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Background: Penile cosmetic enhancement procedures have been performed for many years with varying success. However, they have historically been relegated to niche areas of sexual medicine, with limited data, and have not achieved mainstream adoption. More recently, the topic has been increasingly discussed within academic congresses due to availability of novel techniques, therapies, and procedures. Given their distinctive nature, the Sexual Medicine Society of North America (SMSNA) felt that it was pertinent to develop formal position statements to help guide both patients and sexual medicine providers on the current state of the scientific literature and to give recommendations for future research. Aim: The study sought to provide an evidence-based set of recommendations for injection and surgical procedures designed to lengthen, augment, or otherwise cosmetically enhance the penis. Methods: A review was performed of all scientific literature listed in PubMed from inception through December 2023 relating to penile cosmetic enhancement procedures. Only invasive (injection/surgery) therapies were included due to their distinct risk-benefit profile compared with more conservative treatments (eg, vacuum erection devices, penile traction devices). Similar therapies were categorized, with pertinent data summarized and used to help create relevant position statements. All statements were expert opinion only and were based on analyses of the potential risks and benefits of the specific therapies. Outcomes: A total of 6 position statements were issued relating to 5 distinct sexual medicine cosmetic enhancement procedures. Results: A consensus opinion was reached by SMSNA leadership on the state of injection/surgical penile cosmetic enhancement procedures as of 2024. Key topic areas addressed included injectable soft tissue fillers, suspensory ligament division, graft-and-flap procedures, silicone sleeve implants, and sliding/slicing techniques. Distinct recommendations were tailored to each therapy and were based solely on the current state of the literature. It is anticipated that future studies will further inform position statements and will lead to ongoing modifications. Clinical Implications: The current position statements provide both patients and clinicians evidence-based, expert recommendations on best practices relating to penile cosmetic enhancement procedures. Strengths and Limitations: Strengths include the use of an expert panel of sexual medicine clinicians, consensus design, and summary of existing literature. Limitations include expert opinion and limited research on the topic. Conclusion: The current SMSNA position statements provide evidence-based, consensus opinions on the appropriate role for penile augmentation and cosmetic procedures in 2024. [ABSTRACT FROM AUTHOR]

In this article, authors discuss the study "Cardiovascular Outcomes Among Sildenafil Users: Results of the International Men's Health Study," that was published in the "International Journal of Clinical Practice" in 2008. Topics discussed include approval of sildenafil for the treatment of erectile dysfunction (ED) in the U.S., the planning of the International Men's Health Study (IMHS) on sexual dysfunction and risks associated with phosphodiesterase type 5 inhibitor (PDE5).

Sildenafil treatment has not been evaluated in a double-blind, placebo-controlled (DBPC) trial specific to men with mild erectile dysfunction (ED), defined by a 22-25 score on the International Index of Erectile Function-erectile function domain (IIEF-EF). To assess sildenafil efficacy in sexually dissatisfied men with mild ED. Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS), IIEF, Quality of Erection Questionnaire (QEQ), Erection Hardness Score (EHS 4 = completely hard/fully rigid), general efficacy questions (GEQs), event log questions (hardness sufficient for penetration, duration sufficient for successful intercourse, ejaculation/orgasm, and second erection within 24 hours), and analog scales (erection firmness, reliability, and maintenance, and general sexual performance). Eight-week DBPC flexible-dose (25, 50, or 100 mg) trial with 6-week, open-label (OL) extension. One hundred and seventy-six men were randomized (mean ± standard deviation: age, 50 ± 12 year; ED duration, 3.5 ± 3.2 year). Most had organic or mixed ED. For sildenafil vs. placebo, 66% vs. 89% titrated to 100 mg and efficacy at DBPC end was better, including the EDITS Index score (least squares mean [standard error], 80.3 [2.3] vs. 62.1 [2.5]; P < 0.0001); treatment satisfaction (EDITS Index score >50 in 89% vs. 63%; P = 0.0001); no ED (IIEF-EF ≥26 in 58% vs. 39%; P < 0.05); GEQs (≥4.9-fold greater odds of improved erections and ability to have sexual intercourse); and EHS 4 (47.2% vs. 25.2% of occasions; P < 0.0001). At OL end, 93% of men were satisfied (EDITS Index score > 50), 77% had no ED, and ≥89% were GEQ responders; mean scores on IIEF domains, the QEQ, and analog scales were >80% of the maximum; 60% of occasions had EHS 4; and event log responses were positive on >80% of occasions, except for second erections (41.9%). Headache, nasal congestion, and flushing, mostly mild to moderate, were the most common adverse events. Men with mild ED derive substantial benefit from sildenafil treatment. [ABSTRACT FROM AUTHOR]

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. 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]

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]

To evaluate the oxidative status of the bladder 8 weeks after diabetes induction. Oxidative stress has recently been implicated in the pathogenesis of diabetes complications, but its role in diabetic cystopathy has not been studied.Sprague-Dawley rats were divided into three groups: control (n = 11), diuretic control (5% sucrose drink; n = 6), and streptozotocin-induced diabetic group (n = 14). Eight weeks later, the bladders were dissected. We measured the antioxidant scavenging enzymes (catalase and superoxide dismutase)-like activity and the levels of the thiobarbituric acid reactive substances, as a marker of lipid peroxidation. We also examined the levels of inducible nitric oxide synthase and apoptosis in the bladders.We found a statistically significant reduction in the catalase-like activity in the bladders from the diabetic group compared with the other groups (P = 0.017, diabetic versus control); the difference in the superoxide dismutase-like activity was not statistically significant among the groups. The thiobarbituric acid reactive substances levels were significantly greater in the diabetic compared with other groups (131.9 ± 47.5, 46.7 ± 17.9, and 60.9 ± 25.4 nmol/mg protein in the diabetic, control, and diuretic group, respectively, P = 0.006, diabetic versus control). Immunohistochemical and apoptosis studies showed a statistically significant increased number of inducible nitric oxide synthase-positive cells and apoptotic cells in the diabetic bladder smooth muscle cells (P <0.001).Our findings showed that oxidative stress occurred in the bladders of the STZ-diabetic rats and was not mediated by diuresis. The oxidative damage of the smooth muscle cells may be a contributory factor in diabetic cystopathy. [Copyright &y& Elsevier]

We evaluated the effect of a somatostatin analog (octreotide) on clitoral and vaginal blood flow following suprasacral spinal cord injury (SCI) in rats. Twenty-four spinalized female Sprague-Dawley rats were randomized into 4 equal groups. The first group served as control paraplegics. The other three groups received octreotide (60µg/day/4weeks) immediately, 2 weeks, and 4 weeks following SCI. At the end of the experiment, a laser Doppler was used to measure blood flow changes following clitoral and pelvic nerve plexus stimulations. Marked decreases in both clitoral and vaginal blood flow in the control paraplegics were recorded. Significant increases (p < 0.05) in both clitoral and vaginal blood flow were recorded in animals that received octreotide; however, the increase was marked in the animals that received the drug immediately following SCI. Improvement in the clitoral and vaginal blood flow of spinalized rats using octreotide indicates that octreotide may be helpful for patients with SCI. [ABSTRACT FROM AUTHOR]

We evaluated the effect of a somatostatin analog (octreotide) on clitoral and vaginal blood flow following suprasacral spinal cord injury (SCI) in rats. Twenty-four spinalized female Sprague-Dawley rats were randomized into 4 equal groups. The first group served as control paraplegics. The other three groups received octreotide (60 micrograms/day/4 weeks) immediately, 2 weeks, and 4 weeks following SCI. At the end of the experiment, a laser Dopper was used to measure blood flow changes following clitoral and pelvic nerve plexus stimulations. Marked decreases in both clitoral and vaginal blood flow in the control paraplegics were recorded. Significant increases (p < 0.05) in both clitoral and vaginal blood flow were recorded in animals that received octreotide; however, the increase was marked in the animals that received the drug immediately following SCI. Improvement in the clitoral and vaginal blood flow of spinalized rats using octreotide indicates that octreotide may be helpful for patients with SCI. [ABSTRACT FROM AUTHOR]

Introduction. Potassium para-aminobenzoate is an agent used in the treatment of sclerotic diseases including Peyronie's disease of the penis. It has been reported that this medication may have been responsible for cases of acute liver injury. Aim. To inform clinicians of the possibility of an adverse drug event associated with the oral intake of potassium para-aminobenzoate by reporting an additional case and compiling information from previous reports. Methods. The affected patient's medical records were diligently reviewed; all available and relevant information pertaining to this adverse event is reported. Similar case reports were analyzed and compared, and relevant information was compiled in this report. Results. The patient enjoyed a full biochemical recovery from his hepatitis 4 months after discontinuation of potassium para-aminobenzoate. Conclusion. To date, the oral use of potassium para-aminobenzoate has been reported to be linked to acute liver injury in six individuals. Appropriate management of this adverse drug event is the immediate discontinuation of the offending drug and general patient support measures. Roy J, and Carrier S. Acute hepatitis associated with treatment of Peyronie's disease with potassium para-aminobenzoate (Potaba). J Sex Med **;**:**–**. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this white paper is to educate health care professionals about the evolution of telemedicine (TM) and to propose a hybrid model that leverages the strengths of traditional in-person medicine as well as virtual medicine while maximizing the safety and quality of men's sexual health care. Literature Search Strategy: A literature search focused on the use of TM in urology and men's health was performed through PubMed/MEDLINE, Embase, and Web of Science (January 1, 2012–April 26, 2022). Keywords included all known permutations of the terminology used to refer to virtual health, care as well as the terminology used to refer to urologic diseases, issues specific to men's health, and men's sexual health concerns. Publications that emerged after the literature search that met this criterion also were incorporated. Opinion pieces, letters to the editor, meeting abstracts, and conference proceedings were excluded. Additional resources were retrieved, such as governmental technical reports, legislative updates and reviews, and blogs. This search strategy yielded 1684 records across databases after removal of duplicates. Abstracts from the retrieved records were reviewed for relevance. Relevant publications were defined as those that reported data on any aspect of TM use specific to urology, men's health, and/or men's sexual health. If relevance was unclear from the abstract, then the full text of the article was retrieved for a more detailed review. In addition, the published evidence-based practice guidelines relevant to care for erectile dysfunction, Peyronie's disease, ejaculatory dysfunction, and hypogonadism were retrieved. The most common reasons for article exclusions were a focus on TM use in disciplines other than urology and the absence of data (ie, opinion pieces). After exclusions, a total of 91 publications remained and constituted the evidence base for this paper. [ABSTRACT FROM AUTHOR]

The article presents answers to a question on whether a urologist should do cardiac disease screening for all patients with erectile dysfunction.

Purpose: To address the pattern of urodynamic findings in diabetic patients with lower urinary tract symptoms (LUTS), comparing short-standing and long-standing type 2 diabetes mellitus (T2DM). Methods: A prospective study was conducted on 50 patients presenting with LUTS and a concurrent diagnosis of T2DM, between February 2016 and May 2018. Patients were classified and evaluated according to the duration of diabetes into two groups: short-standing DM (< 15 years, n = 31), and long-standing DM (= 15 years, n = 19) groups. The impact of LUTS and quality of life were assessed in female patients using ICIQFLUTS and male patients using ICIQ-MLUTS. Results: A total of 50 patients were included in the study. The mean duration of T2DM was 10 ± 0.7 years. The mean age was 56.3 ± 1.2 years, and the mean HbA1c was 7.5 ± 1.2%. Urodynamic evaluation detected significantly higher detrusor overactivity (DO) and increased bladder sensation with the short-standing DM group (35.5 vs. 15.8%, p = 0.01 and 32.3 vs. 5.3%, p = 0.01, respectively). Comparatively, weak, or absent detrusor contractility were more frequent in patients with longstanding DM (52% and 26% respectively p = 0.01). As expected, overflow incontinence and straining during voiding were significantly higher in the long-standing DM group (p = 0.04 and p = 0.03, respectively). Surprisingly, there was no significant correlation between patients presenting with urgency in their voiding diary (subjective) and urodynamic detection of DO (p = 0.07). Conclusions: There are different patterns in urodynamic characterizations of T2DM. Patients with short-standing DM present more commonly with storage symptoms and detrusor overactivity on urodynamics. Contrastingly, patients with long-standing DM present more frequently with voiding symptoms and detrusor underactivity on urodynamics. Thus, screening for an underactive bladder is advisable in patients with long-standing T2DM. [ABSTRACT FROM AUTHOR]

Introduction: Siliconoma represents an inflammatory tissue response to extravasated silicone. Penile enhancing silicone injections have been described for over 50 years. Most of the publications report complications including negative effects on penile appearance and function which require corrective procedures. Penile circumferential skin and siliconoma excision with skin grafting has been described in multiple case reports and series as an effective and feasible option to remove the silicone and achieve good esthetic results. Methods: We describe a simple and feasible single stage procedure removing the siliconoma with adjacent non-viable skin while preserving 50% of healthy penile skin and resurfacing the defect with a split-thickness skin graft to treat a long-term complication of penile silicone injection associated with recurrent infections and a chronic skin ulceration. Conclusion: Partial excision of the affected penile skin and siliconoma with defect resurfacing with a split-thickness skin graft is a feasible with good functional and cosmetic outcomes. [ABSTRACT FROM AUTHOR]

The article discusses authors' view over the need of cardiac assessment for patients with erectile dysfunction (ED). The authors state that patients with ED should be assessed to assess for the extent and type of cardiovascular status. The authors further conclude that change of lifestyle and treatment of patients with ED are safe and beneficial in treating ED and it will reduce the risk of cardiovascular diseases in future.

Objective: To quantify the predictors for the ancillary treatments after extracorporeal shock wave lithotripsy (SWL) for renal and upper ureteral stones. Materials and methods: From January 2014 to January 2017, patients undergoing SWL using an electromagnetic lithotripter machine (Compact Delta; Dornier MedTech GmbH, Wessling, Germany) for renal and upper ureteral stones = 20 mm were retrospectively reviewed. All patients underwent CT urography prior to SWL. The cohort was subdivided into three groups according to stone attenuation values in Hounsfield Units (HU). Group I; HU < 500 (n = 20), group II; HU 500-1000 (n = 51) and group III; HU = 1000 (n = 180). The parameters included for multivariate analysis were stone size, location, multiplicity, stone attenuation value, number of shocks and stone clearance rate by 3 months. The ancillary treatments were ureteroscopy (URS), ureteral stenting and hospital readmission for pain or fever. Results: A total of 251 patients were included in the study. The overall SWL success rate was 92.4%. Mean stone size was 10.9 ± 2.1, 11.6 ± 3 and 11.4 ± 3.6 mm and mean stone attenuation values were 364 ± 125, 811 ± 154 and 1285 ± 171 HU for groups I, II and III respectively. The stone clearance rates by 3 months were 96%, 92% and 88.4% for groups I, II and III respectively. On subgroup analysis, group III required ancillary treatments in 70% of patients whereas group I, II, did not require any ancillary treatments. On multivariate analysis, stone multiplicity, stone location (lower calyceal stones) and HU were independent significant predictors for the need for ancillary treatments after SWL (p values < 0.05). Conclusions: Patients with stone attenuation value (HU) > 1000, multiple stones and/or lower calyceal stones have higher risk to necessitate ancillary treatments after SWL. These patients would likely benefit from upfront endoscopic lithotripsy for treating symptomatic renal or upper ureteral stones. [ABSTRACT FROM AUTHOR]

The article offers information on the Canadian Urological Association (CUA) guidelines for treatment and management erectile dysfunction (ED) in men. Topics include the need for addressing psychosocial contributing factors in men to improve treatment efficacy, the assessment of family history, nicotine use and lipid profile for management of cardiovascular risk factors associated with ED, and the need of stepwise treatment approach based on patient follow-up and treatment requirements.

Introduction: Penile compression using a tourniquet is common with several materials and designs that have been previously described. The objective of the tourniquet is to induce an artificial erection through corporal occlusion for intra-operative penile curvature assessment or to obtain a clear visible bloodless surgical field. Objective: We sought to describe our novel step-by-step technique of applying penile tourniquet using silicone Penrose drain tube designed as a strap by creating a small hole on the side of the tube to obtain a loop at the base of the penis Conclusions: This novel technique is simple, effective and requires no additional materials nor special equipment, and facilitates the application and release of a tourniquet during penile surgery. [ABSTRACT FROM AUTHOR]

Testosterone deficiency seems to impair the clinical response to phophodiesterase-5 (PDE-5) inhibitors in patients with erectile dys-function (ED). In hypogonadal men, testosterone repletion was associated with enhanced sexual function in patients who failed initial treatment with sildenafil or tadalafil. We conducted a sys-tematic review of studies that evaluated combination therapy of testosterone and PDE-5 inhibitors in patients with ED and low, low-normal testosterone levels who failed monotherapy. The stud-ies we examine are heterogeneous with several methodological drawbacks and that, overall, the addition of testosterone to PDE-5 inhibitors might benefit patients with ED associated with testoster-one <300 ng/dL (10.4 nmol/L) who failed monotherapy. Further studies, with a randomized placebo-controlled and double blind design, are needed to describe the appropriate target patient group, testosterone cut-off and to define the optimal dose and duration of combination therapy. [ABSTRACT FROM AUTHOR]

OBJECTIVE • To compare the underlying risk for diseases associated with erectile dysfunction (ED; i.e. cardiovascular disease and diabetes) in a population of men with mild ED relative to a general ED clinical trial population. PATIENTS AND METHODS • Men enrolled in a randomized, doubleblind placebo-controlled (DBPC) trial of sildenafil for the treatment of mild ED were compared with a database of men enrolled in 67 of the manufacturer’s other DBPC sildenafil trials. • The main outcome measures were baseline demographics, comorbidities and concomitant medications. RESULTS • In both populations, most men were white, approximately one quarter were smokers, and most had an organic component to their ED etiology. • In the mild ED population ( N = 176) versus the database population ( N = 14 537), mean ± SD (range) age was 50 ± 12 (19-84) versus 55 ± 11 (18–89) years, body mass index was 29 ± 5 (20–48) versus 28 ± 5 (11–64) kg/m² and ED duration was 3.5 ± 3.2 ( < 1–18) versus 4.6 ± 4.7 ( < 1–45) years. • The prevalence of comorbidities associated with ED was similar (hypertension 26.1% ( n = 46) vs 32.8%; diabetes mellitus 13.6% ( n = 24) vs 22.1%; dyslipidemias 12.5% ( n = 22) vs 11.7%; hypercholesterolemia 12.5% ( n= 22) vs 9.5%; gastro-esophageal reflux disease 10.8% ( n = 19) vs 6.0%; benign prostatic hyperplasia 9.7% ( n = 17) vs 9.9%; depression 6.3% ( n = 11) vs 5.6%; and anxiety 4.0% ( n = 7) vs 1.6%), as was the rate of use of medications for those comorbidities. CONCLUSIONS • Men with mild ED have similar risk factors to a general ED clinical trial population. Thus, mild ED is an important indicator of risk for underlying disease associated with ED. • Inquiry into ED should be part of routine clinical evaluation to facilitate rapid identification and early intervention. • Men complaining of mild ED should be evaluated adequately for underlying cardiovascular risk. [ABSTRACT FROM AUTHOR]

Male pelvic pain, often referred to as chronic prostatitis or chronic pelvic pain syndrome (CP/CPPS), is a common yet poorly understood problem, associated with significant sexual dysfunction. A critical review of the literature is presented, with specific attention to co-morbid sexual dysfunction. Recommendations for future multidisciplinary research and clinical work are also made. [ABSTRACT FROM AUTHOR]

Introduction. Erectile dysfunction (ED) and cardiovascular disease often coexist and have many common risk factors. In hypertension, the structure of blood vessels is modified such that there is an increase in medial wall thickness relative to lumen size. Certain antihypertensive agents have been found to induce a regression of vascular structure such that a “hypertensive” vessel appears phenotypically more like that from a normotensive. Aim. To provide an update on the findings to date on the impact of vascular remodeling on erectile function. Main Outcome Measures. Review of peer reviewed literature related to vascular remodeling induced by antihypertensive agents and the potential impact on sexual function. Methods. A literature review was performed on clinical and experimental evidence regarding the association between cardiovascular disease and ED, the impact of vascular remodeling on these conditions, the impact of antihypertensive therapy on ED, and the mechanisms of antihypertensive drug-induced remodeling. Results. There is increasing evidence that ED may be an early marker for progressing cardiovascular disease. Certain antihypertensive agents have beneficial effects on both vascular structure and erectile function. The major site of resistance in the penile vasculature occurs at the level of the pudendal artery. Although structural remodeling has not yet been investigated in this vessel specifically, antihypertensive drugs have been shown to induce remodeling of the pudendal-penile vasculature and cavernosal arteries. Antihypertensive drug-induced vascular remodeling can be characterized by a decrease in the ratio of wall thickness to lumen diameter, and may result from vascular smooth muscle cell apoptosis, rearrangement of cells around a smaller lumen, and/or changes in the extracellular matrix composition depending on the vessel type. Conclusion. Determining the mechanisms involved in antihypertensive drug-induced vascular remodeling in the pudendal vasculature may provide novel targets for the treatment of ED. Hale TM, Hannan JL, Carrier S, deBlois D, and Adams MA. Targeting vascular structure for the treatment of sexual dysfunction. J Sex Med **;**:**–**. [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]

Associate EditorMichael G. WyllieEditorial BoardIan Eardley, UKJean Fourcroy, USASidney Glina, BrazilJulia Heiman, USAChris McMahon, AustraliaBob Millar, UKAlvaro Morales, CanadaMichael Perelman, USATo evaluate the efficacy of vardenafil in patients previously unresponsive to sildenafil.A multicentre, double-blind, 12-week, flexible-dose, placebo-controlled trial was conducted, involving 463 men aged≥ 18 years with moderate-to-severe erectile dysfunction (ED) and who were unresponsive to sildenafil (by history). After a 4-week treatment-free run-in, patients received placebo or vardenafil 10 mg with the option to maintain current dose or to titrate by one dose level (5, 10 or 20 mg) based on efficacy and tolerability at 4 and 8 weeks. Outcome measures were the erectile function (EF) domain score of the International Index of Erectile Function, two Sexual Encounter Profile diary questions (vaginal penetration and maintenance of erection until successful completion of intercourse), and the Global Assessment Question (GAQ).There was significantly better EF with vardenafil than with placebo throughout the study. The least-square mean EF domain scores increased from 9.3 at baseline to 17.6 at the‘last’ observation carried forward (LOCF) analysis with vardenafil (P < 0.001). Overall least-square mean per-patient success rates more than doubled for penetration (30.3% to 62.3%) and quadrupled for successful intercourse (10.5% to 46.1%) with vardenafil. Improved erections (positive response to the GAQ) were reported by 61.8% of patients receiving vardenafil and 14.7% of those receiving placebo at LOCF (P < 0.001). Normal EF (domain score≥ 26) was achieved by 30% of patients receiving vardenafil and 6% receiving placebo at LOCF (P < 0.001). Adverse events were infrequent and representative of the phosphodiesterase-5 inhibitor profile.Vardenafil is an effective and generally safe treatment for ED, even in men unresponsive to sildenafil (by history). [ABSTRACT FROM AUTHOR]

Objective: To compare regular and Moses modes of holmium laser lithotripsy during ureteroscopy in terms of fragmentation/pulverization and procedural times in addition to perioperative complications. Patients and Methods: After obtaining ethics approval, a prospective double-blinded randomized trial was conducted for patients undergoing holmium laser lithotripsy during retrograde ureteroscopy. Patients were randomly assigned to either regular or Moses modes. Patients and surgeons were blinded to the laser mode. Lumenis 120W generator with 200 Moses D/F/L fibers were used. Demographic data, stone parameters, perioperative complications, and success rates were compared. The degree of stone retropulsion was graded on a Likert scale from 0—no retropulsion to 3—maximum retropulsion. Results: A total of 72 patients were included in the study (36 per arm). Both groups were comparable in terms of age and preoperative stone size (1.4 cm vs 1.7 cm, p > 0.05). When compared with the regular mode, Moses mode was associated with significantly lower fragmentation/pulverization time (21.1 minutes vs 14.2 minutes; p = 0.03) and procedural time (50.9 minutes vs 41.1 minutes, p = 0.03). However, there were no significant differences in terms of lasing time (7.4 minutes vs 6.1 minutes, p > 0.05) and total energy applied to the stones (11.1 kJ vs 10.8 kJ, p > 0.05). Moses mode was associated with significantly less retropulsion (mean grade was 1.0 vs 0.5, p = 0.01). There were no significant differences between both modes in terms of intraoperative complications (11.1% vs 8.3%, p > 0.05), with one patient requiring endoureterotomy for stricture in the Moses group. Success rate at the end of 3 months was comparable between both groups (83.3% vs 88.4%, p > 0.05). Conclusion: Moses technology was associated with significantly lower fragmentation/pulverization and procedural times. The reduced fragmentation/pulverization time seen using Moses technology could be explained by the significantly lower retropulsion of stones during laser lithotripsy. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to compare efficacy, safety, and cost of disposables of the DrillCut™ morcellator with the VersaCut™ morcellator after holmium laser enucleation of the prostate (HoLEP). Methods: After obtaining ethical approval, consecutive patients undergoing HoLEP for symptomatic benign prostatic hyperplasia were randomized to have their enucleated prostates morcellated by either Karl Storz® DrillCut™ or Lumenis® VersaCut™ morcellators. All procedures were performed by two experienced urologists. Patients' demographics and perioperative data were recorded. Both morcellators were compared for their safety, efficacy, and cost-effectiveness. Results: Eighty-two patients were included in the study (41 per arm). Both groups were comparable in terms of age, preoperative prostate size (114 vs. 112 m l; p>0.05), enucleation time (95.3 vs. 91.7 minutes; p>0.05), and morcellation time (22.6 vs. 17.3 minutes; p>0.05). The DrillCut was associated with significantly lower morcellation rate when compared with the VersaCut (3.6 vs. 4.9 g/min; p= 0.03). In terms of safety, there was no significant difference between both morcellators in complication rates (2.4% vs. 7.3 %; p=0.1). However, there was one case of bladder perforation requiring exploration with the VersaCut. The DrillCut was associated with significantly higher cost of disposables when compared with the VersaCut ($247.5 vs. $160.9; p<0.01). Conclusions: Despite the small sample size, the DrillCut was associated with lower morcellation rate when compared with the VersaCut. However, this difference may not be clinically significant. Although both morcellators were comparable in their safety, the DrillCut was associated with higher cost of disposables when compared with the VersaCut. [ABSTRACT FROM AUTHOR]

The article presents guidelines for peyronie's disease (PD) and congenital penile curvature by the Canadian Urological Association. Topics discussed include peyronie's disease as an acquired penile disorder characterized by benign fibrotic changes primarily to the tunica albuginea (TA), guidelines for the management of PD and Congenital Penile Curvature by the Canadian Urological Association and framework for the evaluation of patients with any type of sexual dysfunction.

Introduction Sexual dysfunction is common in patients after radical prostatectomy (RP) for prostate cancer. Aim To provide the International Consultation for Sexual Medicine (ICSM) 2015 recommendations concerning prevention and management strategies for post-RP erectile function impairment in terms of preoperative patient characteristics and intraoperative factors that could influence erectile function recovery. Methods A literature search was performed using Google and PubMed databases for English-language original and review articles published up to August 2016. Main Outcome Measures Levels of evidence (LEs) and grades of recommendations (GRs) based on a thorough analysis of the literature and committee consensus. Results Nine recommendations are provided by the ICSM 2015 committee on sexual rehabilitation after RP. Recommendation 1 states that clinicians should discuss the occurrence of postsurgical erectile dysfunction (temporary or permanent) with every candidate for RP (expert opinion, clinical principle). Recommendation 2 states that validated instruments for assessing erectile function recovery such as the International Index of Erectile Function and Expanded Prostate Cancer Index Composite questionnaires are available to monitor EF recovery after RP (LE = 1, GR = A). Recommendation 3 states there is insufficient evidence that a specific surgical technique (open vs laparoscopic vs robot-assisted radical prostatectomy) promotes better results in postoperative EF recovery (LE = 2, GR = C). Recommendation 4 states that recognized predictors of EF recovery include but are not limited to younger age, preoperative EF, and bilateral nerve-sparing surgery (LE = 2, GR = B). Recommendation 5 states that patients should be informed about key elements of the pathophysiology of postoperative erectile dysfunction, such as nerve injury and cavernous venous leak (expert opinion, clinical principle). Conclusions This article discusses Recommendations 1 to 5 of the ICSM 2015 committee on sexual rehabilitation after RP. Salonia A, Adaikan G, Buvat J, et al. Sexual Rehabilitation After Treatment for Prostate Cancer—Part 1: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017;14:285–296. [ABSTRACT FROM AUTHOR]

Introduction Sexual dysfunction is common in patients after radical prostatectomy (RP) for prostate cancer. Aim To provide the International Consultation for Sexual Medicine (ICSM) 2015 recommendations concerning management strategies for post-RP erectile function impairment and to analyze post-RP sexual dysfunction other than erectile dysfunction. Methods A literature search was performed using Google and PubMed database for English-language original and review articles published up to August 2016. Main Outcome Measures Levels of evidence (LEs) and grades of recommendations (GRs) are provided based on a thorough analysis of the literature and committee consensus. Results Nine recommendations are provided by the ICSM 2015 committee on sexual rehabilitation after RP. Recommendation 6 states that the recovery of postoperative erectile function can take several years (LE = 2, GR = C). Recommendation 7 states there are conflicting data as to whether penile rehabilitation with phosphodiesterase type 5 inhibitors improves recovery of spontaneous erections (LE = 1, GR = A). Recommendation 8 states that the data are inadequate to support any specific regimen as optimal for penile rehabilitation (LE = 3, GR = C). Recommendation 9 states that men undergoing RP (any technique) are at risk of sexual changes other than erectile dysfunction, including decreased libido, changes in orgasm, anejaculation, Peyronie-like disease, and changes in penile size (LE = 2, GR = B). Conclusion This article discusses Recommendations 6 to 9 of the ICSM 2015 committee on sexual rehabilitation after RP. Salonia A, Adaikan G, Buvat J, et al. Sexual Rehabilitation After Treatment For Prostate Cancer–Part 2: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017;14:297–315. [ABSTRACT FROM AUTHOR]

Peyronie's disease (PD) has a negative impact on men's sexual functioning and quality of life, but little is known about why some men cope better than others and what the effects of PD are on their relationships. The aims of the present study were to describe negative affect, pain, and relationship and sexual satisfaction in men with PD, and to explore their psychosocial correlates. Participants were 110 men diagnosed with PD. All men completed questionnaires. The main outcome measures were as follows: Global Measure of Sexual Satisfaction, Dyadic Adjustment Scale, McGill Pain Questionnaire, and Negative Affect Scale. The predictor variables were the following: Experience of Shame Scale, Body Esteem Scale, Body Image Self-Consciousness Scale, Index of Male Genital Image, a modified Pain Catastrophizing Scale, and a modified Multidimensional Pain Inventory. Although men with PD had mean sexual/relationship satisfaction and negative affect scores indicating mild impairment, there was a wide range of variation, with 42% to 52% scoring in the clinical range. Catastrophizing was significantly associated with reduced sexual satisfaction and increased negative affect and pain. Shame was also associated with increased negative affect. The significant associations of relationship satisfaction were partner responses and shame. Given the lack of curative treatment in PD, understanding why some men cope better than others may guide therapy. Shame, catastrophizing, and partner responses may be important therapeutic targets. [ABSTRACT FROM AUTHOR]

Introduction Testosterone deficiency (TD), also known as hypogonadism, is a condition affecting a substantial proportion of men as they age. The diagnosis and management of TD can be challenging and clinicians should be aware of the current literature on this condition. Aim To review the available literature concerning the diagnosis and management of TD and to provide clinically relevant recommendations from the Fourth International Consultation for Sexual Medicine (ICSM) meeting. Methods A literature search was performed using the PubMed database for English-language original and review articles published or e-published up to January 2016. Main Outcome Measures Levels of evidence (LoEs) and grades of recommendations are provided based on a thorough analysis of the literature and committee consensus. Results Recommendations were given for 12 categories of TD: definition, clinical diagnosis, routine measurement, screening questionnaires, laboratory diagnosis, threshold levels for the biochemical diagnosis of TD, prostate cancer, cardiovascular disease, fertility, testosterone (T) formulations, alternatives to T therapy, and adverse events and monitoring. A total of 42 recommendations were made: of these, 16 were unchanged from the Third ICSM and 26 new recommendations were made during this Fourth ICSM. Most of these recommendations were supported by LoEs 2 and 3. Several key new recommendations include the following: (i) the clinical manifestations of TD occur as a result of decreased serum androgen concentrations or activity, regardless of whether there is an identified underlying etiology [LoE = 1, Grade = A]; (ii) symptomatic men with total T levels lower than 12 nmol/L or 350 ng/dL should be treated with T therapy [LoE = 1, Grade = C]; (iii) a trial of T therapy in symptomatic men with total T levels higher than 12 nmol/L or 350 ng/dL can be considered based on clinical presentation [LoE = 3, Grade = C]; (iv) there is no compelling evidence that T treatment increases the risk of developing prostate cancer or that its use is associated with prostate cancer progression [LoE = 1, Grade = C]; and (v) the weight of evidence indicates that T therapy is not associated with increased cardiovascular risk [LoE = 2, Grade = B]. Conclusion TD is an important condition that can profoundly affect the sexual health of men. We provide guidance regarding its diagnosis and management. Men with TD who receive treatment often experience resolution or improvement in their sexual symptoms and non-sexual health benefits. [ABSTRACT FROM AUTHOR]

Background The association between phosphodiesterase type 5 inhibitors (PDE5-Is), drugs used in the treatment of erectile dysfunction (ED), and melanoma skin cancer is controversial. Objective To assess whether the use of PDE5-Is is associated with an increased risk of melanoma skin cancer. Design, setting, and participants Using the UK Clinical Practice Research Datalink, we assembled a cohort of men newly diagnosed with ED between 1998 and 2014 and followed until 2015. PDE5-I exposure was considered as a time-varying variable lagged by 1 yr for latency purposes. Outcome measurements and statistical analysis Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of incident melanoma associated with PDE5-I use overall and by number of prescriptions and pills received. Identical analyses were conducted for basal and squamous cell carcinoma, two cancers for which PDE5-related pathways are not thought to be involved. Results and limitations The cohort included 142 983 patients, of whom 440 were newly diagnosed with melanoma during follow-up (rate: 63.0 per 100 000 person-years). Compared with nonuse, PDE5-I use was not associated with an overall increased risk of melanoma (rates: 66.7 vs 54.1 per 100 000 person-years; HR: 1.18; 95% CI, 0.95–1.47). The risk was significantly increased among those who had received seven or more prescriptions and ≥25 pills (HR: 1.30 [95% CI, 1.01–1.69] and 1.34 [95% CI, 1.04–1.72], respectively). In contrast, there was no overall association with basal and squamous cell carcinoma, with an unclear association with numbers of prescriptions and pills received. Conclusions The use of PDE5-Is was not associated with an overall increased risk of melanoma skin cancer. The increased risks observed in the highest prescription and pill categories require further validation. Patient summary In this study, the use of phosphodiesterase type 5 inhibitors was not associated with an increased risk of melanoma skin cancer. [ABSTRACT FROM AUTHOR]

Recent findings suggest that there is considerable interindividual variability in how mood affects sexual arousal and that the dual control model may be helpful in explaining this variation. The current research investigated whether mood interacted with sexual excitation and inhibition proneness to predict subjective and genital arousal. In this study, 33 participants (18 men; 15 women), ages 18 to 45, attended three laboratory sessions where they completed questionnaires assessing preexisting mood and propensity for sexual excitation and inhibition, then watched a series of neutral and sexually explicit films. Subjective sexual arousal was continuously indicated during each film, while genital temperature was measured using thermographic imaging. Sexual excitation and inhibition interacted with various mood scores to significantly predict both subjective and genital arousal in men and women. Several gender differences were found. For example, vigor scores interacted with sexual excitation proneness to significantly predict genital but not subjective arousal in women, while the same interaction significantly predicted subjective but not genital arousal in men. The findings supported the hypothesis that the dual control model is an important framework in understanding how mood influences both subjective and genital sexual arousal. [ABSTRACT FROM PUBLISHER]

Introduction and Objectives: Photoselective vaporization of the prostate (PVP) is a frequently performed procedure by postgraduate trainees (PGTs). However, there is no PVP-specific objective assessment tool to evaluate the acquisition of PVP skills. The aim of the present study was to develop and validate an objective structured assessment of technical skills tool for the PVP procedure (PVP-OSATS). Methods: This study was conducted in two phases. Phase I included the development of PVP-OSATS and assessment of its reliability and construct validity. Panel discussion among experts led to the development of the PVP-OSATS tool with 12 parameters, each scored from 1 (worst) to 5 (best) with a maximum score of 60. Laser prostatectomy experts and PGTs from postgraduate years (PGY) 4 and 5 were recruited. Inter-rater reliability, using Cohen's and Fleiss's kappa, was calculated for all parameters. To assess for construct validity, PGTs were compared with experts. Phase II included assessment of the concurrent validity of this novel tool. This was performed by recruiting Quebec urology PGTs between PGY-3 and -5 to test their PVP skills during the semiannual objective structured clinical examination using the validated GreenLight simulator. Results: During phase I,116 intraoperative PVP-OSATS assessments were collected; 102 for PGTs and 14 for experts. Cohen's and Fleiss's kappa was adequate (k ≥ 0.6) for all 12 parameters, confirming adequate inter-rater reliability. There was significant difference between PGTs and experts in all PVP-OSATS parameters (p ≤ 0.01) except in respect to anatomical landmarks and instrument damage. During phase II, there was significant positive correlation between PVP-OSATS scores inside the operating room and global scores obtained by the GreenLight™ simulator (r = 0.814; p<0.001). Conclusion: This study reports inter-rater reliability, construct, and concurrent validity of PVP-OSATS as a novel PVP-specific objective assessment tool. [ABSTRACT FROM AUTHOR]

Introduction Peyronie's disease (PD) causes penile deformity and can result in sexual dysfunction and psychological distress. Currently, nothing is known about the psychosexual impact on the partners of men with PD. Research carried out on the partners of men with other chronic illnesses suggests that the partners of men with PD might have increased rates of sexual dysfunction and decreased sexual satisfaction. Aims To examine (i) sexual functioning, sexual satisfaction, negative affect, and relationship satisfaction of men with PD and their female partners and (ii) the effect of male-perceived sexual interference on partners' outcomes. Methods Forty-four men diagnosed with PD and their female partners completed a questionnaire package. Main Outcome Measures Each partner filled out the Revised Dyadic Adjustment Scale, the Positive and Negative Affect Scale, the Global Measure of Sexual Satisfaction, and the Female Sexual Function Index (women) or the International Index of Erectile Function (men). Results Overall, partners of men with PD were found to have decreased sexual function, sexual satisfaction, and mood compared with population-based norms. Men and their partners showed non-distressed levels of relationship satisfaction. The degree to which PD interfered with sexual activity was an important correlate of outcomes. Increased sexual interference was associated with lower sexual function and satisfaction for the person experiencing interference. Sexual interference also was associated with negative affect and relationship satisfaction in partners and the person experiencing interference. Conclusion PD is associated with negative psychosexual and psychosocial effects on those with the disease and their partners. As a result, assessment and intervention should include the two members of the couple. [ABSTRACT FROM AUTHOR]

Introduction Treatment of erectile dysfunction is based on pharmacotherapy for most patients. Aim To review the current data on pharmacotherapy for erectile dysfunction based on efficacy, psychosocial outcomes, and safety outcomes. Methods A review of the literature was undertaken by the committee members. All related articles were critically analyzed and discussed. Main Outcome Measures Levels of evidence (LEs) and grades of recommendations (GRs) are provided based on a thorough analysis of the literature and committee consensus. Results Ten recommendations are provided. (i) Phosphodiesterase type 5 (PDE5) inhibitors are effective, safe, and well-tolerated therapies for the treatment of men with erectile dysfunction (LE = 1, GR = A). (ii) There are no significant differences in efficacy, safety, and tolerability among PDE5 inhibitors (LE = 1, GR = A). (iii) PDE5 inhibitors are first-line therapy for most men with erectile dysfunction who do not have a specific contraindication to their use (LE = 3, GR = C). (iv) Intracavernosal injection therapy with alprostadil is an effective and well-tolerated treatment for men with erectile dysfunction (LE = 1, GR = A). (v) Intracavernosal injection therapy with alprostadil should be offered to patients as second-line therapy for erectile dysfunction (LE = 3, GR = C). (vi) Intraurethral and topical alprostadil are effective and well-tolerated treatments for men with erectile dysfunction (LE = 1, GR = A). (vii) Intraurethral and topical alprostadil should be considered second-line therapy for erectile dysfunction if available (LE = 3, GR = C). (viii) Dose titration of PDE5 inhibitors to the maximum tolerated dose is strongly recommended because it increases efficacy and satisfaction from treatment (LE = 2, GR = A). (ix) Treatment selection and follow-up should address the psychosocial profile and the needs and expectations of a patient for his sexual life. Shared decision making with the patient (and his partner) is strongly recommended (LE = 2, GR = A). (x) Counterfeit medicines are potentially dangerous. It is strongly recommended that physicians educate their patients to avoid taking any medication from unauthorized sources (LE = 2, GR = A). The first seven recommendations are the same as those from the Third International Consultation for Sexual Medicine and the last three are new recommendations. Conclusion PDE5 inhibitors remain a first-line treatment option because of their excellent efficacy and safety profile. This class of drugs is continually developed with new molecules and new formulations. Intracavernosal injections continue to be an established treatment modality, and intraurethral and topical alprostadil provide an alternative, less invasive treatment option. [ABSTRACT FROM AUTHOR]

Study Type - Aetiology (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? This study provides the first questionnaire on the specific bodily sensations that can be perceived at orgasm thereby complementing the subjective phenomenological experience of orgasm. OBJECTIVES [ABSTRACT FROM AUTHOR]

Study Type - Therapy (outcomes research) Level of Evidence 2c OBJECTIVE [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction. An important cause or maintaining factor for pain in Urological Chronic Pelvic Pain Syndrome (UCPPS) may be pelvic floor muscle (PFM) dysfunction, which may also be implicated in sexual dysfunction and influenced by psychosocial factors. Pelvic floor ultrasound is a noninvasive, reliable, and relatively simple method to assess PFM morphology and function and can be assessed by the anorectal angle (ARA) and levator plate angle (LPA). Aims. The aim of the present study was to examine PFM morphology in men with UCPPS as compared with controls and to examine the correlation with pain and psychosocial measures. Methods. Our participants were 24 men with UCPPS and 26 controls. A GE Voluson E8 ultrasound probe was placed on the perineum, and three-dimensional images were taken at rest and during PFM contraction. Main Outcome Measures. The main outcomes were ARA and LPA at rest and contraction. Participants also completed the National Institute of Health (NIH) Chronic Prostatitis Symptom Index, Male Sexual Health Questionnaire, State Anxiety Inventory, and Pain Catastrophizing Scale. Results. Men with UCPPS had more acute ARAs than controls both at rest and during contraction. The two groups did not differ in LPA at rest; however, men with UCPPS had significantly more acute angles during contraction and LP excursion. Acute ARAs were positively correlated with greater pain report and sexual dysfunction. Anxiety was correlated with more acute ARAs and more obtuse LPAs. Conclusions. Three implications can be drawn from the findings. First, ARA at rest and during contraction as well as LP angle during contraction and LPA excursion separates men with UCPPS from controls. Second, ARA at rest and during contraction was correlated with pain and sexual dysfunction, while LPA at rest was related to anxiety. Third, pelvic floor ultrasound has the potential to be a useful and objective method of assessing PFM morphology in UCPPS. Davis SN, Morin M, Binik YM, Khalife S, and Carrier S. Use of pelvic floor ultrasound to assess pelvic floor muscle function in urological chronic pelvic pain syndrome in men. J Sex Med 2011;8:3173-3180. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction. Surgical treatment is indicated in severe cases of Peyronie's disease. Incision of the plaque with subsequent graft material implantation is the option of choice. Ideal graft tissue is not yet available. Aim. To evaluate the use of an autologous tissue-engineered endothelialized graft by the self-assembly method, for tunica albuginea (TA) reconstruction in Peyronie's disease. Methods. Two TA models were created. Human fibroblasts were isolated from a skin biopsy and cultured in vitro until formation of fibroblast sheets. After 4 weeks of maturation, human umbilical vein endothelial cells (HUVEC) were seeded on fibroblasts sheets and wrapped around a tubular support to form a cylinder of about 10 layers. After 21 days of tube maturation, HUVEC were seeded into the lumen of the fibroblast tubes for the endothelialized tunica albuginea (ETA). No HUVEC were seeded into the lumen for the TA model. Both constructs were placed under perfusion in a bioreactor for 1 week. Main Outcome Measures. Histology, immunohistochemistry, and burst pressure were performed to characterize mature tubular graft. Animal manipulations were also performed to demonstrate the impact of endothelial cells in vivo. Results. Histology showed uniform multilayered fibroblasts. Extracellular matrix, produced entirely by fibroblasts, presented a good staining for collagen 1. Some elastin fibers were also present. For the TA model, anti-human von Willebrand antibody revealed the endothelial cells forming capillary-like structures. TA model reached a burst pressure of 584 mm Hg and ETA model obtained a burst pressure of 719 mm Hg. Conclusions. This tissue-engineered endothelialized tubular graft is structurally similar to normal TA and presents an adequate mechanical resistance. The self-assembly method used and the autologous property of this model could represent an advantage comparatively to other available grafts. Further evaluation including functional testing will be necessary to characterize in vivo implantation and behavior of the graft. Imbeault A, Bernard G, Ouellet G, Bouhout S, Carrier S, and Bolduc S. Surgical option for the correction of Peyronie's disease: An autologous tissue-engineered endothelialized graft. J Sex Med 2011;8:3227-3235. [ABSTRACT FROM AUTHOR]

Urological Chronic Pelvic Pain Syndrome (UCPPS) in men is a common complaint, and causes significant impairment in quality of life. Until recently, the focus of research has primarily been on pain symptoms or underlying prostate pathology. However, new clinical phenotyping demonstrates pelvic tenderness to be an important component of UCPPS. Unfortunately, mechanisms underlying tenderness remain to be understood, and tenderness itself has not been well quantified. To validate the use of pressure pain thresholds as a method of measuring tenderness in UCPPS and to demonstrate that tenderness extends beyond the pelvis. Fifty-five men diagnosed with UCPPS and 46 healthy controls were recruited through referrals and advertisements. Each participant filled out questionnaires and was assessed by a structured interview. In addition, all UCPPS men underwent urological assessment. Demographic information was collected as well as the National Institutes of Health-Chronic Prostatitis Symptom Index. Using a digital algometer, pressure pain thresholds on 10 genito-pelvic and one control site (deltoid) were measured. The four-glass test was used for all UCPPS men. UCPPS men had reliably lower pain thresholds compared to controls in all locations, including the deltoid. UCPPS men also demonstrated consistently lower overall pain thresholds regardless of location. Furthermore, pressure pain thresholds were able to correctly distinguish patients from controls 77% of the time. Prostate infection did not influence pain thresholds. Lower pelvic and nonpelvic thresholds suggest the involvement of a central mechanism in UCPPS. Overall, the data confirm the move away from a prostate-based view of UCPPS. This is supported by the failure to find threshold differences related to prostate infection. Pressure pain thresholds appear to be a promising method of assessing tenderness in UCPPS. [ABSTRACT FROM AUTHOR]

Thermography is a promising technology for the physiological measurement of sexual arousal in both men and women. This study was designed to extend our previous college student thermography study findings to an older sample ( M age = 37.05 years), add an anxiety control group to further examine the specificity of temperature change, and examine the relationship between genital temperature and a continuous measure of subjective sexual arousal. Healthy men ( n = 40) and women ( n = 39) viewed a neutral film clip after which they were randomly assigned to view one of four other videos: neutral ( n = 20), humor ( n = 19), anxiety provoking ( n = 20) or sexually explicit ( n = 20). Genital and thigh temperature were continuously recorded using a TSA ImagIR thermographic camera. Continuous and discrete reports of subjective sexual arousal were also obtained. Results supported the validity of thermography as a measure of sexual arousal: temperature change was specific to the genitals during the sexual arousal condition and was significantly correlated with subjective continuous and discrete reports of sexual arousal. Further development should assess the potential of thermography as a tool for the diagnosis and treatment evaluation of sexual arousal difficulties and for studying sex differences. [ABSTRACT FROM AUTHOR]

Introduction. Research, theory, and popular belief all suggest that penile sensation is greater in the uncircumcised as compared with the circumcised man. However, research involving direct measurement of penile sensation has been undertaken only in sexually functional and dysfunctional groups, and as a correlate of sexual behavior. There are no reports of penile sensation in sexually aroused subjects, and it is not known how arousal affects sensation. In principle, this should be more closely related to actual sexual function. Aim. This study therefore compared genital and nongenital sensation as a function of sexual arousal in circumcised and uncircumcised men. Methods. Twenty uncircumcised men and an equal number of age-matched circumcised participants underwent genital and nongenital sensory testing at baseline and in response to erotic and control stimulus films. Touch and pain thresholds were assessed on the penile shaft, the glans penis, and the volar surface of the forearm. Sexual arousal was assessed via thermal imaging of the penis. Results. In response to the erotic stimulus, both groups evidenced a significant increase in penile temperature, which correlated highly with subjective reports of sexual arousal. Uncircumcised men had significantly lower penile temperature than circumcised men, and evidenced a larger increase in penile temperature with sexual arousal. No differences in genital sensitivity were found between the uncircumcised and circumcised groups. Uncircumcised men were less sensitive to touch on the forearm than circumcised men. A decrease in overall touch sensitivity was observed in both groups with exposure to the erotic film as compared with either baseline or control stimulus film conditions. No significant effect was found for pain sensitivity. Conclusion. These results do not support the hypothesized penile sensory differences associated with circumcision. However, group differences in penile temperature and sexual response were found. Payne K, Thaler L, Kukkonen T, Carrier S, and Binik Y. Sensation and sexual arousal in circumcised and uncircumcised men. J Sex Med 2007;4:667–674. [ABSTRACT FROM AUTHOR]

Introduction. Current physiological measures of sexual arousal are intrusive, hard to compare between genders, and quantitatively problematic. Aim. To investigate thermal imaging technology as a means of solving these problems. Methods. Twenty-eight healthy men and 30 healthy women viewed a neutral film clip, after which they were randomly assigned to view one of three other video conditions: (i) neutral (N = 19); (ii) humor (N = 19); and (iii) sexually explicit (N = 20). Main Outcome Measures. Genital and thigh temperatures were continuously recorded using a TSA ImagIR camera. Subjective measures of sexual arousal, humor, and relaxation were assessed using Likert-style questions prior to showing the baseline video and following each film. Results. Statistical (Tukey HSD) post-hoc comparisons ( P < 0.05) demonstrated that both men and women viewing the sexually arousing video had significantly greater genital temperature (mean = 33.89°C, SD = 1.00) than those in the humor (mean = 32.09°C, SD = 0.93) or neutral (mean = 32.13°C, SD = 1.24) conditions. Men and women in the erotic condition did not differ from each other in time to peak genital temperature (men mean = 664.6 seconds, SD = 164.99; women mean = 743 seconds, SD = 137.87). Furthermore, genital temperature was significantly and highly correlated with subjective ratings of sexual arousal (range r = 0.51–0.68, P < 0.001). There were no significant differences in thigh temperature between groups. Conclusion. Thermal imaging is a promising technology for the assessment of physiological sexual arousal in both men and women. Kukkonen TM, Binik YM, Amsel R, and Carrier S. Thermography as a physiological measure of sexual arousal in both men and women. J Sex Med 2007;4:93–105. [ABSTRACT FROM AUTHOR]

Summary of Committee. For the complete report please refer to Sexual Medicine: Sexual Dysfunctions in Men and Women, edited by T.F. Lue, R. Basson, R. Rosen, F. Giuliano, S. Khoury, F. Montorsi, Health Publications, Paris 2004. Introduction. Advances in understanding of the biochemistry and physiology of penile erection have led to breakthroughs in pharmacotherapy of erectile dysfunction. Aim. To provide recommendations/guidelines concerning state-of-the-art knowledge for the putative molecular and cellular mechanisms of action of centrally and peripherally acting drugs currently utilized in pharmacotherapy of erectile dysfunction. Methods. An international consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a two-year period. Concerning the Pharmacotherapy for Erectile Dysfunction Committee there were 25 experts from 10 countries. Main Outcome Measure. Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. Results. Selective and potent oral PDE5 inhibitors have significantly more affinity than cGMP and form broader molecular interactions with multiple amino acids, thereby blocking access to cGMP in the catalytic sites of the PDE5 enzyme. PDE5 inhibitors, which vary as to biochemical potency, selectivity and pharmacokinetics, lead to cGMP elevation and relaxation facilitation of penile corpus cavernosum smooth muscle cells following sexual stimulation. Various centrally acting drugs influence sexual behaviour. In particular, the dopaminergic substance apomorphine is a central enhancer that acts in the paraventricular nucleus of the hypothalamus as a dopamine (D2) receptor agonist, induces and increases penile erection responses via disinhibition, following sexual stimulation. Conclusions. There is a need for more research in the pharmacotherapeutic development of central and peripheral agents for safe and effective erectile dysfunction treatment. [ABSTRACT FROM AUTHOR]