The first-generation phosphodiesterase 5 inhibitors and their pharmacokinetic issue

Background

Erectile dysfunction (ED) is a relatively frequent disease that negatively impacts the overall quality of life, well‐being, and relationships. Although the use of phosphodiesterase 5 inhibitors (PDE5is) has revolutionized the treatment of ED, a high percentage of ED patients discontinue PDE5i treatment.

Objectives

(i) To analyze the reasons for patient dissatisfaction leading to PDE5i discontinuation; (ii) analyze the pharmacokinetics of new formulations focusing on the time needed to reach an effective plasma concentration of PDE5is (T_onset) following drug intake; and (iii) summarize the physicochemical properties of sildenafil to understand which excipients may increase the absorption rate.

Material and methods

An online PubMed literature search was conducted to identify English language publications from inception to January 2019.

Results

The main reasons for patient dissatisfaction when using PDE5is on demand are the relatively long T_onset after taking vardenafil and sildenafil, including formulations such as film‐coated tablets, fine granules, orally disintegrating tablets (ODTs), and oral thin films (ODFs). The relatively long T_onset, further worsened when accompanied by eating, highlights the following: (i) the need for planning intercourse, determining partner‐related issues; (ii) issues when having sex before the maximum effect of the drug; and (iii) lower drug‐related placebo effects. Some data suggest that sildenafil is a ‘difficult’ molecule, but T_onset can be improved following absorption by buccal mucosa using appropriate excipients.

Conclusions

We conclude that several ODT and ODF formulations can improve the ‘discretion’ issue because they are taken without water, but they have similar pharmacokinetics to corresponding film‐coated tablet formulations. One ODF formulation of sildenafil was characterized by a shorter T_onset and could potentially increase patient satisfaction following treatment. However, more clinical studies are needed to confirm the findings. Surfactants and ascorbic acid appear to be crucial excipients for achieving a high absorption rate, but more studies are needed.

No Treatment Required for Asymptomatic Vaginal Mesh Exposure

INTRODUCTION

There is no specific recommendation for the management of asymptomatic vaginal mesh erosions post antiincontinence or prolapse surgery, but revision or excision may represent overtreatment. We hypothesize that asymptomatic vaginal exposures remain asymptomatic during follow-up and do not require any intervention.

METHODS

We evaluated a "no treatment" approach by prospectively following-up women with asymptomatic vaginal exposures after antiincontinence and pelvic organ prolapse surgery. After a 1-month course of vaginal oestrogen, they underwent the "wait and see" protocol. It consisted of no treatment. Women were followed-up every 3 months, for the first year and then every 6 months with history, clinical examination with measurement of size of the exposure, and the evaluation of possible infection signs or vaginal discharge.

RESULTS

Forty women were followed-up for a median of 33.52 months (range 8-48 months). All exposures were ≤1 cm (mean 6.5 ± 1.5 mm, range 4-10 mm), patients were asymptomatic and without pain. During the observation period, the size of the exposure did not change and all women remained asymptomatic.

DISCUSSION/CONCLUSION

No treatment seems to be required for asymptomatic and small vaginal mesh exposures after prolapse or incontinence surgery.

Successful treatment with pollen extract of hematospermia in patients with xanthogranolomatous prostatitis

INTRODUCTION

The aim of this study was to report our experience in the management of hematospermia observed in 16 patients suffering from xanthogranulomatous prostatitis.

METHODS

Recurrent episodes of hematospermia were the onset symptom in all patients, and in 25% of patients it was combined with fever. All patients reported PSA value elevation and the digital rectal examination (DRE) revealed an increase of the gland size and of its consistency in all cases. In all patients, the hematospermia was treated with the oral administration of two tablets of pollen extract in a single (1 g) dose daily for 30 days.

RESULTS

Sixteen patients were observed between 2008 and 2016, referring hematospermia, progressive lower urinary tract symptoms (LUTS), and serum PSA level increase. To exclude the prostate cancer presence all patients were submitted to transperineal TRUS guided biopsy. In all the patients complete resolution of hematospermia was achieved treatment with pollen extract. All patients were subsequently treated for LUTS (alpha-adrenergic blockers), but none reported any significant improvement of symptoms. Basing on these pieces of evidence, after 90 days of alpha-blockers therapy, all patients underwent bipolar TURP. Histological examination of resected prostatic tissue revealed in all patients the diagnosis of xanthogranulomatous prostatitis.

CONCLUSIONS

Patients with xanthogranulomatous prostatitis especially experience irritative symptoms, sometimes combined with fever or hematospermia. Hematospermia as the onset symptom has not been reported so far. The administration of the pollen extract for 30 days was associated with a complete resolution of hematospermia.

Transobturator Tape: Over 10 Years Follow-up

OBJECTIVES

To assess subjective and objective outcomes in incontinent patients following "out-in" TOT, at >10-year follow-up; to evaluate effect on quality of life and other urinary symptoms, late adverse events and predictive factors for failure.

METHODS

This single-centre prospective study evaluated women with "complicated" or "uncomplicated" stress urinary incontinence (SUI) following "out-i"' TOT between 2003 and 2007. The pre-op work-up comprised: history; pelvic examination; cough stress test; urodynamic study; UDI-6; and King's Health questionnaires. Work-up was the same as pre-op plus the Patient Global Impression of Improvement scale with final follow-up in 2017.

RESULTS

One hundred thirty six consecutive patients underwent TOT; at final follow-up (mean 145 months) we evaluated 123. Cure rates: objective: 78.9%; subjective: 62.6%; no significant deterioration in SUI cure rates over time. Urgency and urgency urinary incontinence (UUI) significantly reduced. Voiding dysfunction increased without urodynamic obstruction. De novo urgency appeared in 7.3% and de novo UUI in 4.1%. In the 31 uncomplicated SUI patients, the objective cure rate was 87.1% and the subjective cure rate was 72.2%. De novo urgency appeared in 9.7% and de novo UUI in 3.2%. Nine King's Health questionnaires domains saw statistically significant improvements. In univariate analysis, pre-op wet OAB was associated with subjective recurrent SUI (P < .038) and parity >2 was associated with objective recurrent SUI (P = .023). We had 5 cases of partial mesh exposure.

CONCLUSION

Cure rates are satisfactory, 10 years after TOT surgery, with good quality of life and few major complications. However, some postoperative symptoms may be caused by long-term treatment failure or by advancing age or another pathology.

Extremely low-frequency electromagnetic fields accelerates wound healing modulating MMP-9 and inflammatory cytokines

OBJECTIVES

In our previous reports, we have demonstrated that extremely low-frequency electromagnetic fields (ELF-EMF) exposure enhances the proliferation of keratinocyte. The present study aimed to clarify effects of ELF-EMF on wound healing and molecular mechanisms involved, using a scratch in vitro model.

MATERIALS AND METHODS

The wounded monolayer cultures of human immortalized keratinocytes (HaCaT), at different ELF-EMF and Sham exposure times were monitored under an inverted microscope. The production and expression of IL-1β, TNF-α, IL-18 and IL-18BP were measured by enzyme-linked immunosorbent assay and quantitative real-time PCR. The activity and the expression of matrix metalloproteinases (MMP)-2/9 was evaluated by zymography and Western blot analysis, respectively. Signal transduction proteins expression (Akt and ERK) was measured by Western blot.

RESULTS

The results of wound healing in vitro assay revealed a significant reduction of cell-free area time-dependent in ELF-EMF-exposed cells compared to Sham condition. Gene expression and release of cytokines analysed were significantly increased in ELF-EMF-exposed cells. Our results further showed that ELF-EMF exposure induced the activity and expressions of MMP-9. Molecular data showed that effects of ELF-EMF might be mediated via Akt and ERK signal pathway, as demonstrated using their specific inhibitors.

CONCLUSIONS

Our results highlight ability of ELF-EMF to modulate inflammation mediators and keratinocyte proliferation/migration, playing an important role in wound repair. The ELF-EMF accelerates wound healing modulating expression of the MMP-9 via Akt/ERK pathway.

Aneurysm of Arteriovenous Fistula in Uremic Patients: Is Endograft a Viable Therapeutic Approach?

One of the complications of arteriovenous fistulas in chronic hemodialyzed patients is the onset of an aneurysm which can be at risk of rupture.

Traditional surgical repair is not always feasible and may not be successful in these cases, leading therefore to the loss of a functioning vascular access and requiring in any case the temporary use of a central venous catheter to allow regular hemodialysis sessions.

We applied to this kind of aneurysm the same experience developed in the management of major arterial aneurysms and we considered endografting repair a good alternative in this case. In this paper we present the successful treatment of an arteriovenous fistula aneurysm using that technique.

A distal radio-cephalic arteriovenous fistula in one of our patients presented an aneurysm with high risk of rupture. The endografting repair with percutaneous insertion of a Wallgraft™ endoprosthesis was well tolerated and the vascular access could be used the day after, without the need for a central venous catheter insertion.

Urological dysfunction in young women: an inheritance of childhood?

OBJECTIVE

To investigate the correlation of a history of lower urinary tract symptomatology during childhood with lower urinary tract dysfunction in young adult women.

SUBJECTS AND METHODS

This was a multicentre, prospective, case-control study conducted between April 2013 and November 2015. A total of 300 women, aged 18-40 years, participated. The case group comprised women attending urogynaecology clinics for various lower urinary tract complaints and the control group was recruited from a healthy population. Exclusion criteria were designed to avoid common causes of lower urinary tract dysfunction and symptoms and included diabetes mellitus, neurological disease and pelvic inflammatory disease. All women completed a self-administered 77-item questionnaire, exploring childhood urological and bowel history, as well as current urological, bowel and sexual symptoms. Statistical analysis was performed using chi-squared and Fisher's exact tests to compare categorical variables. Multivariate logistic regression models were fit for the prediction of the adult outcomes, incorporating as explanatory variables all those that showed a significant P value in bivariate analysis. P values < 0.05 were considered statistically significant.

RESULTS

Women with childhood urinary voiding and storage symptoms had a higher prevalence of these symptoms in adult life compared with women without such history. Women with urinary tract infections (UTIs) during childhood had a higher incidence of adult UTIs compared with women without this problem in childhood.

CONCLUSIONS

Lower urinary tract dysfunction in childhood seems to 'persist' in young adult life but the implications of this finding in clinical practice need to be defined in future studies.

Urodynamics before surgery for stress urinary incontinence in female patients: An open debate

Currently the debate on the role of urodynamic tests in the preoperative evaluation of female stress urinary incontinence is alight. Although urodynamic investigation (UDI) has been considered mandatory before surgery in all female patients affected by stress urinary incontinence, nowadays international guidelines are more cautious. Literature on this topic has been reviewed in order to clarify the role of UDI before surgery for "complicated" and "uncomplicated" stress urinary incontinence in female patients. We focused on if and how UDI may improve clinical outcomes and alter clinical decision making. In conclusion, we believe that in most patients (the "complicated" ones) the role of UDI has not been fully evaluated. In "uncomplicated" cases, pretreatment UDI might not improve clinical outcomes but it could give important informations (voiding dysfunction in about 10% of cases) offering a valuable guide to the surgeon and to the patient. Interestingly though, UDI could alter clinical decision making being a valuable tool in counseling our patients with the aim of cure their symptoms, never risking of worsening them or causing further discomfort.

Increased risk of erectile dysfunction in men with multiple sclerosis: an Italian cross-sectional study

INTRODUCTION

Sexual dysfunctions (SDs) are common, but often underestimated symptoms in men with multiple sclerosis (MS). The most common sexual complaint in a multiple sclerosis male is erectile dysfunction (ED). The aim of this observational, cross-sectional study was to assess the prevalence of erectile dysfunction (ED) and its relationship with neurological disability, depression, urodynamic findings and lower urinary tract symptoms (LUTS) in these patients.

MATERIAL AND METHODS

From January 2014 to January 2016, there were 101 consecutive male patients with a diagnosis of Multiple Sclerosis according to the McDonald revised criteria and stable sexual relationships were included. Patients were evaluated with the International Index of Erectile Function (IIEF-15), Sexual Quality of Life Questionnaire-Male version (SQoL-M), International Prostate Symptom Score (I-PSS) and the Beck Depression Inventory-II (BDI-II). Neurological impairment was assessed using the Expanded Disability Status Scale (EDSS). The presence of Detrusor Overactivity (DO), Detrusor Underactivity (DU) and Detrusor Sphincter Dyssynergia (DSD), was defined by International Continence Society (ICS) criteria.

RESULTS

Erectile dysfunction (ED) defined according to the erectile function (EF)-subdomain score ≤25 was present in 75 patients (74.25%). Univariate regression analysis showed that Sexual Quality of Life Questionnaire-Male version (P <0.0001), age (P = 0.021), Expanded Disability Status Scale score (P = 0.001), Beck Depression Inventory-IIscore (P = 0.001),International Prostate Symptom Score (P = 0.001), Detrusor Underactivity (P = 0.002), Multiple Sclerosis-Secondary Progressive (P = 0.002) was significantly associated with erectile dysfunction. All significant findings in univariate analysis were then entered into a multiple logistic regression model. The results indicated that the Beck Depression Inventory-II score (P = 0.011) and International Prostate Symptom Score (P = 0.043) were the only independent predictive factors of erectile dysfunction onset in these patients.

CONCLUSIONS

Hence, in order to provide an effective approach and management for erectile dysfunction all the mentioned symptoms and clinical variables should be kept in mind.

Urinary symptoms and sexual dysfunction among Italian men: The results of the #Controllati survey

OBJECTIVE

Prevention may improve the quality of life and sexual and reproductive health. To improve prevention require a comprehensive research approach that examines the frequency and risk factors for urologic conditions. In June 2016 the Italian Urologic Society coordinated a preventive initiative : the 1st Week of Male Urologic Prevention "#Controllati".

MATERIAL AND METHODS

During the 1st Week of Male Urologic Prevention "#Controllati", men aged 18 years or more were invited to attend participating urologic centers for a free of charge visit for counseling about urologic or andrologic conditions. Each participating man underwent a physical examination. Further he was asked about his a medical history and about his urologic symptoms, sexual activity and possible related problems.

RESULTS

Data were collected in 81 centers: 2380 men answered the questionnaire. A total of 1226 subjects participating in the study reported one or more urinary symptom [51.5% (IC 95% 48.9%-54.5%)]. The risk of any urinary symptoms increased with age: in comparison with men aged &lt; = 30 years or less the risk of any urinary symptoms was 2.31, 2.92, 5.12, 7.82 and 17.02 respectively in the class age 31-40, 41-50, 51-60, 61-70 and &gt; = 71. Overweight/obese men were at increased risk of any urinary symptoms [OR1.35 (95% CI 1.12-1.64)]. 27.2% (IC 95% overall 25.2% -29.3%) of the subjects had at least a sexual disorder (erectile dysfunction, premature ejaculation, hypoactive sexual desire). The erectile dysfunction and hypoactive sexual desire increased with age, but premature ejaculation tended to be higher among younger aged men aged 40 years or more. Current any urinary symptoms [OR 1.85 (CI 1.40-2.43)], hypertension [OR 1.66 (95% CI 1.21-2.26) and diabetes (OR 2.37 (95% CI 1.45-3.88)] increased the risk of erectile dysfunction.

CONCLUSIONS

This large survey gives a picture of the burden of the more frequent urologic conditions offering useful information in order to focus preventive campaign.

Trocar-guided trans-vaginal mesh surgery for pelvic organ prolapse: effects on urinary continence and anatomical and functional outcomes. A prospective observational study

OBJECTIVE

Primary objective of this study was to assess the effects of trocar-guided transvaginal mesh surgery (TVM) on cure and prevention rates for incontinence, without concomitant surgery for Stress Urinary Incontinence (SUI). Our secondary objectives were anatomical outcomes, relief of symptoms and effect on quality of life (QoL).

STUDY DESIGN

This prospective observational study evaluated women who underwent TVM for symptomatic stage >2 Pelvic Organ Prolapse (POP). SUI was evaluated objectively using the cough stress test with prolapse reduced. SUI and urge urinary incontinence (UUI) were subjectively evaluated using ICIQ-SF. Anatomical cure was defined as stage <2 at POP-Q.

STATISTICAL ANALYSIS

McNemar chi-square test; paired t-test; Mann-Whitney test.

RESULTS

Seventy-two patients reached final evaluation (mean follow-up 72 months). In the 40 pre-op continent patients, 34 (85%) remained continent postoperatively and 6 (15%) showed de novo SUI. Only 1 patient chose to undergo subsequent TVT. The number needed to treat was 6 to prevent 1 women developing de novo objective SUI and 39 to prevent 1 woman having to undergo SUI surgery. In the 32 pre-op incontinent patients, 18 (56.3%) became continent postoperatively. Only 1 patient chose to undergo subsequent TVT. UUI was present in 44 patients pre-operatively and 15 (20.8%) post-operatively (1 de novo). Forty-four patients (61.1%) were continent post-operatively for SUI and UUI. We observed a significant improvement in storage, voiding, post-micturition and prolapse-related symptoms. The anatomical cure rate was 87.5% for the anterior compartment and 90.3%.for the apical segment. The apical recurrence was 8.3% in the patients previously hysterectomised, 18.8% in the patients with uterus preservation and 0% in the patients with concomitant hysterectomy. QoL scores improved in all domains except sleep and personal relationships. We observed mesh exposure in 10 patients (13.9%), in 5 of whom it was associated with a concomitant hysterectomy CONCLUSIONS: TVM showed excellent results in terms of continence and can be performed without contemporary anti-incontinence surgery, for both continent and incontinent women. Patients should have pre-operative counselling before POP surgery. For severe uterine prolapse the Perigee™ System should be employed with concomitant hysterectomy because uterus preservation is associated with significantly higher apical recurrence rates.

The role of detrusor overactivity in urinary incontinence after radical prostatectomy: a systematic review

INTRODUCTION

The purpose of this review was to assess the evidence provided by literature regarding the role of detrusor overactivity (DO) in determining urinary incontinence in patients submitted to radical prostatectomy.

EVIDENCE ACQUISITION

The research was based on the online PubMed database spanning the period from November 1997 to May 2016. The review was conducted in accordance with the systematic review guidelines provided by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

EVIDENCE SYNTHESIS

A total of twenty-three articles met the eligibility criteria for this systematic review. The eligible studies included a total of 812 patients with a mean number of 36 patients per study (range 29-264). The rate of patients with urodynamic DO after radical prostatectomy and reporting urge urinary incontinence ranged from 3 to 63%. The postradical prostatectomy DO was more likely to occur in patients who already had it preoperatively [OR =2.30, 95% CI: 1.39-3.82; studies 9; participants 419]. However, most representative studies accordingly indicate that intrinsic sphincter deficiency is the most common cause of postprostatectomy incontinence (PPI), considered as the sole responsible factor for such patients' incontinence (88-100% of patients evaluated); the same studies report that isolated bladder dysfunction is uncommon and that it occurs in only 3% of patients.

CONCLUSIONS

The review results suggest that DO could be considered as another possible underlying mechanism for PPI. Although sphincter incompetence and weakness are the most common mechanisms related to incontinence after prostatectomy, DO may coexist or be an isolated cause of PPI. Therefore, urodynamic studies are essential to show which is and/or are the exact cause(s) of incontinence in each individual patient after RP.

Sacrocolpopexy for pelvic organ prolapse: evidence-based review and recommendations

Sacrocolpopexy is considered a reference operation for pelvic organ prolapse repair but its indications and technical aspects are not standardized. A faculty of urogynecology surgeons critically evaluated the peer-reviewed literature published until September 2015 aiming to produce evidence-based recommendations. PubMed, MEDLINE, and the Cochrane Library were searched for randomized controlled trials published in English language. The modified Oxford data grading system was used to access quality of evidence and grade recommendations. The Delphi process was implemented when no data was available. Thirteen randomized, controlled trials were identified, that provided levels 1 to 3 of evidence on various aspects of sacrocolpopexy. Sacrocolpopexy is the preferred procedure for vaginal apical prolapse (Grade A), monofilament polypropylene mesh is the graft of choice and the laparoscopic approach is the preferred technique (Grade B). Grade B recommendation supports the performance of concomitant procedures at the time of sacrocolpopexy. Grade C recommendation suggests either permanent or delayed sutures for securing the mesh to the vagina, permanent tackers or sutures for securing the mesh to the sacral promontory and closing the peritoneum over the mesh. A Delphi process Grade C recommendation supports proceeding with sacrocolpopexy after uncomplicated, intraoperative bladder or small bowel injuries. There is insufficient or conflicting data on hysterectomy (total or subtotal) or uterus preservation during sacrocolpopexy (Grade D). Sacrocolpopexy remains an excellent option for vaginal apical prolapse repair. The issue of uterine preservation or excision during the procedure requires further clarification. Variations exist in the performance of most technical aspects of the procedure.