The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine

Erectile Dysfunction and Oxidative Stress: A Narrative Review

Erectile dysfunction (ED) is a prevalent condition affecting male sexual health, characterized by the inability to achieve or maintain satisfactory erections. ED has a multifactorial pathogenesis in which psychological, hormonal, neurologic, cardiovascular, and lifestyle factors all contribute to a progressive decline of erectile function. A critical underlying mechanism involves oxidative stress (OS), an imbalance between reactive oxygen species (ROS) production and antioxidant defenses, which disrupts endothelial function, reduces nitric oxide (NO) bioavailability, and contributes to vascular dysfunction. This narrative review explores the interplay between OS and ED, focusing on the roles of ROS sources such as NADPH oxidase, xanthine oxidase, uncoupled nitric oxide synthase, and mitochondrial dysfunction. It examines the impact of OS on chronic conditions like hypertension, diabetes mellitus, hyperlipidemia, hypogonadism, and lifestyle factors like smoking and obesity, which exacerbate ED through endothelial and systemic effects. Emerging research underscores the potential of antioxidant therapies and lifestyle interventions to restore redox balance, improve endothelial function, and mitigate ED's progression. This review also highlights gaps in understanding the molecular pathways linking ROS to ED, emphasizing the need for further research to develop targeted therapeutic strategies.

Future perspectives for PDE5 inhibitors bridging the gap between cardiovascular health and psychological status

The serendipitous discovery that inhibiting type 5 phosphodiesterase (PDE5) using sildenafil, a potent PDE5 inhibitor (PDE5i) initially developed for cardioprotection, introduced the possibility of orally managing erectile dysfunction (ED) led to an increase in research data, which are currently considered groundbreaking for the new discipline of sexual medicine. Findings from a number of laboratories and clinics around the world unanimously demonstrated the following: (i) the major cause of ED is directly or indirectly related to cardiovascular disease (CVD); (ii) ED and CVDs share the same risk factors, which are related mainly to lifestyle choices; (iii) the first therapeutic approach to both ED and CVDs is to transform harmful lifestyles into virtuous lifestyles; and (iv) PDE5is in general, particularly sildenafil, are very safe, if not protective, for use in CVD patients. However, the use of PDE5is has faced several challenges. Many patients and some healthcare providers (HCPs) often share the misconception that using these drugs can increase the risk of CVD. Some patients might desire to fulfill the unmet need for privacy linked to the stigma of being treated for ED or might be enticed by the idea of buying drugs online, either because of shame or cheaper prices, without knowing the risks associated with counterfeit drugs. The aim of this narrative revision of the current literature is to demonstrate that (i) the orodispersible film of sildenafil is safe from a CV perspective; (ii) it is a discreet formulation that respects the need for privacy; and (iii) it is virtually the unique PDE5i formulation too expensive to produce outside the correct channels, making it impossible to be counterfeit.

Efficacy and safety of PDE5 inhibitors in middle-aged and old patients with and without hypogonadism

PURPOSE

Although several reviews have evaluated the use of PDE5 inhibitors (PDE5i) for treating erectile dysfunction (ED), their specific use in middle-aged and old patients has not been fully evaluated. Given that elderly patients with ED often have a complex combination of systemic and sexual health risk factors, the safety and efficacy of PDE5i in such a context are hereby reviewed.

MATERIALS AND METHODS

A thorough examination of existing literature has been conducted on PubMed.

RESULTS

PDE5i has good safety and efficacy, but the situation is more complex for patients with hypogonadism than those with normal testosterone levels, with reduced responsiveness to PDE5i. In this case, combination therapy with testosterone is recommended, safe and effective.

CONCLUSIONS

Eliminating or reducing reversible risk factors and controlling or slowing the development of irreversible factors is an important foundation for using PDE5i to treat ED in all patients, especially middle-aged and elderly ones.

The Impact of Vaginoplasty on Female and Male Sexual Function and Satisfaction

BACKGROUND

The association of vaginal laxity with female sexual function is clinically significant. Male sexual pleasure can also be affected by vaginal laxity.

OBJECTIVES

The aim of this study was to investigate the effect of vaginoplasty on a cohort of women who underwent this procedure for indications of vaginal laxity/impaired sexual function. The sexual satisfaction of partners after vaginal tightening was also evaluated.

METHODS

Fifty women who underwent vaginoplasty and their male partners (n = 50) were included in the study. The State-Trait Anxiety Inventory (STAI) and the Female Sexual Function Index (FSFI) were administered to female patients 3 months before and after the treatment. In addition, the sexual function of male partners was assessed by the International Index of Erectile Function-5 (IIEF-5) 3 months before and after the treatment. A 5-question questionnaire inquiring about pleasure status, scored on a 4-point Likert scale, was administered to the male partners.

RESULTS

The posttreatment STAI-State and STAI-Trait scores of the female patients were statistically significantly lower than their pretreatment scores (52.5 vs 32, P < .001; 56 vs 44, P < .001, respectively). The posttreatment FSFI score of the female patients was significantly higher than their pretreatment score (19.2 vs 29.7, P < .001).

CONCLUSIONS

The results demonstrated a significant improvement in the sexual function of males and females, and additionally, a significant decrease in the indices of temporary anxiety levels and the inherent predisposition for anxiety disorders after vaginoplasty.

LEVEL OF EVIDENCE: 4

Association between COVID-19 and sexual health: an umbrella review

PURPOSE

We conducted this umbrella review to review the current evidence on the relationship between COVID-19 and sexual health in both men and women.

METHODS

We conducted searches in Pubmed, Embase, and the Cochrane dataset for meta-analyses that met our pre-set inclusion criteria. We included studies with detailed information investigating the link between COVID-19 and sexual health in men/women. We did not limit the language.

RESULTS

The results of the included studies frequently relied on the Female Sexual Function Index to assess sexual health in women. For men, the International Index of Male Function and hospital diagnoses were commonly used to assess sexual health. Currently, there is conflicting evidence regarding the impact of COVID-19 on sexual health. However, since most studies were observational in nature, additional study designs are necessary to draw definitive conclusions across different contexts.

CONCLUSION

Our findings highlight the importance of sexual health among COVID-19 patients and people affected due to COVID-19. Further critical studies should investigate the mechanism underlying the association between COVID-19 and sexual health.

Unconsummated marriage among Chinese couples: a retrospective study

Background

Unconsummated marriage (UCM) is a significant problem among couples who are unable to achieve successful sexual intercourse and penovaginal penetration, and the etiology and clinical characteristics of UCM in Chinese couples remain unknown.

Aim

In a retrospective analysis of patients with UCM, we investigated clinical characteristics and treatment outcomes among Chinese couples with UCM.

Methods

During the period from January 2019 to May 2021, we examined 127 consecutive couples with unconsummated marriage. The couples were evaluated separately by andrologists and gynecologists, and combined treatments were conducted by therapists.

Outcomes

We calculated the distribution of etiologies of UCM in Chinese couples.

Results

Among the couples whose data were evaluated, 93 couples visited the andrologist first and 34 couples visited the gynecologist first. The most common complaints associated with sexual dysfunction were erectile dysfunction (ED) in male patients and vaginismus and dyspareunia in female patients. Unconsummated marriage among Chinese couples was caused primarily by female factors (55.8%). With couple-oriented treatment conducted by sexual therapists, the success rate was 67.7%.

Clinical Translation

If a couple is diagnosed with UCM, both the husband and wife should be treated individually receive guidance from a sex therapist toward successful sexual intercourse.

Strengths and Limitations

This is to our knowledge the first report regarding the etiology of UCM in Chinese couples. Here we report our routine diagnostic and therapeutic workups. However, we were not able to perform hormonal and imaging studies of the female partners. Moreover, patients presenting with UCM who visited our department without a partner were not included in the statistics.

Conclusions

Unconsummated marriage among Chinese couples may be caused byfactors affecting both the husband and wife or the husband and wife individually; however, factors affecting women are the predominant causes of UCM. Lack of knowledge about sex-related issues, as well as cultural beliefs, play an important role. A preliminary evaluation by an andrologist and a gynecologist, followed by couple treatment conducted by the sex therapist, is highly `recommended to treat UCM effectively.

The Sexual Long COVID (SLC): Erectile Dysfunction as a Biomarker of Systemic Complications for COVID-19 Long Haulers

Introduction

Long term complications of COVID-19, the disease caused by the SARS-CoV-2, involve many organ systems, dramatically worsening the quality of life, and finally contributing to impaired physical functioning. Despite the presence of well-identified pathogenetic mechanisms, the effect of “Long COVID” on sexual health has been only marginally addressed.

Objectives

To provide coverage of the current literature on long COVID, its epidemiology, pathophysiology, and relevance for erectile function. Methods. Comprehensive review of literature pertaining to the epidemiology and pathophysiology of long COVID, and its relevance for erectile function.

Results

Symptoms of long COVID are highly prevalent and involve almost all systems of the human body, with a plethora of clinical manifestations which range from minor nuisances to life-threatening conditions. “Brain fog” and fatigue are the most common complaints, although other neuropsychiatric complications, including sensory dysfunctions, anxiety, depression, and cerebrovascular events have also been reported. The respiratory and cardiovascular systems are also affected, with dyspnea, pulmonary fibrosis, endothelial dysfunction, and myocarditis occurring in some COVID long haulers. A subset of patients might develop endocrine manifestations, including onset of diabetes, thyroid dysfunction, and hypogonadism. Overall, long COVID features many complications which can impair erectile function by multiple pathogenetic mechanisms, and which could require tailored treatment: (i) careful investigation and management from the sexual medicine expert are therefore much needed, (ii) and future research on this topic is warranted.

Conclusion

in COVID-19 long haulers, several complications can adversely affect erectile function which, upon future tailored studies, could be used as biomarker for the severity of the long COVID disease and for its follow-up.

Sansone A, Mollaioli D, Limoncin E et al. The Sexual Long COVID (SLC): Erectile Dysfunction as a Biomarker of Systemic Complications for COVID-19 Long Haulers. Sex Med Rev 2022;10:271–285.