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The Sexual and Reproductive Health guidelines of the European Association of Urology (EAU) suggest stratifying patients complaining of haemospermia into low versus high-risk categories for treatable aetiologies. To validate EAU guidelines in a homogeneous cohort of men with haemospermia and to identify a novel and better performing risk stratification compared to EAU guidelines. Data from 283 consecutive patients complaining of a single episode/recurrent haemospermia were retrospectively analysed. Patients were stratified into low vs. high-risk according to EAU guidelines, whose diagnostic performance was then validated. We identified a new risk stratification model based on clinical factors associated with i) positive semen culture and ii) prostate cancer (PCa) and bladder cancer (BC). Diagnostic accuracy of the two predictive models (EAU vs. New) was assessed and decision curve analyses (DCA) tested their clinical benefit. Overall, 259 (91.5%) were high-risk and 24 (8.5%) low risk according to the EAU guidelines. Recurrent haemospermia was reported by 134 (47.4%) patients. 126 (44.5%) had baseline CCI score ≥ 1. At MVA logistic regression analysis, history of recurrent genito – urinary tract infections was identified as a predictor for positive semen culture (OR: 3.39, 95% CI: 1.77 – 6.57, p=0.002). Likewise, baseline CCI ≥ 1 was identified as a predictor for PCa and BC (OR: 1.55, 95% CI: 1.17 – 2.04, p=0.009). Sensitivity, specificity, and AUC of the EAU guidelines were 13.3%, 89.2% and 51% respectively, whereas the new model performed substantially better: 98.9%, 58% and 78% respectively. The application of the EAU risk stratification does not ensure proper identification of high-risk patients complaining of haemospermia. We propose a novel, better performing and easily implementable risk stratification. Work supported by industry: no. [ABSTRACT FROM AUTHOR]

There is a current lack of effective conservative treatments for Peyronie Disease (PD). Surgery represents an effective treatment, despite being associated with bothering complications, including erectile dysfunction (ED). We investigated patients wish of being operated for PD at a single center. Data were prospectively collected for patients managed for penile curvature because of PD in 2016-2020. Baseline data included age, time from PD onset, penile pain, curvature degree, difficulty at penetration, concomitant hour-glass deformity and ED. All patients were offered conservative treatments, including oral therapy or topical injections regardless of curvature degree. Tunical shortening or lengthening procedures were offered as an alternative to conservative treatments. Penile prosthesis implantation was offered to those with concomitant ED. Patients compliance with surgery was recorded. Logistic regression analyses tested the profile of patients who were more likely to comply with surgery. Data were available for 218 patients. Median(IQR) age was 57(49,63) yrs and length of PD after onset was 14(3,28) months. Median curvature was 30°(20,45); of 218, 8(3.7%) patients had concomitant hour-glass deformity. Pain was complained by 30(14%) patients, while difficulty at penetration and ED were reported by 62(28%) and 87(40%) patients. Of all, 78(32%) patients had been treated with tadalafil OaD; 41(19%) patients received iontophoresis with verapamil; 35(16%) SWT; and, 31(14%) CCH injections. A significant improvement (defined as a curvature reduction≥20°) was reported in 52(24%) cases. Overall, only 59 (27%) patients were willing to eventually undergo surgery for PD. Younger patients (OR:0.95, 95%CI: 0.92,0.98;p=0.003) and patients with more severe curvatures (OR:1.03; 95%CI: 1.01,1.04;p=<0.001) were more likely to comply with surgery, after accounting for other clinical variables. According to this model, a man aged 50 yrs with a curvature <20° would accept surgery only in 24% of cases compared to 45% for a same age man with >45° of curvature (Fig1). Compliance to surgery is low among patients with PD, thus further stressing the urgent need for effective conservative treatments. Surgery should be comprehensively discussed with younger patients with a severe curvature. Work supported by industry: no. [ABSTRACT FROM AUTHOR]

The routine use of dynamic duplex ultrasound of the penis (DDUP) to detect vasculogenic erectile dysfunction (V-ED) has been questioned because of a related patient' discomfort and costs issues. to investigate clinical factors which could guide the physician in selecting candidates for DDUP in routine practice. Data were collected for 119 patients with ED who underwent DDUP regardless of their clinical history, to rule out V-ED at a single centre. Baseline data included: age, comorbidities (as scored with the Charlson Comorbidity Index (CCI)), BMI, recreational habits and the International Index of Erectile Function–6 (IIEF-6). DDUP was performed after intracavernous injection of alprostadil 20 ug and self sexual stimulation. V-ED was defined as a peak systolic velocity (PSV)<30 cm/s ± end diastolic velocity (EDV) of >3 cm/s and a resistance index (RI)<0.8. Logistic regression analysis tested clinical predictors of V-ED. The accuracy of the predictive model was assessed and decision curve analyses (DCA) tested their clinical benefit. Median (IQR) age was 54(43-60) years and IIEF-6 was 15(8-21). Of 119, 44 (37%) patients had comorbidities (CCI≥1), with cardiovascular disease (CVDs) and diabetes in 13(11%) and 16(14%) patients. Of all, 18(15%) patients were current smokers and 58(49%) had no regular physical activity. At DDUP, median right and left PSV were 36.7(25.7-43.9) and 36.1(25.3-44.9) cm/s. V-ED was detected in 50(42%) patients. Age (OR:1.05;95%CI 1.01–1.08; p=0.004) and smoking history (OR:3.33; 95%CI 1.13–9.8; p=0.02) were associated with a higher risk of V-ED, while physical activity was a protective factor (OR:0.43; 95%CI:0.20-091; p=0.03). Conversely, BMI, IIEF-6, CVDs, diabetes and CCI were not associated with V-ED. The model including age, smoking and physical activity had a fine accuracy to predict V-ED (AUC:0.70;95%CI:0.60- 0.79). At DCA (fig 1), the use of those clinical factors to select candidates for DDUP would result in the best clinical strategy if a threshold risk of V-ED≥35% is considered as a reasonable value to trigger the investigation. Clinical factors including age and lifestyle habits could be used in the everyday clinical practice to better select patients for DDUP, if the use of this test is considered clinically reasonable for patients with ≥35% risk of V-ED. Work supported by industry: no. [ABSTRACT FROM AUTHOR]

The interrelationship between male sexual desire and erectile dysfunction (ED) has been variously investigated. We aimed to investigate the prevalence of and the predictors of unrecognized low sexual desire (LSD) in a cohort of men seeking medical help for new onset ED in the real-life setting. Data from 1509 men seeking first medical help for new-onset ED at a single andrology centre between 01/2010 and 01/2020 were analyzed. Patients were assessed with a thorough medical and sexual history. Comorbidities were scored with the Charlson Comorbidity Index (CCI). All participants were asked to self-report the presence of LSD. Moreover, patients completed the International Index of Erectile Function (IIEF) and the Beck Depression Inventory (BDI). Depressive symptoms were defined as BDI ≥11. The median value of the IIEF-Sexual desire domain (IIEF-SD) was used to categorize the cohort in low SD (IIEF-SD <7) vs. normal SD (IIEF-SD ≥7). The IIEF-Erectile function (IIEF-EF) domain was categorized according to Cappelleri's criteria. Circulating hormones were measured in every patient. Hypogonadism was defined as total testosterone (tT) < 3.0 ng/mL. Descriptive statistics and logistic regression models tested the association between clinical variables and unrecognized LSD. Overall, 312 (20.7%) patients self-reported LSD and were excluded from further analyses. Of 1197 patients not self-reporting LSD, 369 (30.8%) had IIEF-SD <7 (arbitrarily defined as unrecognized LSD). Patients with unrecognized LSD were older [median (IQR) 54 yrs (41-63) vs. 49 yrs (36-59), p<0.001], had lower IIEF-EF [10 (5-20) vs. 22 (11-28)] but higher BDI [6 (3-12) vs. 4 (1-8)] and lower tT [4.3 (3.2-5.7) vs. 4.7 (3.2-7.3) ng/ml] (all p<0.001) than men without LSD. Overall, men with unrecognized LSD presented a higher rate of severe ED (50% vs. 24%, p<0.001), and of BDI suggestive for depressive symptoms (30.6% vs. 18.3%) and of hypogonadism (19.9% vs. 10%) (all p<0.001). At multivariable logistic regression analysis, lower tT, despite not suggestive for hypogonadism (OR 0.91, p=0.03), lower IIEF-EF (OR 0.94, p<0.001) and BDI suggestive for depressive symptoms (OR 1.83, p<0.001) were found to be independent predictors of unrecognized LSD, after accounting for age. One out of three men seeking first medical help for ED showed unrecognized LSD according to the IIEF-SD domain scores. Men with unrecognized LSD were older, had higher rates of severe ED and depressive symptoms and lower tT values despite not suggestive for hypogonadism than men with normal SD. A detailed investigation of sexual desire should be always included in the diagnostic work-up of men with ED, in order to better tailoring patient therapeutic management. Work supported by industry: no. [ABSTRACT FROM AUTHOR]

High serum estrogens levels have been associated with higher rates of heart attacks, strokes, and prostate cancer. Moreover, hyperestrogenism is believed to be harmful to male sexuality. We aimed to investigate the prevalence of and the impact of hyperestrogenism on sexual functioning in a cohort of men seeking medical attention for new onset erectile dysfunction (ED) in the real-life setting. Data from 481 men seeking first medical help for new-onset ED at a single andrology centre were analyzed. Patients were assessed with a thorough medical and sexual history. Comorbidities were scored with the Charlson Comorbidity Index (CCI). All patients completed the International Index of Erectile Function (IIEF) and the IIEF-Erectile function (IIEF-EF) domain was categorized according to Cappelleri's criteria. Circulating hormones were measured in every patient. Hyperestrogenism was defined as estrogen (E2) levels >42.6 pg/mL (Tan RS et al. 2015). Descriptive statistics and logistic/linear regression models tested the association between hyperestrogenism and IIEF scores. Overall, 88 (18.3%) patients had serum estrogen levels suggestive for hyperestrogenism. Men with hyperestrogenism were older [median (IQR) 46 (34-58) vs. 44 (32-55) years; p<0.001], had more comorbidities [CCI≥2: 18 (20.5%) vs. 28 (7.1%); p<0.001] and higher serum testosterone (TT) levels [5.4 (4.2-7.3) vs. 4.3 (3.1-5.7); p=0.02] than those with normal E2 values. A higher rate of severe ED was found in men with elevated E2 levels (48.9% vs. 30%; p=0.02). Moreover, the IIEF-orgasmic function (IIEF-OF) domain was lower in ED men with hyperestrogenism than those with normal E2 values [6 (3-10) vs. 9 (6-10), p=0.03]. Serum E2 levels were positively correlated with TT levels (rho 0.25, p<0.001), but negatively correlated with IIEF-OF scores (rho -0.17, p=0.005) and IIEF-EF scores (rho -0.32, p<0.001) (Figure 1). At multivariable logistic regression analysis, hyperestrogenism (OR 2.37, p=0.03) was associated with severe ED after accounting for age, BMI, CCI and serum T values. One out of five men seeking first medical help for ED showed elevated serum E2 values in the real-life setting. Hyperestrogenism was associated with health significant comorbidities, orgasmic function impairment and higher severity of ED. Work supported by industry: no. [ABSTRACT FROM AUTHOR]