocarcinoma of the prostate and preoperative IIEF-EF ≥22 who underwent nsRP at 50 centers from 9 European countries and Canada. Patients were randomized post-nsRP 1:1:1 to 9-month double-blind treatment (DBT) with tadalafil 5 mg OaD (n = 139), tadalafil 20 mg on-demand ( pro-re-nata , PRN; n = 142), or placebo (n = 141), followed by 6-week drug-free washout (DFW) and 3-month open-label tadalafil OaD treatment (OLT). Main Outcome Measures Proportion of patients returning to their preoperative IIEF-EF category (22–25 or ≥26) at the end of DBT, DFW, and OLT. Results Overall, 92.4% of patients had pre-surgery (baseline) IIEF-EF scores ≥26 (tadalafil OaD 94.2%, PRN 91.6%, placebo 91.5%), 7.4% had IIEF-EF 22–25. At the end of DBT, 22.3% of patients on tadalafil OaD had achieved “back-to-baseline” IIEF-EF, compared with 11.3% on tadalafil PRN and 7.8% on placebo. Of all 58 patients “back-to-baseline” at the end of DBT, only 1 PRN-group patient had started from a baseline IIEF-EF <26. The treatment-group difference at the end of DBT was not maintained after DFW. After 3 months of OLT with tadalafil OaD, the proportion of patients with “back-to-baseline” IIEF-EF had almost doubled in all 3 groups. Conclusion Changing the definition for EF-recovery from IIEF-EF ≥22 to the more strict definition of “returning back-to-baseline IIEF-EF” had no major impact. Tadalafil OaD started early after nsRP improved drug-assisted EF, but had no effect on unassisted EF following treatment cessation after 9 months. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the proportion of patients achieving clinically meaningful improvement of lower urinary tract symptoms suggestive of benign prostatic hyperplasia ( BPH- LUTS) with tadalafil using two definitions of response. Patients and Methods Post hoc integrated analysis of four placebo-controlled studies in men (aged ≥45 years; International Prostate Symptom Score [ IPSS] of ≥13; maximum urinary flow rate [Qmax] of ≥4 to ≤15 mL/s) with BPH- LUTS randomised to tadalafil 5 mg (752 patients) or placebo (747) for 12 weeks after a 4-week placebo run-in. Responders were defined as having a total IPSS improvement of ≥3 points or ≥25% from randomisation to endpoint (Week 12). Response status was calculated per patient, and relative benefit and odds ratio ( OR) with 95% confidence interval ( CI) of tadalafil vs placebo was calculated using a logistic Generalised Mixed Model for Repeated Measures. Results Tadalafil 5 mg once daily resulted in a significantly greater proportion of patients achieving a ≥3-point IPSS improvement (71.1% and 56.0% for tadalafil and placebo patients, respectively [ OR 1.9, 95% CI 1.5, 2.4; P < 0.001]) and achieving a ≥25% improvement in total IPSS randomisation to endpoint (61.7% and 45.5% for tadalafil and placebo patients, respectively [ OR 2.0, 95% CI 1.6, 2.5; P < 0.001]). Conclusion About two-thirds of tadalafil-treated patients achieve a clinically meaningful improvement in BPH- LUTS symptoms, based on two different definitions of responder status. [ABSTRACT FROM AUTHOR]

Objective To report penile integrity measures, including stretched penile length (SPL), from a randomized, double-blind, double-dummy, placebo-controlled trial evaluating treatment with tadalafil initiated after nerve-sparing radical prostatectomy (nsRP). Methods Patients aged ≤68 years were randomized after nsRP 1:1:1 to 9-month double-blind treatment (DBT) with tadalafil 5 mg once daily (OaD), 20-mg tadalafil on-demand (“pro-re-nata”; PRN), or placebo, followed by 6-week drug-free washout and 3-month open-label OaD treatment. Secondary outcome measures included the change in SPL from pre-nsRP to the end of DBT (analysis of covariance adjusting for treatment, country, baseline, age, and nerve-sparing score), responses to Sexual Encounter Profile (SEP) questions 1-3 (mixed models for repeated measures adjusting for treatment, country, visit, visit-treatment-interaction, age), and Standardized Morning Erection Question (Cochran-Mantel-Haenszel test adjusted for age and country). Results Four hundred twenty-three patients were randomized to tadalafil OaD (N = 139), tadalafil PRN (N = 143), and placebo (N = 141). Greater retainment of SPL was observed with tadalafil OaD vs placebo at the end of DBT (least-square mean [95% confidence interval] difference OaD vs placebo, 4.1 mm [0.4 to 7.8 mm]; P = .032). No significant effects on SPL were found for tadalafil PRN vs placebo, or for the nerve-sparing score. Penile tumescence (SEP1) and ability for vaginal insertion (SEP2) significantly improved vs placebo at the end of double-blind and open-label treatment for patients randomized to tadalafil OaD only. The ability for successful sexual intercourse (SEP3) significantly improved with tadalafil OaD vs placebo only during DBT. The distribution of Standardized Morning Erection Question responses was different at the end of DBT ( P = .045); 34.2% of patients on tadalafil OaD, 50.0% on tadalafil PRN, and 56.5% on placebo reported absence of morning erections. Conclusion These data suggest the early initiation of tadalafil OaD protects from penile length loss and may contribute to protection from structural cavernosal changes after nsRP. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 37-year-old man was referred for assessment of a lifelong inability to achieve and maintain erections. It is noted that the patient reported normal libido and normal ejaculatory function but denied having morning erections, penile curvature, penile pain, or pelvic trauma. The article discusses examination, including penile angiography and cavernosometry, a surgical correction with a fully satisfying result was achieved in the patient.

Abstract: Background: The potential rehabilitative and protective effect of phosphodiesterase type 5 inhibitors (PDE5-Is) on penile function after nerve-sparing radical prostatectomy (NSRP) remains unclear. Objective: The primary objective was to compare the efficacy of tadalafil 5mg once daily and tadalafil 20mg on demand versus placebo taken over 9 mo in improving unassisted erectile function (EF) following NSRP, as measured by the proportion of patients achieving an International Index of Erectile Function-Erectile Function domain (IIEF-EF) score ≥22 after 6-wk drug-free washout (DFW). Secondary measures included IIEF-EF, Sexual Encounter Profile question 3 (SEP-3), and penile length. Design, setting, and participants: Randomised, double-blind, double-dummy, placebo-controlled trial in men ≤68 yr of age with adenocarcinoma of the prostate (Gleason ≤7) and normal preoperative EF who underwent NSRP at 50 centres from nine European countries and Canada. Interventions: 1:1:1 randomisation to 9 mo of treatment with tadalafil 5mg once daily, tadalafil 20mg on demand, or placebo followed by a 6-wk DFW and 3-mo open-label tadalafil once daily (all patients). Outcome measurements and statistical analysis: Logistic regression, mixed-effects model for repeated measures, and analysis of covariance, adjusting for treatment, age, and country, were applied to IIEF-EF scores ≥22, SEP-3, and penile length. Results and limitations: Four hundred twenty-three patients were randomised to tadalafil once daily (n =139), on demand (n =143), and placebo (n =141). The mean age was 57.9 yr of age (standard deviation: 5.58 yr); 20.9%, 16.9%, and 19.1% of patients in the tadalafil once daily, on demand, and placebo groups, respectively, achieved IIEF EF scores ≥22 after DFW; odds ratios for tadalafil once daily and on demand versus placebo were 1.1 (95% confidence interval [CI], 0.6–2.1; p =0.675) and 0.9 (95% CI, 0.5–1.7; p =0.704). At the end of double-blind treatment (EDT), least squares (LS) mean IIEF-EF score improvement significantly exceeded the minimally clinically important difference (MCID: ΔIIEF-EF ≥4) in both tadalafil groups; for SEP-3 (MCID ≥ 23%), this was the case for tadalafil once daily only. Treatment effects versus placebo were significant for tadalafil once daily only (IIEF-EF: p =0.016; SEP-3: p =0.019). In all groups, IIEF-EF and SEP-3 decreased during DFW but continued to improve during open-label treatment. At month 9 (EDT), penile length loss was significantly reduced versus placebo in the tadalafil once daily group only (LS mean difference 4.1mm; 95% CI, 0.4–7.8; p =0.032). Conclusions: Tadalafil once daily was most effective on drug-assisted EF in men with erectile dysfunction following NSRP, and data suggest a potential role for tadalafil once daily provided early after surgery in contributing to the recovery of EF after prostatectomy and possibly protecting from penile structural changes. Unassisted EF was not improved after cessation of active therapy for 9 mo. Trial registration: ClinicalTrials.gov identifier NCT01026818. [Copyright &y& Elsevier]

Objectives To assess the safety and efficacy of tadalafil once daily on lower urinary tract symptoms suggestive of clinical benign prostatic hyperplasia ( BPH-LUTS) in men without erectile dysfunction ( ED)., To compare these with effects in men with ED., Patients and Methods After a 4-week washout period and 4-week placebo run-in period, 1089 men without ED ( n = 338) and with ED ( n = 751) were randomly assigned to placebo or tadalafil 5 mg once daily for 12 weeks in three global clinical studies with similar designs., In the pooled dataset, post hoc analyses of covariance assessed the impact and severity of BPH-LUTS using the International Prostate Symptom Score ( IPSS) and the BPH Impact Index ( BII) and IPSS quality-of-life ( IPSS- QoL) subscores., Safety was assessed using treatment-emergent adverse events., The treatment-by- ED-status interaction was used to assess efficacy differences between the with/without ED subgroups., Results Men without ED were similar in BPH-LUTS severity/previous therapy to men with ED., Tadalafil significantly reduced BPH-LUTS from baseline when compared with placebo in men without ED ( IPSS −5.4 vs −3.3, P < 0.01; IPSS voiding subscore −3.5 vs −2.0, P < 0.01; IPSS storage subscore −1.9 vs −1.3, P < 0.05)., Tadalafil also significantly improved quality of life from baseline when compared with placebo in men without ED ( IPSS- QoL −1.0 vs −0.7, BII −1.4 vs −1.0; both P < 0.05)., Between- ED-subgroup interactions were not significant (all P > 0.68)., Tadalafil was safe and well tolerated., Conclusion Tadalafil 5 mg once daily improved BPH-LUTS in men without ED by a magnitude similar to that observed in men with ED., The adverse event profile in men without ED was consistent with that observed in men with ED. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction. The challenges for prostate cancer survivors include the surveillance of prostate cancer recurrence and management of physical, cognitive, sexual, and socioeconomic quality of life issues. Sexual function remains an important issue in men, who often continue to be interested in sex after prostate cancer treatment. The various post-prostate cancer treatment-related sexual dysfunctions are penile deformities and erectile dysfunction (ED); sexual desire and mental health; ejaculatory and orgasmic dysfunctions; and changes in partner relationship and dynamics. Aims. The aim of this study is to provide state of art review of the various male sexual dysfunctions in prostate cancer survivors and the management strategies in sexual rehabilitation. Methods and Materials. A literature search for English language original and review articles either published or e-published was performed using PubMed database. Keywords included prostate cancer, prostate cancer treatment, prostate prostatectomy (RP), sexual dysfunction, erectile dysfunction (ED), sexual desire, mental health, ejaculation, orgasmic, climacturia, and relationship. Results. There has been considerable volume of publication in recent years on prostate cancer-related male sexual dysfunction. Penile deformities and ED shared similar pathophysiology and that penile smooth muscle fibrosis ultimately results in structural alterations and end-organ failure. Penile rehabilitation using oral phosphodiesterase type 5 (PDE5) inhibitors is considered the standard of care especially in patients who received nerve-sparing RP and should be instituted as soon as possible to protect and prevent corporal endothelial and smooth muscle damage. However, there is no consensus on the exact timing, dose, and duration of PDE5 inhibitors and its impact in non-nerve-sparing RP and other forms of prostate cancer treatment modalities. Current literature on hypoactive sexual desire, ejaculatory, and orgasmic dysfunctions in patients who received prostate cancer treatment is limited. Psychological and sexual counseling play an important role in rehabilitation and treatment of various forms of male sexual dysfunctions. Conclusion. While several preventive and treatment strategies for the preservation and recovery of sexual function are available, no specific recommendation or consensus guidelines exist regarding the optimal rehabilitation or treatment protocol. While medical and surgical therapies are effective in erectile function recovery and/or preservation, psychological and sexual counseling are equally important in sexual rehabilitation. Chung E and Brock G. Sexual rehabilitation and cancer survivorship: A state of art review of current literature and management strategies in male sexual dysfunction among prostate cancer survivors. J Sex Med 2013;10(suppl 1):102-111. [ABSTRACT FROM AUTHOR]

Erectile physiology, in order to function normally, requires the complex coordination of endocrine, neurocognitive, neuromuscular and vascular mechanisms. Testosterone (T) influences male sexuality as well as penile erections at multiple levels, including a direct influence on the nitric oxide synthase (NOS)/cGMP/phosphodiesterase 5 pathway in the penis. However, the precise role of testosterone replacement (TRT) to "salvage" men with mixed ED failing phosphdiesterase-5 inhibitors (PDE5i) remains unclear. We conducted a scoping review identifying the rationale for TRT in ED failing PDE5i, and we critically discuss clinical trials that have examined TRT in the setting of PDE5i use. Overall, TRT replacement appears to be well tolerated and may enhance the response to PDE5i and quality of life, particularly for men with mixed ED, and particularly among men with very low levels of testosterone. However, most of the available literature examines concurrent TRT alone or simultaneous TRT + PDE5i usage, without necessarily selecting for PDE5i failure cases. The present studies are limited to heterogenous studies with small sample sizes, without an exact predominant etiologic factor causing ED. Furthermore, studies showing the most benefit are non-placebo-controlled trials; however, the correction of more profound hypogonadism may lead to an improved response to PDE5i. Stronger conclusions would require properly selected patient populations and larger placebo-controlled RCTs. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction. A single-armed, prospective, multicenter international study evaluated the redesigned Coloplast Titan One Touch Release (OTR) pump inflatable penile prosthesis. The OTR pump has a unique release valve that permits deflation of the implant with one squeeze of opposing touch pads. Aims. To assess the impact of a new penile prosthesis design, the Titan OTR, on patient ease of operation. Furthermore, to assess patient satisfaction, surgeon acceptance, and the ease with which patients were trained in device operation in the clinic setting. Methods. A total of 113 eligible patients from eight centers were recruited from men presenting with erectile dysfunction without prior prosthetic implantation. The subjects had a mean age of 61 years, and had a number of comorbidities, including diabetes (31.9%), hypertension (34.5%), and Peyronie's disease (23.9%). All underwent implantation of the study device. Main Outcome Measures. Questionnaires were used to capture patient satisfaction as well as physician feedback on ease of implantation and patient education. A paired analysis was completed for patient satisfaction at 6 (N = 96) and 12 (N = 90) months. Results. Overall satisfaction with the device was 90.6% and 90.0% at 6 and 12 months, respectively. The primary end point, ease of deflation, was seen in 70.8% and 73.3% at these two time points, with the 12-month value statistically better than historical controls. Physicians overwhelmingly reported straightforward/simple intraoperative product preparation (97.3%) and equivalent or easier training compared with their previous pump of choice (96.4%). Adverse events for all subjects (N = 113) included removal of the device in four cases (3.5%) for infection and one case for chronic pain (0.8%). Conclusions. The Titan OTR represents an advance in penile prosthetic technology that is well accepted by patients and physicians. The study design allowed for realistic evaluation of the new technology aimed at enhancing clinical outcomes. Ohl DA, Brock G, Ralph D, Bogache W, Jones L, Munarriz R, Levine L, and Ritenour C. Prospective evaluation of patient satisfaction, and surgeon and patient trainer assessment of the Coloplast Titan One Touch Release three-piece inflatable penile prosthesis. J Sex Med 2012;9:2467-2474. [ABSTRACT FROM AUTHOR]

Phosphodiesterase type 5 (PDE5) inhibitors have proved to be efficacious, safe, and well tolerated, in clinical trials and practice, for men with erectile dysfunction (ED). However, many patients are not satisfied with treatment and discontinue it prematurely. This review discusses evidence-based strategies that nurse practitioners (NPs) can use to improve diagnosis of ED, optimize patient outcomes, and identify opportunities to detect other potentially serious comorbid conditions. This article was based on a previously published review, which involved a PubMed-MEDLINE search of the clinical literature from January 1, 1998 (year of sildenafil's approval in many markets), through August 30, 2008 (date of search). Strategies to optimize responses to PDE5 therapy are summarized by the mnemonic '': valuating and ducating to ensure realistic xpectations of therapy; rescribing a treatment individualized to the couple's needs and preferences; ptimizing drug dose/regimen and revisiting key educational messages at follow-up visits; ontrolling omorbidities via lifestyle counseling, medications, and/or referrals; and elping patients and their partners to seek other forms of therapy if they have decided not to use a PDE5 inhibitor. The 'EPOCH' mnemonic may remind NPs of steps to optimize treatment outcomes with PDE5 inhibitors. [ABSTRACT FROM AUTHOR]

Cryptorchidism is associated with impairment of germ cell maturation and subsequent infertility in adulthood. The present report details common scenarios of referral of men with prior history of cryptorchidism and orchidopexy seeking advice for infertility, and examines the association between cyrptorchidism and male infertility. The increase in the understanding of the hormonal profiles and patho-physiological changes in germ cell maturation in cryptorchid boys may potentially change our approach and management strategies. Improvement in sperm retrieval techniques and micromanipulation techniques, such as intracytoplasmic sperm injection, has led to excellent fertilization and pregnancy outcomes of treatment cycles. [ABSTRACT FROM AUTHOR]

Robotic-assisted laparoscopic radical prostatectomy (RARP) is becoming the preferred surgical treatment option for management of organ-confined prostate cancer. Although not a contraindication, previous pelvic surgery can make RARP challenging. Presence of a three-piece inflatable penile prosthesis, with a perivesical pelvic reservoir, has the potential to induce steric hindrance making RARP difficult. The main purpose of this publication is to report our experience with RARP in patients with previously inserted three-piece inflatable penile prostheses. Two patients with previously inserted AMS 700 penile prosthesis and with organ-confined, biopsy proven adenocarcinoma of the prostate underwent RARP. We describe intraoperative findings, surgical technique, oncologic and functional outcomes. Both patients underwent safe and successful RARP with out any complications. Surgical margins were not affected with pelvic reservoir-sparing technique. In both patients, the penile prosthesis remained functional postoperatively. RARP can be safely performed in patients with previously inserted three-piece inflatable penile prosthesis. Nontraumatic handling of the pelvic reservoir is mandatory to preserve prosthesis' integrity. [ABSTRACT FROM AUTHOR]

The article describes the case of a 54-year-old married male who had delayed penis rehabilitation following a retropubic robotic prostatectomy. The patient had normal erectile and sexual function before the surgery. Viagra was ineffective in retuning his erection and sexual function. He underwent penile rehabilitation and received intracavernous injection (CIC) therapy supplemented with low-dose PDE5i. He experienced erections on ICIs.

Introduction. The Clinical Global Impression of Change (CGIC) measures have high utility in clinical practice. However, it is unknown whether the CGIC is valued for assessing premature ejaculation (PE) symptoms and/or the relationship between CGIC and other validated PE patient-reported measures. Aim. The study aims to assess the validity of the patient-reported CGIC measure in men with PE and to examine the relationship between CGIC ratings and assessments of control, satisfaction, personal distress, and interpersonal difficulty. Methods. Data from a randomized, double-blind, 24-week phase 3 trial in 1,162 men with PE who received dapoxetine (30 mg or 60 mg) or placebo on demand provided the basis for the analysis. Patients were ≥18 years, in a stable monogamous relationship for ≥6 months, met the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision criteria for PE for ≥6 months, and had an intravaginal ejaculatory latency time (IELT) ≤2 minutes in ≥75% of intercourse episodes. Main Outcome Measures. The CGIC asked patients to rate improvement or worsening of their PE compared with the start of the study using a 7-point response scale; other patient-reported measures were control over ejaculation, satisfaction with sexual intercourse, interpersonal difficulty, and personal distress related to ejaculation. Stopwatch-measured IELT was recorded. Associations between CGIC and change in other measures at study end point were assessed. Results. The magnitude of IELT increased for each category of improvement on the CGIC: 1.63, 4.03, and 7.15 minutes for slightly better, better, and much better, respectively. Higher CGIC ratings were correlated with greater improvement in control ( r = 0.73), satisfaction ( r = 0.62), greater reduction in distress ( r = −0.52), and interpersonal difficulty ( r = −0.39). Total variance accounted for was 57.4%: control (48.7%), satisfaction (4.5%), IELT (2.8%), and distress (1.15%). Conclusions. The analyses support the validity of the CGIC measure in men with PE. The CGIC can provide clinicians in practice with a valid and brief outcome assessment of their patient's condition. Althof SE, Brock GB, Rosen RC, Rowland DL, Aquilina JW, Rothman M, Tesfaye F, and Bull S. Validity of the patient-reported clinical global impression of change as a measure of treatment response in men with premature ejaculation. J Sex Med 2010;7:2243–2252. [ABSTRACT FROM AUTHOR]

Objectives: To compare the safety and efficacy of the daily erectogenic therapy, tadalafil, on lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH-LUTS) in men with or without comorbid erectile dysfunction (ED). Methods: Following a 4-week placebo run-in period, men with moderate-to-severe BPH-LUTS were randomized to placebo or tadalafil 2.5, 5, 10, or 20 mg once daily for 12 weeks. International Prostate Symptom Scores (IPSS), IPSS quality of life, and BPH Impact Index were measured every 4 weeks. Safety was mainly assessed via spontaneous reports of adverse events. Data from men with (n = 716) or without (n = 340) ED at baseline were compared in posthoc analyses. Results: Men with ED were older and had more frequent hypertension, hyperlipidemia, coronary artery disease, and diabetes at baseline compared with men without ED. After 12 weeks, changes in IPSS in men with ED (least squares mean change from baseline, placebo: −2.4; tadalafil 2.5, 5, 10, 20 mg: −4.3, −4.8, −5.3, −5.6) and without ED (−2.4, −3.2, −5.3, −5.1, −4.5) were not significantly different (subgroup/interaction P values: .352/.644). Similar effects were observed for IPSS quality of life (with ED: −0.6, −0.9, −0.9, −1.0, −1.1; without ED: −0.6, −0.7, −0.9, −0.8, −0.8; 0.090/0.773) and BPH Impact Index (with ED: −0.7, −0.9, −1.3, −1.3, −1.4; without ED: −1.0, −0.7, −1.3, −1.3, −1.2; 0.753/0.852). Tadalafil was generally well tolerated, and men with or without ED had similar tolerability profiles. Conclusions: Changes in BPH-LUTS after 12 weeks of treatment with placebo or various doses of once daily tadalafil were similar in men with or without comorbid ED. [Copyright &y& Elsevier]

Introduction. This study evaluated the prevalence of complaints of premature ejaculation (PE) among a cross-sectional sample of Canadian males and their partners. Aim. It sought to quantify measures of behavior and attitudes as they relate to PE. It evaluated the level of patient knowledge, physician engagement, and patient satisfaction with treatment options for PE, a common sexual complaint. It also explored the patient and partner-reported impacts on quality of life and well-being. Main Outcome Measure. The main outcome measure for the study was the statistical analysis of data on different facets of PE and associated factors from a comprehensive population-based survey conducted in Canada. Methods. A web-based survey was carried out among adults in Canada (phase 1, N = 3,816) followed by a focused telephone interview in phase 2 for those who met the criteria for PE (phase 2, N = 1,636). Men were classified as having PE based on self-report of low or absent control over ejaculation, irrespective of the duration of the ejaculation time, resulting in distress for them or their sexual partner or both, or reporting that they “climaxed too soon.” Results. The prevalence of PE in the survey, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders-III criteria, ranged from 16% to 24% depending on the definition of PE utilized, and did not vary significantly with age. Ninety percent of those with a determination of PE in this survey had not discussed alternatives to prolong time to ejaculation with a physician, pointing to gaps in patient/physician communication around sexual health. Conclusions. PE is a prevalent sexual problem that poses special challenges to clinicians and causes considerable burden to Canadian men and their partners. There remains a stigma associated with PE, resulting in the existence of significant barriers to obtaining assistance from physicians for this problem. The majority of those interviewed who sought and received treatment have not been satisfied with the results. Brock GB, Bénard F, Casey R, Elliott SL, Gajewski JB, and Lee JC. Prevalence and treatment of premature ejaculation in Canada. J Sex Med 2009;6:2115–2123. [ABSTRACT FROM AUTHOR]

Objectives: To identify the patient demographic factors, comorbidities, and concomitant medications associated with a change in the likelihood of tadalafil-associated adverse events (AEs) in men with erectile dysfunction. Methods: Pooled safety data were analyzed from 3488 tadalafil-treated men who participated in 21 placebo-controlled clinical trials of tadalafil taken as needed or once daily. Three categories of tadalafil-associated AEs were defined: vasodilatory (headache, flushing, nasal congestion, nasopharyngitis, and dizziness); musculoskeletal (back pain and myalgia); and gastrointestinal (dyspepsia). A classification and regression tree analysis was used to determine the patient characteristics most likely to be associated with a change in the likelihood of these types of AEs. Results: Of the 3488 tadalafil-treated patients, 973 (27.9%) had any vasodilatory, musculoskeletal, and/or gastrointestinal tadalafil-associated AE. The patient characteristics associated with a change in the likelihood of any tadalafil-associated AE were diabetes, geographic region, and age. The patient characteristics associated with a change in the likelihood of a vasodilatory tadalafil-associated AE included antihypertensive medication use, geographic region, and height, with several additional splits occurring along these primary and secondary nodes. No patient characteristics associated with a change in the likelihood of musculoskeletal or gastrointestinal AEs were identified owing to the limitation of a relatively low incidence of these types of AEs. Conclusions: The findings from classification and regression tree analyses could help physicians to better understand some of the associations between patient characteristics and the tolerability of phosphodiesterase type 5 inhibitors and could contribute to improved patient outcomes, satisfaction, treatment seeking, and treatment persistence. [Copyright &y& Elsevier]

The article presents the discussion on Erectile dysfunction (ED) management. Topics include promoting better sexual health and satisfaction within the Canadian population remain elusive; treating physician, and well-established links between ED and cardiovascular disease (CVD) and lower urinary tract symptoms (LUTS); and delivering hundreds of peer lectures on the subject to urologists, primary physicians, specialists, and the public.

Abstract: Background: To date, no data have been available from large, well-designed trials comparing on demand and nightly dosing of phosphodiesterase type 5 (PDE5) inhibitors on recovery of erectile function in postprostatectomy patients with erectile dysfunction (ED). Objective: To investigate the effect of early postoperative dosing with vardenafil, administered either nightly or on demand, compared with placebo on recovery of erectile function in men with ED following bilateral nerve-sparing radical prostatectomy (NSRP) surgery. Design, setting, and participants: A randomised, double-blind, double-dummy, multicentre, parallel group study conducted at 87 centres across Europe, Canada, South Africa, and the United States. For inclusion, patients had to be scheduled to undergo bilateral NSRP within 1 mo of screening and have a normal International Index of Erectile Function erectile function domain (IIEF-EF) score of ≥26 at screening. A total of 628 men, aged 18–64 yr, were randomised to treatment. Study design consisted of a 9-mo double-blind treatment period, a 2-mo single-blind washout period, and an optional 2-mo open-label period. Intervention: Patients received placebo, nightly vardenafil, or on demand vardenafil. Measurements: Primary outcome measure was the percentage of subjects with an IIEF-EF score of ≥22 after the 2-mo washout period. Secondary variables included mean per-patient success rates for Sexual Encounter Profile (SEP) questions 2 and 3. Results and limitations: No statistically significant differences were observed among treatment groups in the proportion of patients with an IIEF-EF score of ≥22 or in SEP3 success rates after the washout period. On-demand vardenafil treatment resulted in significantly greater IIEF-EF scores and better SEP3 response rates than placebo over the entire treatment period. Conclusions: In this study of men with ED following bilateral NSRP, vardenafil was efficacious when used on demand, supporting a paradigm shift towards on demand dosing with PDE5 inhibitors in this patient group. Trial registration: European clinical trials database (EudraCT; available at http://eudract.emea.europa.eu/). Trial registration number: 11336. [Copyright &y& Elsevier]

Introduction. Studies evaluating the effect of education on treatment success with phosphodiesterase type 5 (PDE5) inhibitor therapy in men with erectile dysfunction (ED) are limited. Additional education of the primary care physician (PCP) and the patient are thought to optimize the treatment of ED. Aim. To assess the impact of education of the PCP or of the patient in the treatment of ED with vardenafil relative to usual care. Methods. In this 12-week, open-label, multicenter, factorial-designed, cluster-randomized Canadian study, 1,029 patients with ED were enrolled into four different education groups: usual care, patient education, PCP education, and both PCP and patient education. All groups started on vardenafil 10 mg, with the option to titrate at weeks 4 and 8. Main Outcome Measures. The primary efficacy measure was the difference at week 4 last observation carried forward (LOCF) in the overall improvement in erectile function (EF) as measured by the Global Assessment Question (GAQ), while on background vardenafil, between those receiving education vs. those who did not. Other secondary assessments included responses to diary questions regarding penetration (sexual encounter profile, SEP2) and erection maintenance (SEP3), and to questionnaires regarding treatment satisfaction (Erectile Dysfunction Inventory of Treatment Satisfaction [EDITS]). Results. A total of 956 patients were included in the intent-to-treat population. Mean baseline International Index of Erectile Function-EF domain score was 13. GAQ response rates at week 4 LOCF were high (>80%) for all groups, regardless of the education given. Mean per patient SEP2 and SEP3 rates at week 12 LOCF were 86–89% and 79–83%, respectively. In an exploratory analysis, a positive relationship between GAQ responses and EDITS scores was observed ( P ≤ 0.0007). Vardenafil was generally well tolerated. Conclusions. In men with moderate ED, vardenafil led to high success rates and satisfaction regardless of the education given. The benefits of education for PCP and patients in Canada were possibly masked by a ceiling effect in this study population. Brock G, Carrier S, Alarie P, Pommerville P, Casey R, Harris S, and Ward R. The effect of physician and patient education when combined with vardenafil treatment in Canadian males with erectile dysfunction: An open-label, factorial-designed, cluster-randomized clinical trial. J Sex Med 2008;5:705–715. [ABSTRACT FROM AUTHOR]

Introduction. Peyronie's disease, a localized fibrosis of the tunica albuginea surrounding the penile corpora, results in penile curvature and sexual dysfunction. Surgical management involving grafting to straighten the penis is the treatment of choice in conditions unresponsive to conservative therapy where penile length preservation is important. Aim. To determine surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease. Main Outcome Measures. The International Index of Erectile Function (IIEF), postoperative self-reports, patient satisfaction, and clinical characteristics were used to measure outcomes. Methods. We retrospectively reviewed charts of 36 patients who underwent surgery for Peyronie's disease requiring grafting from 1999 to 2005. Follow-up to subjectively assess outcomes was conducted. Results. Average patient age at surgery was 55 ± 1 years. Body mass indexes were similar among all groups. Erectile dysfunction risk factors were comparable with 36% reporting hypertension and 22% hypercholesterolemia. Overall patient follow-up time was 673 ± 98 days. Self-reported resolution of penile curvature was noted in 60% of dermal, 100% of Tutoplast, and 76.9% of Stratasis graft recipients. Stratasis patients maintained presurgery length (54%) and rigidity (77%) more so than dermal (30%, 60%) and Tutoplast (23%, 39%) patients. Assessment of erectile dysfunction using the IIEF-5 captured significant improvements in patients receiving Stratasis grafts (preoperative: 10.1 ± 1.1 vs. postoperative: 17 ± 1.6). Overall, 89% of patients reported satisfaction following surgical intervention. Conclusions. Surgical management of Peyronie's disease results in correction of penile curvatures and high rates of patient satisfaction. Loss of penile length and decreased rigidity occurred to a lesser degree with Stratasis grafts. While detailed informed consent is essential in this patient population, novel materials such as Tutoplast and Stratasis grafts improve outcomes following surgical correction of Peyronie's disease. Kovac JR, and Brock GB. Surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease. J Sex Med 2007;4:1500–1508. [ABSTRACT FROM AUTHOR]

Introduction. The importance of patient instructions, designed to optimize therapy with phosphodiesterase type 5 inhibitors for the treatment of erectile dysfunction (ED), has recently been demonstrated. Aim. To evaluate the impact of an educational program for new sildenafil users against usual ED management in Canadian primary care practices. Methods. This multicenter, 6-month cluster randomized prospective study was conducted across Canada in general practitioners' offices where sites were randomized to receive a treatment optimization program (TOP) tool at visit 1 (TOP sites) or not to receive the TOP tool (non-TOP sites) while continuing with usual practice. Study participants were men seeking medical attention for ED and who were sildenafil naïve. The TOP tool consisted of a tear-off sheet, a brochure, and a video. Study drug was not provided to the patients. Sildenafil samples and prescriptions were dispensed as per usual care practices. Main Outcome Measures. The Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire was used to determine treatment satisfaction at visit 2 (month 3) and visit 3 (month 6). Patient and physician satisfaction with the TOP tool was assessed using self-reported questionnaires. Results. The intent-to-treat (ITT) population consisted of 2,573 patients from 231 primary care sites. At visits 2 and 3, treatment satisfaction with sildenafil was high with almost 9 patients out of 10 satisfied with treatment. No significant statistical differences were observed in the EDITS scores between the TOP and the non-TOP groups at visits 2 and 3. More than 80% of the participants were satisfied or very satisfied with the video and the brochure. More than 8 out of 10 participating physicians (84%) would use the TOP tool in their current practice if available. Conclusions. TOP is a valuable and time-efficient ED management tool providing benefits to newly diagnosed ED patients and to their physicians. Brock G, Carrier S, Casey R, Tarride J-E, Elliott S, Dugré H, Rousseau C, D'Angelo P, and Defoy I. Can an educational program optimize PDE5i Therapy? A study of Canadian primary care practices. J Sex Med 2007;4:1404–1413. [ABSTRACT FROM AUTHOR]

Introduction. While the efficacy of sildenafil for the management of erectile dysfunction (ED) has been demonstrated in randomized clinical trials, few data exist on its effectiveness in a real-life setting. Aim. The objective of this study was to examine the treatment satisfaction and effectiveness with sildenafil in a real-life setting in Canada. Methods. A multicenter, prospective study, using an educational program aimed at optimizing sildenafil treatment, was conducted at 231 primary care sites across Canada. Patients who received their first prescription of sildenafil for ED within the usual practice of medicine were invited to participate in the study. Data were collected through patient self-administered questionnaires. Main Outcome Measures. The Sexual Health Inventory for Men (SHIM) questionnaire was used to determine the erectile function at baseline, month 3 and month 6. Treatment satisfaction at months 3 and 6 was assessed using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. Results. The intent-to-treat population consisted of 2,573 patients. The mean age was 55 years (18 to 92 years). At baseline, the mean SHIM score was 11.9 with 21.7% of men having severe ED, 22.9% moderate ED, 36.5% mild-to-moderate ED, and 16.9% mild ED. At month 3, the mean SHIM score improved significantly to 18.0 ( P < 0.0001) and 33.3% of patients had a SHIM score above 21 (no ED). At 6 months, the mean SHIM score was 18.7. At both months 3 and 6, approximately 89% of patients were satisfied with their treatment (i.e., EDITS score ≥ 50), suggesting no attenuation of the satisfaction over the 6 months of use. Conclusions. The effectiveness of sildenafil in the management of ED was demonstrated in a large cohort of men treated in a primary care setting in this Canadian real-life study. Persistence with therapy and lack of attenuation over time among the vast majority of men was shown. Carrier S, Brock G, Casey R, Tarride J-E, Elliott S, Dugré H, Rousseau C, D’Angelo P, and Defoy I. Treatment satisfaction with sildenafil in a Canadian real-life setting. A 6-month prospective observational study of primary care practices. J Sex Med 2007;4:1414–1421. [ABSTRACT FROM AUTHOR]

Introduction. Testosterone treatment of older symptomatic men with reduced testosterone availability is increasing. There is an expanding body of literature to support such treatment in a large subset of aging men, but there has not yet been a long-term placebo-controlled double-blind study of several thousand men to confirm the efficacy and safety of this treatment as indicated by shorter-term studies. The absence of a long-term study has been used by governmental agencies as a limiting factor in providing full access and payment for this treatment in government-sponsored health care plans. Health Canada issued a testosterone analysis document to the pharmaceutical industry, the implications of which may make it more difficult for appropriate patients to receive such treatment. The Canadian Society for the Study of the Aging Male (CSSAM) believed it had an obligation to advocate on behalf of men requiring this treatment. Aim. To provide an international consensus on the use of testosterone treatment in appropriately selected hypogonadal men. Main Outcome Measure. To determine whether the literature supports the use of testosterone treatment in a selected population of hypogonadal men, to achieve consensus on this point among an international consulting group, and to transmit this view to health care workers and insuring and governmental agencies. Methods. Email communication among the consulting group to prepare a response to Health Canada, followed by a review of appropriate literature and international practice guidelines, incorporating the literature and guidelines together with the CSSAM letter and Health Canada's response. Result. The literature and international guidelines support the initiation of testosterone therapy in symptomatic hypogonadal men, recognizing that there is no universal agreement on the criteria for the diagnosis of hypogonadism in each suspected case. The need for careful monitoring of such men is stressed. Conclusion. CSSAM acted as an advocate for hypogonadal men who may benefit from treatment with testosterone. Short-term studies and 60 years of experience with testosterone therapy attest to its efficacy. Long-term studies are desirable, but it may take many years before results could be forthcoming. There is no evidence to suggest that testosterone treatment increases the risk of prostate cancer or cardiovascular disease. Current evidence suggests, in fact, that testosterone treatment may be cardioprotective. It is important to bring this information to the attention of governments and insuring agencies through the collaboration of groups devoted to the diagnosis and treatment of hypogonadal men. Bain J, Brock G, and Kuzmarov I, for the International Consulting Group. Canadian Society for the Study of the Aging Male: Response to Health Canada's position paper on testosterone treatment. J Sex Med 2007;4:558–566. [ABSTRACT FROM AUTHOR]

OBJECTIVE To assess patient and partner preferences for, and satisfaction with, tadalafil or sildenafil (phosphodiesterase type 5 inhibitors) in routine clinical practice for treating erectile dysfunction (ED), as these are important outcomes that might influence treatment adherence. PATIENTS AND METHODS In a multicentre, prospective observational trial in Canada, patients with ED were eligible if they planned to change treatment from tadalafil to sildenafil or vice versa. Data were collected at baseline and 4–12 weeks later (endpoint). Satisfaction was assessed using patient and partner versions of the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. EDITS index scores range from 0 (extremely low treatment satisfaction) to 100 (extremely high treatment satisfaction). RESULTS Of 2425 patients, approximately 98% completed the study and 295 partners participated. When patients changed from sildenafil to tadalafil (1722 men) the mean EDITS index scores increased significantly for both patients (from 61.6 to 78.3) and partners (from 65.0 to 82.6; both P < 0.001). When patients changed from tadalafil to sildenafil (703 men), the mean EDITS index scores increased slightly but significantly for patients (from 68.8 to 70.2; P = 0.007) but not partners (from 76.8 to 68.9; P = 0.066). For the individual EDITS questions, mean scores increased significantly from baseline to endpoint on all questions for patients (all 11 questions; P < 0.001) and partners (all five questions; P < 0.001) in the sildenafil-to-tadalafil group, and in the tadalafil-to-sildenafil group, mean scores for patients decreased on nine of 11 questions (seven of nine significantly; P < 0.041) and mean scores for partners decreased on all five (two significantly; P < 0.049). For treatment preference, regardless of the change in treatment (i.e. sildenafil-tadalafil or tadalafil-sildenafil), a significantly higher percentage of patients and partners preferred tadalafil to sildenafil. CONCLUSIONS These data indicate that patients with ED (and their partners) who changed from sildenafil to tadalafil treatment or vice versa in a routine clinical practice setting had higher treatment satisfaction when taking tadalafil than sildenafil, as assessed by most measures of EDITS. The higher treatment satisfaction with tadalafil might help to explain the greater preference for tadalafil compared with sildenafil in both patients and partners in this observational study. [ABSTRACT FROM AUTHOR]

The article focuses on the interconnection policy and technological development in the U.S. Although public policy toward interconnection has also evolved, there is no mechanism that automatically adjusts the policy to changing technological requirement and dominant firms can be expected to resist the extension of interconnection policy to accommodate new technological requirements. The U.S. Federal Communications Commission grant of interconnection authority to specialized common carriers set initial competition in long-distance private-line circuits that was later extended to switched long-distance service. The Telecommunications Act of 1996 emerged due to dissatisfaction with the divestiture interconnection agreement.

Erectile dysfunction (ED) is a highly prevalent, often undertreated condition. This 12-week, double-blind, parallel, placebo-controlled study was conducted at 25 sites in Canada to evaluate the efficacy and safety of oral tadalafil, a phosphodiesterase type 5 inhibitor, for the treatment of ED. Men with ED of organic, psychogenic, or mixed etiology were stratified by baseline ED severity then randomly assigned to placebo (N = 50), tadalafil 10 mg (N = 103), or tadalafil 20 mg (N = 100), taken as needed (maximum, once daily). Efficacy was assessed by the International Index of Erectile Function (IIEF), a Sexual Encounter Profile diary, and a global assessment question (GAQ). Tadalafil 10 mg and tadalafil 20 mg significantly improved erectile function compared with placebo ( P < 0.001, all measures). At end point, the mean IIEF erectile function (EF) domain scores were 14.5, 21.2, and 23.3 of a possible score of 30 for placebo, tadalafil 10 mg, and tadalafil 20 mg, respectively. Patients treated with tadalafil reported greater change from baseline on the IIEF EF domain score compared with placebo, regardless of baseline ED severity. During treatment, the mean per-patient proportion of successful intercourse attempts was higher for tadalafil 10 mg and 20 mg than for placebo (placebo, 31.9%; tadalafil 10 mg, 56.7%; and tadalafil 20 mg, 61.5%), and a greater proportion of patients reported improved erections with tadalafil (GAQ; placebo, 22.0%; tadalafil 10 mg, 67.0%; tadalafil 20 mg, 79.0%). Fifty percent and 62% of patients treated with tadalafil 10 mg and 20 mg, respectively, achieved successful sexual intercourse after their first dose, compared with 31% with placebo. Treatment-emergent adverse events were generally mild or moderate. Tadalafil was an effective, well-tolerated therapy for ED of broad-spectrum etiology and severity. Carrier S, Brock GB, Pommerville PJ, Shin J, Anglin G, Whitaker S, and Beasley CM Jr. Efficacy and safety of oral tadalafil in the treatment of men in Canada with erectile dysfunction: A randomized, double-blind, parallel, placebo-controlled clinical trial. J Sex Med **; **:**–**. [ABSTRACT FROM AUTHOR]

The article discusses the prevalence of erectile dysfunction, as populations age and incidence of co-morbid agreement such as diabetes and cardiovascular disease. In the United States, more than half of the men that aged 40-70 are unable to keep up a penile erection enough for satisfactory sexual performance. A pharmacologic therapy for erectile dysfunction (ED), joined to enhanced understand the physiology and pathophysiology for penile erection and the causes of ED.

DRAMATIC ADVANCES IN THE MANAGEMENT of erectile dysfunction have occurred over the past decade. Oral therapy with vasoactive agents has emerged as first-line treatment and has transformed both the manner in which the public views erectile dysfunction and the way health care providers deliver care. Whereas an ex-tensive investigation was previously common in the management of erectile dysfunction, recent treatment guidelines promote a more minimalist, goal-oriented approach. In this article, we re-view the physiology of erection, and the pathophysiology, diag-nosis and clinical management of erectile dysfunction. We also present the existing evidence for the efficacy of 3 phosphodi-esterase inhibitors, the most widely used class of agents for erec-tile dysfunction. [ABSTRACT FROM AUTHOR]

Oral agents are relatively non-invasive, reversible, readily administered and well tolerated; hence, they are emerging as first-line treatments for patients with erectile dysfunction. Two medications have been licensed in Europe: the dopamine agonist sublingual apomorphine, which influences central regulatory mechanisms, and the phosphodiesterase type 5 (PDE5) inhibitor sildenafil citrate, which affects local regulation of erectile function by potentiating the effects of nitric oxide. Two other potent, selective, reversible PDE5 inhibitors (tadalafil and vardenafil) are under regulatory review in Europe, the United States and other countries. In double-blind, placebo-controlled trials, these compounds significantly enhanced erectile function and increased the likelihood of successful sexual intercourse largely irrespective of etiology or severity of erectile insufficiency. Apomorphine and PDE5 inhibitors also significantly improved scores in the erectile function, orgasmic function, intercourse satisfaction and overall satisfaction domains of the International Index of Erectile Function. Oral agents were well tolerated; adverse events were generally mild or moderate, prompting premature treatment discontinuation in a small minority of patients. The chief adverse effects with apomorphine were nausea and headache, and with PDE5 inhibitors, headache, dyspepsia and flushing. Because of a potential pharmacodynamic interaction between PDE5 inhibitors and nitrates or nitric oxide donors that has been associated with hypotension, concomitant nitrate use is an absolute contraindication. However, the actual incidences of myocardial infarction in sildenafil and tadalafil patients are similar to those in placebo controls. [Copyright &y& Elsevier]

The article provides an answer to a question concerning whether medical associations are still relevant or outdated.

The article discusses the use of botox for erectile dysfunction. It cites several evidence showing the potential of VEED use in facilitating long-acting cavernous smooth muscle relaxation through alteration. It also concludes that the administration of a botulinum toxin A represents a promising avenue for future research for treatment of erectile dysfunction.

The article announces that Gerald B. Brock is stepping down as the president for the Canadian Urological Association.

The author considers the credibility of online medical information, notes that urology patients often struggle to differentiate between real and fake websites proposing treatments, and stresses the importance of evidence-based medical information.