Treatment of lower urinary tract symptoms/benign prostatic hyperplasia and erectile dysfunction

Efficacy and Safety of 12-week Monotherapy With Once Daily 5 mg Tadalafil for Lower Urinary Tract Symptoms of Benign Prostatic Hyperplasia: Evidence-based Analysis

Background: Tadalafil has been approved for the treatment of benign prostatic hyperplasia (BPH) for nearly 10 years. However, there are insufficient evidence-based studies of the efficacy and safety of tadalafil in treating lower urinary tract symptoms of BPH (LUTS/BPH). Objective: To evaluate the therapeutic effect and clinical safety of tadalafil monotherapy (5 mg once daily for 12 weeks) for LUTS/BPH. Methods: A total of 13 studies (15 randomized clinical trials [RCTs]) were extracted from the following databases: PubMed, Cochrane Central Register of Controlled Trials, Embase, and Web of Science for the period up to July 2021. The quality of the included RCTs was evaluated independently by two authors, who, respectively, extracted data according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses principles. Conflicts were settled by a discussion with two-third of senior authors. All data analyses were conducted by the Review Manager, version 5.4. Results: Regarding efficacy, 12-week trials indicated that 5 mg once daily tadalafil showed a significantly lower and, consequently, better total International Prostate Symptom Score (IPSS) than the placebo did (mean difference [MD]: -1.97, 95% CI: -2.24 to -1.70; P < 0.00001). In addition, significant differences were found between the tadalafil regimen and the placebo in the IPSS voiding subscore (MD: -1.30, 95% CI: -1.48 to -1.11; P < 0.00001), the IPSS storage subscore (MD: -0.70, 95% CI: -0.82 to -0.58; P < 0.00001), the IPSS quality of life (MD: -0.29, 95% CI: -0.35 to -0.22; P < 0.00001), and BPH impact index (MD: -0.58, 95% CI: -0.76 to -0.40; P < 0.00001). The safety analysis did not show a significant difference in serious adverse events between the two groups (risk ratio: 1.27, 95% CI: 0.80-2.01; P = 0.31), although the adverse events occurred at a higher incidence in the tadalafil group than in the placebo. Conclusions: This study demonstrates that once daily 5 mg tadalafil is a potentially effective and safe treatment choice with excellent tolerability for patients with LUTS/BPH. Systematic Review Registration: Identifier (CRD42021228840).

Differences in Penile Hemodynamic Profiles in Patients with Erectile Dysfunction and Anxiety

Background: Penile echo-color Doppler ultrasound (PCDU) is the gold standard for the diagnosis of arterial erectile dysfunction (ED). Its reliability in patients with anxiety was questioned, due to false-positive results. Aim: To assess the penile hemodynamic response to intracavernous injection (ICI) of alprostadil in patients with anxiety-related ED. Methods: Patients with non-organic ED and a 5-item International Index of Erectile Function (IIEF-5) score ranging between 5 and 7 were enrolled. They were asked to compile the 7-item Generalized Anxiety Disorder (GAD-7) questionnaire to assess the degree of anxiety and were divided according to the GAD-7 score in Group 1 with minimal level of anxiety (n = 20), Group 2 with mild anxiety (n = 20), Group 3 with moderate anxiety (n = 20), and Group 4 with severe anxiety (n = 20). Peak systolic velocity (PSV) and the end-diastolic velocity (EDV) were sampled in all patients, through PCDU in the flaccid state, and 5, 10, 15, and 20 min after ICI of alprostadil at the standard dose of 10 μg. Results: In penile flaccidity, the patients showed a mean PSV of 8.0 ± 4.0 cm/s. The degree of anxiety was found to significantly influence both PSV and EDV at all assessed time-points. Particularly, it was negatively associated with the PSV at time 5 (r = −0.9, p < 0.01), 10 (r = −0.9, p < 0.01), 15 (r = −0.9, p < 0.01), and 20 (r = −0.7, p < 0.01) minutes, and positively with the EDV at time 5 (r = 0.7, p < 0.01), 10 (r = 0.6, p < 0.01), 15 (r = 0.5, p < 0.01), and 20 (r = 0.3, p < 0.01) minutes. Although all patients showed a mean dynamic PSV > 25 cm/s (which excluded an arterial ED according to the current guidelines), a peculiar hemodynamic pattern was found in patients with severe anxiety. In these patients, normal PSV values were reached only after 20 min from ICI, suggesting a “late-responder” profile. Conclusion: If further studies confirm the existence of a distinct hemodynamic profile in patients with severe anxiety, sampling the PSV and the EDV values could be proposed, for detecting patients with severe anxiety-related ED. Dynamic PCDU could be considered an accurate diagnostic test in patients with non-organic ED, since zero false-positive results were found in the present study. PSV in the flaccid state is not able to discriminate between arterial- or non-organic ED.

Sociodemographic factors that affect the real treatment rate among patients diagnosed with benign prostatic hyperplasia

BACKGROUND

Real treatment rate among patients diagnosed with benign prostatic hyperplasia (BPH/LUTS) and also its association with sociodemographic factor (SDF) have not been extensively investigated.

METHODS

Data were obtained from the 2006, 2008, 2010, 2012, 2014, and 2016 waves of the Korean Longitudinal Study of Aging (KLoSA). Among 10,254 individuals at the first baseline survey in 2006, a total of 4383 participants were ultimately included for final analysis. For statistical analysis, chi-square tests and generalized estimating equation regression models were conducted.

RESULTS

The prevalence rate of BPH/LUTS was 6.1% (266/4383) and real treatment rate was 58.3 percent (155/266). After adjusting for all confounders, odds ratio (OR) for the treatment of prostate disease in patients ages 55-64 and 65 years or more was 1.884 times higher (95% CI 1.096-3.237; p = .022) and 2.989 times higher (95% CI 1.755-5.091; p < .0001) than patients ages under 55, respectively. The OR for treatment of prostate disease in those residing in urban areas was 0.756 times lower (95% CI 0.573-0.998; p = .048) than those residing in metropolitan areas. The OR for treatment of prostate disease in those with bad self-rated health was 1.886 times higher (95% CI 1.461-2.436; p < .0001), compared to those with good self-rated health.

CONCLUSION

The real treatment rate among patients diagnosed with BPH/LUTS was 58.3%, a larger treatment rate than earlier reports. However, there are still a large proportion of patients who do not seek treatment; and age, residential area, and self-rated health were all found to be associated with real treatment rate.

Effect of udenafil administration on postmicturition dribbling in men: a prospective, multicenter, double-blind, placebo-controlled, randomized clinical study

PURPOSE

Postmicturition dribbling (PMD) is a stressful symptom in middle-aged men characterized by urinary leakage after the completion of normal voiding. Appropriate treatments have not yet been introduced. This study assessed the efficacy of treatment of PMD with 75 mg udenafil daily.

MATERIALS AND METHODS

The study included 138 men with regular sexual lifestyles. The Hallym PMD questionnaire (HPMDQ) was used to assess PMD symptoms. After all basic examinations, patients were randomly assigned to either udenafil or placebo. Patients completed the surveys, uroflowmetry (UFM), a bladder scan, and the paper test during the follow-up visit.

RESULTS

The mean age of the patients was 57.6 years. PMD with one of every three urinations was experienced by 59 patients (42.8%), whereas 45 patients (32.6%) experienced PMD with two of every three urinations. PMD with every urination was experienced by 34 patients (24.6%). More than half of the patients (89 patients, 65.4%) indicated that persistent PMD symptoms would likely result in moderate to severe discomfort in their daily activities. As time passed, the udenafil group showed significant improvement in PMD symptoms (p = 0.001).

CONCLUSION

Udenafil 75 mg once daily can be an effective treatment for patients with PMD symptoms.

Pharmacological treatment and inappropriate prescriptions for patients with erectile dysfunction

Background Erectile dysfunction is associated with old age, some morbidities and the use of certain medications. Objective To identify the treatments and drugs related to worsening sexual activity in patients with erectile dysfunction. Setting Patients diagnosed with erectile dysfunction during 2018. Methods This cross-sectional study of a population database identified all drug prescriptions of patients with erectile dysfunction during 2018. Main outcome measure The identification of other comorbidities and potentially inappropriate drugs that could worsen erectile dysfunction. Results A total of 2999 patients with erectile dysfunction (mean age 59.6 ± 12.1 years) were identified. A total of 88.2% received pharmacological treatment for erectile dysfunction, mainly tadalafil (70.5%). A total of 47.6% of all patients received at least one medication associated with worsening erectile dysfunction, especially hydrochlorothiazide (17.0%), metoprolol (7.9%) and sertraline (6.7%). Residing in Cali (OR 1.86; 95% CI 1.52-22.27) or Bucaramanga (OR 2.23; 95% CI 1.39-33.58), having 3 or more chronic comorbidities (OR 1.52; 95% CI 1.04-2.24) and presenting psychiatric (OR 5.5; 95% CI 3.70-8.17), cardiovascular (OR 3.48; 95% CI 2.79-4.33), genitourinary (OR 1.31; 95% CI 1.05-1.64) pathologies or chronic kidney failure (OR 1.84; 95% CI 1.18-2.21) elevated the probability of receiving these prescriptions. Conclusions The pharmacological treatment of erectile dysfunction was in accordance with the recommendations of clinical practice guidelines, but the high proportion of potentially inappropriate prescriptions makes it necessary to promote educational and pharmacovigilance strategies that improve the prescription habits of physicians involved in caring for this group of patients.

Radial Extracorporeal Shock Wave Therapy as a Novel Agent for Benign Prostatic Hyperplasia Refractory to Current Medical Therapy

This study aimed to assess efficacy and safety data from pilot trials of the radial extracorporeal shock wave therapy (rESWT) to treat benign prostatic hyperplasia (BPH) refractory to current medical therapy. A total of 29 men with lower urinary tract symptoms (LUTS) suggestive of BPH who had responded poorly to medical therapy for at least 6 months and were poor surgical candidates were enrolled. Each participant was treated with rESWT once a week for 8 weeks, each by 2000 impulses at 2.0 bar and 10 hertz of frequency. International Prostate Symptom Score (IPSS), quality of life (QoL), and International Index of Erectile Function-5 (IIEF-5) were evaluated before treatment, after the fourth and eighth rESWT, and 3 months after the end of treatment. Peak urinary flow ( Q_max) and postvoid residual (PVR) were assessed. Safety was also documented. Statistically significant clinical improvements were reported for IPSS, QoL, and IIEF-5 after treatment, and those were sustained until 3 months follow-up. Q_max and PVR improved evidently at 8 weeks with a 63% and 70% improvement, respectively. The only adverse event was the occasional perineum pain or discomfort, which usually disappeared within 3 days. The rESWT may be an effective, safe, and noninvasive treatment for symptomatic BPH in selected patients whose medical treatment has faced failure and are poor surgical candidates.

Phosphodiesterase-5 inhibitors: Shedding new light on the darkness of depression?

BACKGROUND

Phosphodiesterase-5 inhibitors (PDE5Is) are used to treat erectile dysfunction (ED). Recently, the antidepressant-like effect of PDE5Is was demonstrated in animal models of depression. In clinical settings, PDE5Is were studied only for ED associated depression. Hence, there are no studies evaluating the effects of PDE5Is for the treatment of major depressive disorder (MDD) without ED. In this review article, we aimed to discuss the use of PDE5Is in the context of MDD, highlighting the roles of PDE genes in the development of MDD, the potential mechanisms by which PDE5Is can be beneficial for MDD and the potentials and limitations of PDE5Is repurposing to treat MDD.

METHODS

We used PubMed (MEDLINE) database to collect the studies cited in this review. Papers written in English language regardless the year of publication were selected.

RESULTS

A few preclinical studies support the antidepressant-like activity of PDE5Is. Clinical studies in men with ED and depression suggest that PDE5Is improve depressive symptoms. No clinical studies were conducted in subjects suffering from depression without ED. Antidepressant effect of PDE5Is may be explained by multiple mechanisms including inhibition of brain inflammation and modulation of neuroplasticity.

LIMITATIONS

The low number of preclinical and absence of clinical studies to support the antidepressant effect of PDE5Is.

CONCLUSIONS

No clinical trial was conducted to date evaluating PDE5Is in depressed patients without ED. PDE5Is' anti-inflammatory and neuroplasticity mechanisms may justify the potential antidepressant effect of these drugs. Despite this, clinical trials evaluating their efficacy in depressed patients need to be conducted.

Systemic effects of the hormonal treatment of male hypogonadism with preliminary indications for the management of COVID-19 patients

Male hypogonadism, defined as an inadequate production of testosterone (T), is associated with a greater morbidity and mortality. Epidemiological studies identified T deficiency as a risk factor for cardiovascular disease. Also, low serum T levels impact on glucose homeostasis through a worse glucose uptake, utilization, and disposal, and the general negative impact on metabolism. The aim of this review is to provide a comprehensive and updated overview of the effects of T replacement therapy on metabolic and cardiovascular systems and prostate tissue in patients with hypogonadism, including molecular mechanisms through which T exerts its actions. Furthermore, recent findings on novel coronavirus disease (COVID-19) epidemiology have shown a greater mortality in male compared with female patients and a role of T in promoting the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection of the host cells has been demonstrated. Hence, the secondary aim of this review is to provide preliminary indications on the management in patients with COVID-19.