The Association between Varicocele, Premature Ejaculation and Prostatitis Symptoms: Possible Mechanisms

The effects of microsurgical varicocelectomy performed for infertility on premature ejaculation

PURPOSE

To investigate the effects of varicocelectomy on premature ejaculation (PE) in patients with varicocele and infertility.

METHODS

A total of 82 sexually active patients aged 18 years or over who had undergone microscopic subinguinal varicocelectomy with a clinical diagnosis of varicocele in 14 urology clinics between October 2021 and March 2023 with primary infertility were evaluated prospectively Patients were evaluated using the Turkish validated form of the 'Premature Ejaculation Diagnostic Tool' (PEDT) scale. A PEDT score of 11 or above was taken to indicate the presence of PE. Turkish validated forms of PEDT and International Index of Erectile Function-5 (IIEF-5) were completed in all patients pre-operatively and at 3 and 6 months post-operatively. Intravaginal ejaculatory latency time (IELT) and serum testosterone measurements were also recorded.

RESULTS

Left varicocelectomy was performed in 70.7% and bilateral varicocelectomy in 29.3% of the participants. A significant difference was found between pre- and post-operative PEDT scores (× 2 (2) = 130.1, p < 0.001). A significant difference was observed between pre- and post-operative IELT time (× 2 (2) = 143.2, p < 0.001). IIEF-5 scores differed before and after surgery (× 2 (2) = 59.5, p < 0.001). A difference was found between the testosterone levels measured before and after surgery (× 2 (2) = 40.9, p < 0.001). No statistically significant difference was observed between the third- and sixth-month testosterone values (p = 0.183). Testosterone levels (p = 0.001) and IELT scores (p < 0.001) were significantly higher, while PEDT scores (p < 0.001) were significantly lower in the bilateral varicocelectomy group at the sixth post-operative month.

CONCLUSION

In light of our findings, it is recommended that infertile patients with varicocele be informed of the positive effects of varicocelectomy on PE.

Varicocele and Interventional Radiology: A Comprehensive Case Study on Diagnosis, Therapeutic Intervention, and Implications for Reproductive Health

Male infertility is known to be influenced by varicocele, a common vascular aberration marked by aberrant dilatation of the pampiniform plexus veins within the scrotum. In this instance, a 38-year-old man showed up with scrotal discomfort and swelling, which are clinical signs of varicocele. Scrotal ultrasonography provided diagnostic confirmation, confirming the existence of varicocele and identifying a concomitant minor hemorrhage in the left scrotal sac. Despite the initiation of conservative measures, such as bed rest, cryotherapy, and analgesics, the patient's clinical course was marked by persistent scrotal swelling and hematoma formation. Subsequently, interventional radiological techniques were employed, specifically coil deployment and varicocele embolization. These interventions demonstrated significant efficacy, leading to a notable reduction in the presenting symptoms. Follow-up assessments, conducted post intervention, indicated a complete resolution of both pain and hematoma. This clinical trajectory underscores the pivotal role of interventional radiology in managing varicocele-related complications. The multi-faceted nature of this case highlights the necessity of a comprehensive, inter-disciplinary approach integrating radiological interventions for the effective management of varicocele-associated symptoms, potentially optimizing reproductive health outcomes.

Prostatitis: A Review

PURPOSE OF REVIEW

Pathologies of the prostate in men are one of the most prevalent clinical conditions today [1]. Specifically, pelvic inflammatory disease such as prostatitis can cause symptoms and syndromes different from urological ones, such as bowel or nervous system manifestations. This has a largely negative impact on the quality of life of patients. Therefore, it is convenient to know and update the information about the therapeutic approach to prostatitis, which is a challenge that involves different medical specialties. The aim of this article is to provide summarized and focused evidence to help in the therapeutic approach of patients with prostatitis. A computer-based search of the PubMed and Cochrane Library databases was used to perform a comprehensive literature review on prostatitis, with special interest in recent findings and latest therapeutic guideline recommendations.

RECENT FINDINGS

Recent discoveries about the epidemiology and clinical classifications of prostatitis seem to incur in an increasingly individualized and directed management, with the aim of covering all the confluent factors in prostatic inflammatory pathology. In addition, the role of new drugs and combination with phytotherapy open up a range of new treatment possibilities, although future randomized studies will be necessary to better understand how to use all treatment modalities. Despite all the knowledge acquired about the pathophysiology of prostate diseases, and due to their interrelation with other pelvic systems and organs, there are still gaps that make it difficult for us to provide an optimal and standardized treatment in many of our patients. Being aware of the influence of all the factors potentially involved in prostate symptoms is crucial for a correct diagnosis and establishing an effective treatment plan.

Microbiology and immune mechanisms associated with male infertility

Up to 50% of infertility is caused by the male side. Varicocele, orchitis, prostatitis, oligospermia, asthenospermia, and azoospermia are common causes of impaired male reproductive function and male infertility. In recent years, more and more studies have shown that microorganisms play an increasingly important role in the occurrence of these diseases. This review will discuss the microbiological changes associated with male infertility from the perspective of etiology, and how microorganisms affect the normal function of the male reproductive system through immune mechanisms. Linking male infertility with microbiome and immunomics can help us recognize the immune response under different disease states, providing more targeted immune target therapy for these diseases, and even the possibility of combined immunotherapy and microbial therapy for male infertility.

Changes in testicular arterial hemodynamic, gonadotropin levels, and semen parameters among varicocele patients randomized to varicocelectomy or observed in Tamale, Ghana

Objective:

A randomized trial to compared testicular blood flow parameters, gonadal hormones, and semen characteristics among three groups; surgery group ( n = 127); observed group ( n = 114); and healthy controls ( n = 33).

Methods:

The blood flow parameter selected was resistive index (RI) measured using color Doppler ultrasonography. Serum total testosterone, FSH, LH were measured, and semen analysis performed at baseline and repeated 12 months of follow-up. The data was computed using GraphPad Prism (v8.0) at an alpha of 0.05.

Results:

In the observed group, increased +0.0060 in the right (R_RI) and in the left (L_RI) +0.0026 capsular arteries from baseline measurement to 12 months follow-up. Surgery group, reduced –0.079 in the right (R_RI) and −0.0731 in the left (L_RI) capsular arteries ( p < 0.0001). At 12 months, the changes for both left and right RIcap in the surgery group did not reach the values of the controls. In the surgery group, L_RIcap ( r = −0.63; p < 0.0001) and R_RIcap ( r = −0.49; p = 0.004) correlated with total testosterone, FSH ( r = 0.57; p = 0.001 for left; r = 0.52; p = 0.002 for right), and LH ( r = 0.61; p = 0.0002 for left; r = 0.41; p = 0.020 for right). Furthermore, L_RIcap correlated with changes in sperm count ( r = −0.46; p = 0.008) and sperm concentration ( r = −0.35; p = 0.011) in the surgery group.

Conclusion:

Microsurgical sub-inguinal varicocelectomy improves blood supply to the testicular tissues evidenced by reduced resistive index in the surgery group. Resistive index in the left capsular artery can be used to evaluate the success of surgery because it correlates with total testosterone, FSH, LH, and semen quality.

The European Academy of Andrology (EAA) ultrasound study on healthy, fertile men: Prostate-vesicular transrectal ultrasound reference ranges and associations with clinical, seminal and biochemical characteristics

Background

Transrectal ultrasound (TRUS) parameters are not standardized, especially in men of reproductive age. Hence, the European Academy of Andrology (EAA) promoted a multicenter study to assess the TRUS characteristics of healthy‐fertile men (HFM) to establish normative parameters.

Objectives

To report and discuss the prostate and seminal vesicles (SV) reference ranges and characteristics in HFM and their associations with clinical, seminal, biochemical parameters.

Methods

188 men (35.6 ± 6.0 years) from a cohort of 248 HFM were studied, evaluating, on the same day, clinical, biochemical, seminal, TRUS parameters following Standard Operating Procedures.

Results

TRUS reference ranges and characteristics of the prostate and SV of HFM are reported herein. The mean PV was ∼25 ml. PV lower and upper limits were 15 and 35 ml, defining prostate hypotrophy and enlargement, respectively. PV was positively associated with age, waistline, current smoking (but not with T levels), seminal volume (and negatively with seminal pH), prostate inhomogeneity, macrocalcifications, calcification size and prostate arterial parameters, SV volume before and after ejaculation, deferential and epididymal size. Prostate calcifications and inhomogeneity were frequent, while midline prostatic cysts were rare and small. Ejaculatory duct abnormalities were absent. Periprostatic venous plexus size was positively associated with prostate calcifications, SV volume and arterial peak systolic velocity. Lower and upper limits of SV anterior‐posterior diameter after ejaculation were 6 and 16 mm, defining SV hypotrophy or dilation, respectively. SV total volume before ejaculation and delta SV total volume (DSTV) positively correlated with ejaculate volume, and DSTV correlated positively with sperm progressive motility. SV total volume after ejaculation was associated negatively with SV ejection fraction and positively with distal ampullas size. SV US abnormalities were rare. No association between TRUS and time to pregnancy, number of children or history of miscarriage was observed.

Conclusions

The present findings will help in better understanding male infertility pathophysiology and the meaning of specific TRUS findings.

Neurons for Ejaculation and Factors Affecting Ejaculation

Ejaculation is a reflex and the last stage of intercourse in male mammals. It consists of two coordinated phases, emission and expulsion. The emission phase consists of secretions from the vas deferens, seminal vesicle, prostate, and Cowper's gland. Once these contents reach the posterior urethra, movement of the contents becomes inevitable, followed by the expulsion phase. The urogenital organs are synchronized during this complete event. The L3-L4 (lumbar) segment, the spinal cord region responsible for ejaculation, nerve cell bodies, also called lumbar spinothalamic (LSt) cells, which are denoted as spinal ejaculation generators or lumbar spinothalamic cells [Lst]. Lst cells activation causes ejaculation. These Lst cells coordinate with [autonomic] parasympathetic and sympathetic assistance in ejaculation. The presence of a spinal ejaculatory generator has recently been confirmed in humans. Different types of ejaculatory dysfunction in humans include premature ejaculation (PE), retrograde ejaculation (RE), delayed ejaculation (DE), and anejaculation (AE). The most common form of ejaculatory dysfunction studied is premature ejaculation. The least common forms of ejaculation studied are delayed ejaculation and anejaculation. Despite the confirmation of Lst in humans, there is insufficient research on animals mimicking human ejaculatory dysfunction.

Short- and long-term follow-up results of daily 5-mg tadalafil as a treatment for erectile dysfunction and premature ejaculation

Objective

To evaluate the safety and effectiveness of daily 5-mg tadalafil treatment for men who have erectile dysfunction (ED) and premature ejaculation (PE), and to assess the long-term follow-up for ED and PE improvement persistence years after the cessation of medication.

Patients and Methods

A prospective, single-blind, randomised study included 160 patients with ED and PE. All were evaluated using the International Index of Erectile Function (IIEF-5) questionnaire to evaluate ED and intravaginal ejaculatory latency time (IELT) for PE. Patients were subdivided into two equal groups. Group I (80 patients) treated with daily 5-mg tadalafil for 3 months, and Group II (80 patients) treated with a placebo for the same period. After 3 months of treatment and 2 years later after cessation of tadalafil, all patients were assessed for ED and PE.

Results

The mean (SD) IELT and IIEF-5 score pre-treatment were 37 (11.24) s and 13.2 (4.2) for Group I, while in Group II they were 35.98 (10.8) s and 13.12 (4.11), respectively. After 3 months of treatment, the mean (SD) IELT in Group I showed a highly significant improvement from 37 (11.24) s to 120.5 (47.37) s (P < 0.001) but Group II showed no significant improvement from baseline to [39.43 (13.6) s; P > 0.05]. For the IIEF-5 score, there was a highly significant improvement from baseline to 20.45 (4.5) in Group I (P < 0.001), while there was no significant difference in Group II from baseline to [15 (4.84); P > 0.05]. At 2 years after cessation of tadalafil, there was statistically significant improvement in the IELT and IIEF-5 from baseline to endpoint .

Conclusion

Oral daily 5-mg tadalafil was effective, tolerable, and safe treatment for patients with ED and PE. Long-term follow-up at 2 years confirmed the persistence of a significant improvement for both ED and PE.

Abbreviations: ED: erectile dysfunction; IIEF-5: five-item version of the International Index of Erectile Function questionnaire; IELT: intravaginal ejaculatory latency time; OAD: once-daily; PDE5i: phosphodiesterase-5 inhibitors; PE: premature ejaculation; PRN: pro re nata

An update on the treatment of premature ejaculation: A systematic review

To analyse the current therapeutic options for patients with premature ejaculation (PE) and highlight their mechanism(s) of action, effectiveness, advantages and limitations. A literature search was conducted using the PubMed database searching for articles exploring different PE treatment modalities. A Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) approach was used to report the results of the literature search. A total of 149 articles were included in this review. The currently available treatment methods for PE include behavioural therapy, local anaesthetics, tricyclic antidepressants, selective serotonin reuptake inhibitors, and selective phosphodiesterase inhibitors. Most PE treatments are either experimental or used off-label. New treatments are certainly warranted to overcome this exasperating sexual dysfunction.

Abbreviations: AIPE: Arabic Index of Premature Ejaculation; CNS: central nervous system; CYP: cytochrome P450; ED: erectile dysfunction; FDA: United States Food and Drug Administration; H1: histamine receptors; 5-HT: 5-hydroxytryptamine; IELT: The intravaginal ejaculation latency time; IPE: Index of Premature Ejaculation; M1: muscarinic receptors; OCD: obsessive–compulsive disorder; PDE5: phosphodiesterase type 5; PE: premature ejaculation; PEP: Premature Ejaculation Profile; PRO: patient-reported outcome; RCT: randomised controlled trial; SS: Severance Secret (cream); SSRIs: selective serotonin reuptake inhibitors; TCAs: tricyclic antidepressants

Varicocele-Mediated Male Infertility: From the Perspective of Testicular Immunity and Inflammation

Background

Varicocele (VC) is present in 35 - 40% of men with infertility. However, current surgical and antioxidant treatments are not completely effective. In addition to oxidative stress, it is likely that other factors such as testicular immune microenvironment disorder contribute to irreversible testicular. Evidence suggests that VC is associated with anti-sperm antibodies (ASAs), spermatogenesis and testosterone secretion abnormalities, and testicular cytokine production. Moreover, inhibition of inflammation can alleviate VC-mediated pathogenesis. The normal function of the testis depends on its immune tolerance mechanism. Testicular immune regulation is complex, and many infectious or non-infectious diseases may damage this precision system.

Results

The testicular immune microenvironment is composed of common immune cells and other cells involved in testicular immunity. The former includes testicular macrophages, T cells, dendritic cells (DCs), and mast cells, whereas the latter include Leydig cells and Sertoli cells (SCs). In animal models and in patients with VC, most studies have revealed an abnormal increase in the levels of ASAs and pro-inflammatory cytokines such as interleukin (IL)-1 and tumor necrosis factor (TNF)-alpha in the seminal plasma, testicular tissue, and even peripheral blood. It is also involved in the activation of potential inflammatory pathways, such as the nucleotide-binding oligomerization domain-like receptor family pyrin domain containing (NLRP)-3 pathway. Finally, the development of VC-mediated infertility (VMI) may be facilitated by abnormal permeability of proteins, such as claudin-11, that constitute the blood-testis barrier (BTB).

Conclusions

The testicular immune response, including the production of ASAs and inflammatory factors, activation of inflammatory pathways, and destruction of the BTB may be involved in the pathogenesis of VMI it is necessary to further explore how patient outcomes can be improved through immunotherapy.

Historical trends for the standards in scrotal ultrasonography: What was, what is and what will be normal

BACKGROUND

Ultrasonography is the gold standard imaging method for scrotal investigation. Colour Doppler ultrasonography, contrast-enhanced ultrasonography and sonoelastography allow sonographers to assess size, echotexture, vascular features and stiffness of the scrotal organs and abnormalities. Scrotal ultrasonography has been used to investigate male reproductive health, scrotal pain, masses and trauma. However, ultrasonography thresholds/classifications used to distinguish normal and pathologic features of the scrotal organs have changed over time, and have not yet been fully standardized.

OBJECTIVES

To evaluate historical trends for the standards in scrotal ultrasonography: what was, what is and what will be normal.

METHODS

An extensive Medline search was performed identifying the most relevant studies in the English language from inception to date.

RESULTS

We provide here (i) a brief overview of the history of ultrasonography, (ii) current indications for scrotal ultrasonography and (iii) previous and current normal values, cut-offs and classifications of the main colour-Doppler ultrasonography parameters/characteristics of the scrotal organs, as derived from recent guidelines and evidence-based studies. In addition, we report recommendations and the clinical utility of contrast-enhanced ultrasonography and sonoelastography. Finally, we discuss critical issues needing further evidence and future directions to fill in the current gaps.

DISCUSSION

Several studies on scrotal ultrasonography are available. However, guidelines/recommendations dealing with specific ultrasonography applications have been published only in recent years. More recently, the European Academy of Andrology published evidence-based scrotal colour-Doppler ultrasonography reference ranges/normative parameters derived from a cohort of healthy, fertile men. In addition, a standardization of the methodology to evaluate qualitative and quantitative colour-Doppler ultrasonography parameters was reported. Other international societies reported indications, methodological standards, clinical utility and limitations of contrast-enhanced ultrasonography and sonoelastography.

CONCLUSIONS

To date, colour-Doppler ultrasonography normative values for the scrotal organs are available. However, a wide international consensus on assessment and classification of several ultrasonography parameters is still lacking. An alignment of the world societies on these issues is advocated.

Male Sexual Dysfunctions in the Infertile Couple-Recommendations From the European Society of Sexual Medicine (ESSM)

INTRODUCTION

Sexual dysfunctions (SDs) have been frequently reported among male partners of infertile couples due to psychogenic, relational and/or organic issues related with the inability to conceive. Likewise, male infertility (MI) could be a consequence of sexual dysfunctions.

AIM

To review the evidence on the prevalence and treatment of male SDs in men of infertile couples and provide clinical recommendations on behalf of the European Society of Sexual Medicine (ESSM).

METHODS

The MEDLINE database was searched in September 2019 for randomized clinical trials (RCTs), meta-analyses and open-label prospective or retrospective studies investigating the presence of erectile dysfunction (ED) and/or ejaculatory dysfunctions (EjDs) and/or low sexual desire (LSD) in conjunction with infertility.

MAIN OUTCOME MEASURE

The panel provided statements on: (i) Prevalence and association between SDs and MI; (ii) Treatment of male SDs in men of infertile couples.

RESULTS

ED has been reported in 9% to 62% of male partners of infertile couples, with severe impairment observed in only 1% to 3% of ED cases. Moreover, worse semen parameters have been associated with greater ED severity. Phosphodiesterase type 5 inhibitors (PDE5is) can be safely used to treat ED among patients seeking fatherhood. Male partners of infertile couples are at higher risk of premature ejaculation (PE). Retrograde ejaculation (RE) and anejaculation are a cause of MI and can be managed with electroejaculation (EEJ) or penile vibratory stimulation (PVS) or, alternatively, with oral treatments, however the latter with limited documented success. Low sexual desire has been reported by one third of men of infertile couples.

CONCLUSION

ED could significantly affect male partners of infertile couple; PDE5is should be suggested to ensure an effective and satisfactory sexual relationship of the couple. Anejaculation and RE should be considered as a possible cause of MI and treated accordingly. Low sexual desire is frequently reported among men of infertile couple and could be a symptom of other systemic conditions or psychological distress. Capogrosso P, Jensen CFS, Rastrelli G, et al. Male Sexual Dysfunctions in the Infertile Couple-Recommendations From the European Society of Sexual Medicine (ESSM). J Sex Med 2021;9:100377.

Sperm DNA damage and cytokines in varicocele: A case-control study

Varicocele is a vascular disease characterised by the abnormal enlargement of the pampiniform plexus veins and a well-known cause of male infertility. The aim of this study was to investigate the relationship between sperm DNA fragmentation (SDF) and inflammation in the pathogenesis of varicocele. We included 84 varicocele patients and 85 normozoospermic healthy controls, further analysed according to the body mass index, the smoking habit (smokers/non-smokers) and the varicocele severity (low/high grade). Semen parameters, SDF (by TUNEL) and inflammatory cytokines (by Luminex xMAP analysis) were evaluated. Varicocele patients showed significantly reduced semen parameters (volume, total sperm number, progressive motility, normal morphology) and increased SDF. Moreover, we observed a significant reduction of IFN-γ, IL-6, TNF-α and an increase of IL-10. No difference was reported according to the smoking habit, body mass index and varicocele severity. The observed cytokines pathway suggests the establishment of a chronic inflammatory condition, which may contribute to the alteration of semen quality. A thorough knowledge of the cytokine network might contribute to better understanding the link between inflammation and semen quality in varicocele and its impact on reproductive health.

Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Disease or Symptom? Current Perspectives on Diagnosis, Treatment, and Prognosis

Definitive diagnosis and selection of effective treatment for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) are frustrations encountered frequently by urology care providers in their practice. Knowledge of etiology and pathophysiology is not sufficient and therapeutic guidelines have not yielded acceptable outcomes and prognoses for both patients and care providers. The authors present updated perspectives on CP/CPPS, including definition, diagnosis, treatment, and prognosis, based on literature review and clinical experience. A key point is to shift the diagnostic and therapeutic focus from a single entity of disease toward associated symptoms of CP/CPPS. An individualized multimodal treatment approach to cope with the course of the disorder is proposed. Communications and personal/family/community supports are emphasized as an important component in the therapeutic regime and rehabilitation of patients with CP/CPPS. The purpose is to improve comprehension on CP/CPPS and to help care providers and patients to achieve the goal of medical intervention-relieving associated symptoms of CP/CPPS and improving the quality of life.

The European Academy of Andrology (EAA) ultrasound study on healthy, fertile men: Scrotal ultrasound reference ranges and associations with clinical, seminal, and biochemical characteristics

BACKGROUND

Scrotal color Doppler ultrasound (CDUS) still suffers from lack of standardization. Hence, the European Academy of Andrology (EAA) has promoted a multicenter study to assess the CDUS characteristics of healthy fertile men (HFM) to obtain normative parameters.

OBJECTIVES

To report and discuss the scrotal organs CDUS reference ranges and characteristics in HFM and their associations with clinical, seminal, and biochemical parameters.

METHODS

A cohort of 248 HFM (35.3 ± 5.9years) was studied, evaluating, on the same day, clinical, biochemical, seminal, and scrotal CDUS following Standard Operating Procedures.

RESULTS

The CDUS reference range and characteristics of the scrotal organs of HFM are reported here. CDUS showed a higher accuracy than physical examination in detecting scrotal abnormalities. Prader orchidometer (PO)- and US-measured testicular volume (TV) were closely related. The US-assessed TV with the ellipsoid formula showed the best correlation with the PO-TV. The mean TV of HFM was ~ 17 ml. The lowest reference limit for right and left testis was 12 and 11 ml, thresholds defining testicular hypotrophy. The highest reference limit for epididymal head, tail, and vas deferens was 12, 6, and 4.5 mm, respectively. Mean TV was associated positively with sperm concentration and total count and negatively with gonadotropins levels and pulse pressure. Subjects with testicular inhomogeneity or calcifications showed lower sperm vitality and concentration, respectively, than the rest of the sample. Sperm normal morphology and progressive motility were positively associated with epididymal head size/vascularization and vas deferens size, respectively. Increased epididymis and vas deferens sizes were associated with MAR test positivity. Decreased epididymal tail homogeneity/vascularization were positively associated with waistline, which was negatively associated with intratesticular vascularization. CDUS varicocele was detected in 37.2% of men and was not associated with seminal or hormonal parameters. Scrotal CDUS parameters were not associated with time to pregnancy, number of children, history of miscarriage.

CONCLUSIONS

The present findings will help in better understanding male infertility pathophysiology, improving its management.

Premature ejaculation: an update on definition and pathophysiology

Premature ejaculation (PE) is the most common male sexual dysfunction, which represents a diagnostic as well as a therapeutic challenge for physicians. However, no universally accepted definition is currently available for PE. As a result, physicians continue to diagnose patients with PE according to major guidelines set by the professional societies. These guidelines either recommend the use of validated questionnaires or patient-reported outcomes. Recent efforts directed toward classifying PE may help provide a better understanding of the prevalence and risk factors of this disorder. While the exact etiology of PE has not been clearly elucidated, several risk factors have been strongly reported in the literature. Clearly, to understand the revised definition of PE, its etiology and pathophysiology is necessary to improve the clinical management of this medical condition and form the basis of future research in this regard. In this review, we highlight the past and current definitions of PE and present an appraisal on the classifications and theories suggested for the etiopathogenesis of PE.

Efficacy of microsurgical varicocelectomy in the treatment of premature ejaculation: A protocol for systematic review and meta-analysis

INTRODUCTION

Premature ejaculation (PE) is the most common type of sexual disorder among men which comprises a great of problems. Varicocele is defined as the dilation of the pampiniform venous plexus draining the testicle. At present, selective serotonin reuptake inhibitors antidepressants, topical anesthetics, tramadol, phosphodiesterase type 5 inhibitors are the common alternative strategy to improve PE. However, these therapeutic measures have several shortcomings and side effects. Recently, the correlation between varicocele and PE has attracted the attention of some researchers. A few studies consider microsurgical varicocelectomy can be a new remedy for PE. But it is still absent enough a great deal of convincing evidence. The study will assess the effectiveness and safety of the microsurgical varicocelectomy treatment in PE patients.

METHODS AND ANALYSIS

Electronic databases including English databases (PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library) and Chinese databases (China National Knowledge Infrastructure, China Biology Medicine Database, Wanfang Database, VIP Database) will be searched from their inception to December 2020 to recognize related studies. All the randomized controlled trials of microsurgical varicocelectomy for the management of PE patients will be included. The potential outcome will include intravaginal ejaculation latency time, Chinese index of sexual function for premature ejaculation-5, visual analogue score, premature ejaculation diagnostic tool, success treatment rate, serum testosterone levels. We will conduct this study strictly according to the Cochrane Handbook for systematic reviews of interventions.

RESULTS

The current study is a protocol for systematic review and meta-analysis without results, and data analysis will be carried out after the protocol. We will share our findings in the February 28, 2021.

CONCLUSION

This systematic review will provide more evidence to assess whether microsurgical varicocelectomy is an effective intervention for patients with PE. The results will be published in a public issue journal and offer the urologists and andrologists help to make clinical decisions.

ETHICS AND DISSEMINATION

Formal ethical approval is not required in this protocol. We will collect and analyze data based on published studies, and since there are no patients involved in this study, individual privacy will not be under concerns. The results of this review will be disseminated to peer-reviewed journals or submit to related conferences.

PROTOCOL REGISTRATION NUMBER

INPLASY202060058.

Left spermatic vein reflux after varicocele repair predicts pregnancies and live births in subfertile couples

PURPOSE

Varicocele repair (VR) is proposed to improve fertility in subfertile couples with a poor semen quality. We explored whether the disappearance of a left continuous spermatic venous reflux (SVR) at scrotal colour-Doppler ultrasound (CDUS), an objective evidence for a VR, is predictive for improved fertility outcome in subfertile couples.

METHODS

VR was performed by left internal spermatic vein sclero-embolisation in 88 males seeking a consultation for subfertility. Semen analysis and scrotal CDUS were evaluated before and 6 months after VR. Serum levels of FSH and total testosterone (TT) were obtained at baseline. Telephone interview was used to obtain information about fertility outcome. Significant predictors of pregnancy and live births, selected by univariate analyses, were included into multiple logistic regression models to assess independent associations.

RESULTS

At the adjusted model, independent significant predictors of pregnancy after VR were a disappeared SVR at CDUS (OR = 5.5, 97.5% CI 2.01-15.4; p = 0.0009) and an improved sperm total motile count (TMC) (OR = 5.5, 97.5% CI 1.4-27.9; p = 0.02). Even live births were independently associated with both disappeared left SVR at CDUS (OR = 4.3, 97.5% CI = 1.6-11.8; p = 0.003) and improved TMC after VR (OR = 4.8, 97.5% CI 1.3-24.2; p = 0.02).

CONCLUSION

The still controversial effect of varicocele repair on fertility in subfertile couples may reside on the undefined objective methods to document a successful VR and its effect on couple fertility. The disappearance of a continuous left SVR at CDUS after VR was the objective best predictor for subsequent improved fertility in subfertile couples.

Impact of varicocelectomy on urine dopamine value in patients with premature ejaculation and varicocele

Dopamine is an important regulator of male sexual function and behaviour. Decreased levels of this substance have been observed in blood and seminal plasma of infertile men. Hence, this study was carried out to determine the impact of varicocelectomy on 24-hr urine dopamine values in patients with both premature ejaculation (PE) and varicocele. In this prospective study, 55 consecutive patients with premature ejaculation and grade 2 or 3 varicocele were enrolled. The urine dopamine level was measured in a 24-hr sample by HPLC method in a single laboratory centre. Two samples were gathered from each patient, one before and the other 1 month after varicocelectomy. The mean initial and final 24-hr urine dopamine levels were 259.6 ± 86.3 and 602.9 ± 88.4 micrograms, respectively, showing statistically significant increase (p = .0001), while there was no statistically significant difference between urine volume and creatinine. However, the change in intravaginal ejaculation latency time value was not statistically significant at this short time visit. According to our findings, varicocelectomy results in a significant increase in 24-hr urine dopamine levels in patients with premature ejaculation and varicocele. However, the effect of this change on premature ejaculation in the long term has yet to be determined.

Sexual dysfunction and male infertility

Infertility affects up to 12% of all men, and sexual dysfunction occurs frequently in men of reproductive age, causing infertility in some instances. In infertile men, hypoactive sexual desire and lack of sexual satisfaction are the most prevalent types of sexual dysfunction, ranging from 8.9% to 68.7%. Erectile dysfunction and/or premature ejaculation, evaluated with validated tools, have a prevalence of one in six infertile men, and orgasmic dysfunction has a prevalence of one in ten infertile men. In addition, infertile men can experience a heavy psychological burden. Infertility and its associated psychological concerns can underlie sexual dysfunction. Furthermore, general health perturbations can lead to male infertility and/or sexual dysfunction. Erectile dysfunction and male infertility are considered proxies for general health, the former underlying cardiovascular disorders and the latter cancerous and noncancerous conditions. The concept that erectile dysfunction in infertile men might be an early marker of poor general health is emerging. Finally, medications used for general health problems can cause sperm abnormalities and sexual dysfunction. The treatment of some causes of male infertility might improve semen quality and reverse infertility-related sexual dysfunction. In infertile men, an investigation of sexual, general, and psychological health status is advisable to improve reproductive problems and general health.

Determination of spermatic vein reflux after varicocele repair helps to define the efficacy of treatment in improving sperm parameters of subfertile men

PURPOSE

A continuous spermatic venous reflux (SVR) at colour Doppler ultrasound (CDU) is an evidence for varicocele, a frequent correlate for male subfertility. We explored whether SVR after left varicocele repair is predictive for changes in semen quality in subfertile men.

METHODS

Blood hormones (FSH, LH, and total testosterone) and scrotal CDU were obtained in subfertile patients with left grade II or grade III varicocele on physical evaluation and a poor sperm quality. Semen analysis and CDU were re-evaluated 6 months after a retrograde internal spermatic vein scleroembolisation.

RESULTS

The retrospective study included 100 men with a baseline SVR >3 cm/s; 60 men showed a disappearance (group 1) and 40 men (group 2) showed a reduced SVR after varicocele repair. Total motile sperm count (TMC) was markedly increased after treatment (p < 0.0001; F = 35.79) and the increase was more relevant in group 1 compared to group 2 (p = 0.04; F = 4.20). TMC and left SVR values after varicocele repair were negatively correlated (R = -0.218; p = 0.035). Multivariate analysis showed that adjusted SVR after repair negatively predicted TMC change (TMC after repair minus baseline TMC) (ß = -2.56; p = 0.022). Disappearance of a continuous left SVR at CDU after varicocele repair was associated to a better improvement of semen parameters in subfertile men.

CONCLUSION

Recording of a continuous left spermatic vein reflux is an objective method to assess a successful varicocele repair aimed to improve sperm parameters in subfertile men.

Effect of tadalafil 5mg daily treatment on the ejaculatory times, lower urinary tract symptoms and erectile function in patients with erectile dysfunction

Objective

To investigate the effect of a 5mg daily tadalafil treatment on the ejaculation time, erectile function and lower urinary tract symptoms (LUTS) in patients with erectile dysfunction.

Materials and Methods

A total of 60 patients diagnosed with erectile dysfunction were retrospectively evaluated using the international index of erectile function questionnaire-5 (IIEF-5), intravaginal ejaculatory latency time (IELT) and international prostate symptoms scores (IPSS). After the patients were treated with 5mg tadalafil once a day for three months, their erection, ejaculation and LUTS were assessed again. The fasting levels of blood glucose, total testosterone, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and total cholesterol were measured. The independent-samples t-test was used to compare the pre- and post-treatment scores of the patients.

Results

The mean age of the 60 participants was 50.4±7.9 and the mean baseline serum total testosterone, total cholesterol, and fasting blood sugar were 444.6±178.6ng dL^-1, 188.7±29.6mg/dL^-1,104 (80-360) mg dL^-1, respectively. The mean baseline scores were 2.2±1.4 min for IELT, 9.5±3.7 for IIEF-5 and 14.1±4.5 for IPSS. Following the three-month daily 5mg tadalafil treatment, the scores were found to be 3.4±1.9 min, 16.1±4.7, and 10.4±3.8 for IELT, IIEF and IPSS, respectively. When the baseline and post-treatment scores were compared, a statistically significant increase was observed in the IELTs and IIEF-5 values whereas there was a significant decrease in IPSS (p<0.01).

Conclusion

A daily dose of 5mg tadalafil can be safely used in the treatment of erectile dysfunction and LUTS, that prolongs the ejaculatory latency time.

Acquired premature ejaculation and male accessory gland infection: relevance of ultrasound examination

We have previously demonstrated a high frequency of premature ejaculation (PE) among patients with male accessory gland infection (MAGI). The aim of this study was to evaluate the ultrasound (US) features of patients with MAGI and acquired premature ejaculation (APE) associated (MAGI-APEpos). US evaluation of 50 MAGI-APEpos patients compared to 50 patients with MAGI without PE (MAGI-PEneg) which represent the control group. The diagnosis of APE was made through the evaluation of Intravaginal ejaculation latency time (IELT) and confirmed with the questionnaire PEDT (Premature Ejaculation Diagnostic Tool). The main outcome measure was represented by the frequency of US criteria suggestive of P (prostatitis), V (vesiculitis), and E (epididymitis) in MAGI-APEpos and MAGI-PEneg patients. MAGI-APEpos patients showed a total number of US criteria significantly higher compared to MAGI-PEneg patients. MAGI-APEpos showed a higher frequency of US criteria of V and E (complicated forms of MAGI). Finally, in MAGI-APEpos group, it was found a positive relationship between the anteroposterior diameter (APD) of the caudal tract of the epididymis and the APD of the seminal vesicles, as well as between both diameters and the PEDT score. MAGI-APEpos patients have a peculiar US characterization compared to MAGI-PEneg patients. According to these results, US evaluation of the epididymal and of the prostato vesicular tract should be considered in the practical clinical approach of patients with MAGI and APE. In particular, it could be a support for a possible pathophysiological interpretation of this clinical problem in these patients.

The relationship between acquired premature ejaculation and metabolic syndrome: a prospective, comparative study

The aim of this study was to investigate the relationship between metabolic syndrome (MetS) and acquired premature ejaculation (PE). A total of 100 patients with acquired PE and 100 control cases were enrolled in the study. After obtaining a detailed medical history, anthropometric (weight, height and waist circumference) and blood pressure measurements were performed. Ejaculation and erection functions were evaluated by Premature Ejaculation Diagnostic Tool (PEDT) and International Index of Erectile Function-5 (IIEF-5), respectively. Self-estimated intravaginal ejaculatory latency time (IELT) of the participants was recorded. Fasting blood samples were taken for biochemical and hormonal work-up. The median PEDT scores were 16 (9-22) and 4.5 (2-8) in acquired PE and control groups, respectively (P<0.001). The mean estimated IELT values in PE patients and controls were 36.1±46.5  versus 488.2±313.8 s (P<0.001). MetS was diagnosed in 51 patients (51%) in the PE group and 24 (24%) participants in the control group (P<0.001). A significant negative correlation was observed between the components of MetS and estimated IELT, except for diastolic blood pressure. Moreover, there was a significant positive correlation between the all components of MetS and total PEDT score, except for fasting blood glucose and high-density lipoprotein cholesterol (HDL) levels. Logistic regression analysis revealed that, except blood pressure and HDL levels, MetS components were significant risk factors for PE after adjusting for age and total testosterone. In conclusion, MetS is associated with acquired PE.

When is a varicocele repair indicated: the dilemma of hypogonadism and erectile dysfunction?

In the past, the indications for varicocelectomy are primarily for infertility with abnormal semen parameters, testicular hypotrophy/atrophy in adolescents, and/or pain. The surgical treatment of varicocele for hypogonadism is controversial and debated. Recently, multiple reports in the literature have suggested that varicocele is associated with hypogonadism and varicocele repair can increase testosterone levels. Men with hypogonadal symptoms should have at least two serum testosterone levels. Microsurgical varicocelectomy may be beneficial for men with clinically palpable varicoceles with documented hypogonadism. In this review, we summarize the most recent literature linking varicocele to hypogonadism and sexual dysfunction and the impact of repair on serum testosterone levels. We performed a search of the published English literature. The key words used were “varicocele and hypogonadism” and “varicocele surgery and testosterone.” We included published studies after 1998. We, also, evaluated the effect of surgery on the changes in the serum testosterone level regardless of the indication for the varicocele repair.

The pathophysiology of acquired premature ejaculation

The second Ad Hoc International Society for Sexual Medicine (ISSM) Committee for the Definition of Premature Ejaculation defined acquired premature ejaculation (PE) as a male sexual dysfunction characterized by a the development of a clinically significant and bothersome reduction in ejaculation latency time in men with previous normal ejaculatory experiences, often to about 3 minutes or less, the inability to delay ejaculation on all or nearly all vaginal penetrations, and the presence of negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy. The literature contains a diverse range of biological and psychological etiological theories. Acquired PE is commonly due to sexual performance anxiety, psychological or relationship problems, erectile dysfunction (ED), and occasionally prostatitis and hyperthyroidism, consistent with the predominant organic etiology of acquired PE, men with this complaint are usually older, have a higher mean BMI and a greater incidence of comorbid disease including hypertension, sexual desire disorder, diabetes mellitus, chronic prostatitis, and ED compared to lifelong, variable and subjective PE.

Efficacy and safety of dapoxetine in treatment of premature ejaculation: an evidence-based review

BACKGROUND

Premature ejaculation (PE) is a major issue in male sexual health, with a global prevalence estimated to be between 20% and 40%, making it the most common sexual dysfunction in men. PE causes distress and reduced quality of life for patients and has a negative impact on interpersonal relationships. Historically, it has been treated with cognitive therapy, behavioural methods and off-label use of selective serotonin reuptake inhibitors (SSRIs) usually used to treat depression and other psychological disorders. Dapoxetine is the only SSRI specifically designed to treat PE.

MECHANISM OF ACTION

Dapoxetine hydrochloride is a potent inhibitor of serotonin reuptake transporters. Dapoxetine is suited for 'on-demand' treatment of PE because of its rapid absorption and short initial half-life.

EFFICACY

Evidence from published studies showed that dapoxetine 30 mg or 60 mg taken 'on-demand' results in a significant increase in intravaginal ejaculatory latency time (IELT) when compared with placebo. Most patient-reported outcomes are clearly improved relative to placebo following dapoxetine therapy, indicating greater control over ejaculation, more satisfaction with intercourse, less ejaculation-related distress and significantly reduced interpersonal difficulties.

SAFETY

The most common adverse events with dapoxetine are nausea, dizziness, somnolence, headache, diarrhoea and insomnia. Usually they do not lead to drug discontinuation.

CONCLUSION

Dapoxetine is the only effective and safe available on-label oral treatment for PE, and its use can result in better quality of life for the patient and their sexual partner.

Varicocele and concomitant dilation of the periprostatic venous plexus: effects on semen viscosity sperm parameters

INTRODUCTION

Since varicocele is often associated with other venous abnormalities, this study was undertaken to evaluate the frequency of dilation of the periprostatic venous plexus (DPVP) in these patients and the effects of this association on sperm parameters before and after varicocelectomy.

MATERIALS AND METHODS

Sperm parameters were evaluated using the conventional WHO criteria, and seminal fluid viscosity was further evaluated by quantitative viscometry, in 50 patients (aged 20-38 years) who underwent surgical treatment for grade III bilateral varicocele.

RESULTS

Thirty patients with varicocele had also DPVP (DPVP+) (60 %). Sperm concentration and the percentage of spermatozoa with normal morphology did not differ significantly in patients with DPVP- or DPVP+ before or after surgical repair. On the other hand, sperm progressive motility was low in all patients and increased significantly after varicocele repair, but only in DPVP- patients. Before varicocele treatment, a significantly higher number of DPVP+ patients (25/30 = 83.3 %) had seminal fluid hyperviscosity compared to DPVP- patient (2/20 = 10.0 %). Viscosity quantitative measurement was significantly higher in DPVP+ patients both before and after varicocele repair compared to DPVP- patients. These latter showed a statistically significant reduction of sperm viscosity after varicocele surgical repair compared to pretreatment values. Finally, periprostatic venous plexus diameter and seminal fluid viscosity correlated directly in DPVP+ patients.

CONCLUSIONS

In conclusion, these results showed that a large number of patients with varicocele had a concomitant DPVP. This subset of patients did not take advantage from varicocele surgical repair since only DPVP- varicocele patients showed a significant improvement of sperm progressive motility and seminal fluid viscosity. These findings suggest the evaluation of the periprostatic venous plexus and seminal fluid viscosity before patients with varicocele undergo surgical repair for asthenozoospemia.

Interplay Between Premature Ejaculation and Erectile Dysfunction: A Systematic Review and Meta-Analysis

INTRODUCTION

The specific determinants and underlying factors linking erectile dysfunction (ED) and premature ejaculation (PE) have yet to be clearly identified.

AIM

The aim of this study was to review and meta-analyze all available data regarding the link between ED and PE.

METHODS

An extensive Medline Embase and Cochrane search was performed including the following words: "premature ejaculation" and "erectile dysfunction".

MAIN OUTCOME MEASURES

All observational trials comparing the risk of ED in relation to PE were included. Data extraction was performed independently by two of the authors (G.R, G.C.), and conflicts resolved by the third investigator (M.M.).

RESULTS

Out of 474 retrieved articles, 18 were included in the study for a total of 57,229 patients, of which 12,144 (21.2%) had PE. The presence of PE, however defined, was associated with a significant increase in ED risk (odds ratio: 3.68[2.61;5.18]; P < 0.0001). Meta-regression analysis showed that the risk of ED in PE subjects was higher in older individuals as well as in those with a lower level of education and in those who reported a stable relationship less frequently. In addition, subjects with PE and ED more often reported anxiety and depressive symptoms and a lower prevalence of organic associated morbidities, including diabetes mellitus, hypertension and dyslipidemia. All the latter associations were confirmed even after adjustment for age. Finally the risk of PE-related ED increased with the increased proportion of acquired ejaculatory problems (adj r = 0.414; P < 0.0001 after the adjustment for age).

CONCLUSIONS

In conclusion, the present data showed that ED and PE are not distinctly separate entities, but should be considered from a dimensional point of view. Understanding this dimensional perspective might help sexual health care professionals in providing the most appropriate therapeutic approach to realistically increase patient related outcomes in sexual medicine.

Clomiphene Effects on Idiopathic Premature Ejaculation

Background:

Premature ejaculation (PE) is the inability to delay ejaculation, occurring sooner than they or their partner would like during sexual activities. PE is a challenging problem that can affect sexual enjoyment and may harm relationships of couples and affect their quality of life. In idiopathic PE, several helpful techniques and medicines are recommended, but none of them has yielded satisfactory results.

Objectives:

Our objective in this study was to evaluate the efficacy and safety of clomiphene as a selective estrogen receptor modulator on the treatment of idiopathic PE.

Patients and Methods:

In a randomized clinical trial, 178 married men with idiopathic PE defined according to the Diagnostic and Statistical Manual of Mental Disorders Third Revised Version (DSM-III-R) who referred to urology clinics over a 10-month period in 2012 were randomized into two groups, namely the study (clomiphene) and control (placebo) groups. They completed self-administered questionnaires that included intravaginal ejaculatory latency time (IELT), erectile dysfunction indexes, quality of life (QOL), sociodemographic characteristics, lifestyle, and medical illness. After 6 months of intervention, all data were compared with the baseline data and between the groups.

Results:

Within the 10-month study course, 126 patients (70.8%) completed this study. After intervention and comparison of the results between the two groups, IELT, sexual indexes, and QOL improved in the study group, but significant differences were observed only in the IELT and QOL findings.

Conclusions:

Clomiphene seems to be useful in the pharmacological treatment of PE compared to the placebo.

Clinical correlates of enlarged prostate size in subjects with sexual dysfunction

Digito-rectal examination (DRE) of the prostate provides useful information on the state of prostate growth and on the presence of suspected peripheral nodules. The aim of this study is to describe the clinical and biochemical correlates of finding an enlarged prostate size at DRE in subjects with sexual dysfunction (SD). A consecutive series of 2379 patients was retrospectively studied. The analysis was focused on a subset of subjects (n = 1823; mean age 54.7 ± 11.4) selected for being free from overt prostatic diseases. Several parameters were investigated. After adjusting for confounders, the presence of an enlarged prostate size at DRE was associated with a higher risk of metabolic syndrome (HR = 1.346 (1.129–1.759); P = 0.030), type 2 diabetes mellitus (HR = 1.489 (1.120–1.980); P = 0.006), increased LDL cholesterol (>100 mg dl⁻¹; HR = 1.354 (1.018–1.801); P = 0.037) and increased mean blood pressure (BP) values (HR = 1.017 (1.007–1.027) for each mmHg increment; P = 0.001). Accordingly, enlarged prostate size was also associated with a higher risk of arteriogenic erectile dysfunction (ED), as well as with other andrological conditions, such as varicocele and premature ejaculation (PE). PSA levels were significantly higher in subjects with enlarged prostate size when compared to the rest of the sample (HR = 3.318 (2.304; 4.799) for each log unit increment in PSA levels; P < 0.0001). Arteriogenic ED, according to different criteria, was also associated with increased PSA levels. In conclusion, our data support the need to examine prostate size either by clinical (DRE) or biochemical (PSA) inspection in subjects with SD, in order to have insights into the nature of the SD and the metabolic and cardiovascular (CV) background of the patient.

Chlamydia trachomatis infection is related to premature ejaculation in chronic prostatitis patients: results from a cross-sectional study

INTRODUCTION

Chronic bacterial prostatitis (CBP) is reported to be a common finding in men with acquired premature ejaculation (PE). The impact of different pathogens on PE development in chronic prostatitis patients is, however, unknown.

AIM

To assess a possible link between CBP caused by Chlamydia trachomatis (Ct) and PE.

METHODS

A consecutive series of 317 patients with clinical and instrumental diagnosis of CBP due to Ct was enrolled (group A) and compared with data obtained from a control group of 639 patients with CBP caused by common uropathogen bacteria (group B). Prostatitis symptoms were investigated with the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), while the ejaculatory status of patients was assessed using the PE Diagnostic Tool (PEDT).

MAIN OUTCOME MEASURES

All participants were asked to complete the NIH-CPSI, the International Index of Erectile Function-15 erectile function domain (IIEF-15-EFD), the PEDT, and the Short Form (SF)-36 questionnaires.

RESULTS

Patient groups A and B had comparable scores of NIH-CPSI (P = 0.07), IPSS (P = 0.32), and IIEF-15-EFD (P = 0.33) tests. PE was assessed in 118 patients in group A (37.2%) and in 73 subjects in group B (11.5%). The two groups are different in terms of PE prevalence (P < 0.0002). Compared with group B, group A showed significantly higher scores of the PEDT test (11.3 [±2.6] vs. 4.5 [±2.9], P < 0.0001) and lower scores of the SF-36 tool (96.5 [±1.1] vs. 99.7 [±1.3], P < 0.0001). In our multivariate model assessment, being positive for a Ct infection marker was independently associated with the PEDT score even after adjusting for age, smoking habit, body mass index, and education level (adjusted odds ratio = 3.21; 95% confidence interval: 2.02-4.27; P < 0.003).

CONCLUSIONS

Patients affected by CBP due to Ct infection reported higher prevalence of PE and lower quality of life when compared with patients affected by CBP caused by traditional uropathogenic bacteria.

An Update of the International Society of Sexual Medicine's Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years. Althof SE, McMahon CG, Waldinger MD, Serefoglu EC, Shindel AW, Adaikan PG, Becher E, Dean J, Giuliano F, Hellstrom WJG, Giraldi A, Glina S, Incrocci L, Jannini E, McCabe M, Parish S, Rowland D, Segraves RT, Sharlip I, and Torres LO. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med 2014;2:60-90.

An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE)

INTRODUCTION

In 2009, the International Society for Sexual Medicine (ISSM) convened a select panel of experts to develop an evidence-based set of guidelines for patients suffering from lifelong premature ejaculation (PE). That document reviewed definitions, etiology, impact on the patient and partner, assessment, and pharmacological, psychological, and combined treatments. It concluded by recognizing the continually evolving nature of clinical research and recommended a subsequent guideline review and revision every fourth year. Consistent with that recommendation, the ISSM organized a second multidisciplinary panel of experts in April 2013, which met for 2 days in Bangalore, India. This manuscript updates the previous guidelines and reports on the recommendations of the panel of experts.

AIM

The aim of this study was to develop clearly worded, practical, evidenced-based recommendations for the diagnosis and treatment of PE for family practice clinicians as well as sexual medicine experts.

METHOD

A comprehensive literature review was performed.

RESULTS

This article contains the report of the second ISSM PE Guidelines Committee. It offers a new unified definition of PE and updates the previous treatment recommendations. Brief assessment procedures are delineated, and validated diagnostic and treatment questionnaires are reviewed. Finally, the best practices treatment recommendations are presented to guide clinicians, both familiar and unfamiliar with PE, in facilitating treatment of their patients.

CONCLUSION

Development of guidelines is an evolutionary process that continually reviews data and incorporates the best new research. We expect that ongoing research will lead to a more complete understanding of the pathophysiology as well as new efficacious and safe treatments for this sexual dysfunction. We again recommend that these guidelines be reevaluated and updated by the ISSM in 4 years.

The effects of varicocelectomy on the patients with premature ejaculation

BACKGROUND

Premature ejaculation is one of the most problems in clinical practice. The association between varicocele and premature ejaculation was poorly understood. The effects of varicocelectomy on premature ejaculation in varicocele patient was studied.

OBJECTIVES

The aim of this study was to determine the impacts of varicocelectomy on patients with both premature ejaculation and varicoceles.

PATIENTS AND METHODS

This was a clinical trial study, conducted on 124 patients (20-35 years old), with varicoceles and premature ejaculation (PE), since March 2011 to April 2013. Inguinal and sub inguinal varicocelectomy were performed for them. All patients had both impairment of spermiogram and PE. These patients were followed up for about 2 years and evaluated for PE, in addition to parameters of spermiogram, before and after the surgery.

RESULTS

A total number of 124 patients with varicoceles and PE were enrolled into the study. Following the surgery 46 patients (37%) were fully treated (P < 0.001), 78 patients (63%) had improvements in PE symptoms changed to early ejaculation (P < 0.05) and 89 patients (72%) had improved parameters of spermiogram (P < 0.002).

CONCLUSIONS

In a significant number of patients who had clinical varicocele and not well responded to medical treatments for PE, varicocelectomy could effectively improve PE and spermiogram parameters.

Impact of varicocelectomy on premature ejaculation in varicocele patients

In a prospective manner, we studied the effect of varicocelectomy on premature ejaculation and testicular hormonal function in patients with varicocele. Microsurgical subinguinal varicocelectomy was carried out in 73 patients with clinical varicocele associated with premature ejaculation (group 1) and compared with 56 patients without operative intervention (group 2; control). The primary efficacy variable was the mean change in the Premature Ejaculation Diagnostic Tool. The changes in International Index of Erectile Function questionnaire, total serum testosterone and testicular size were also assessed. In group 1, the Premature Ejaculation Diagnostic Tool decreased significantly after varicocelectomy, from 15.56 to 11.37 (P < 0.001), indicating improvement of premature ejaculation. Thirty patients (41.1%) showed improvement of premature ejaculation compared to 5.3% in the control group (P < 0.001). In group I, but not in group II, testosterone levels and International Index of Erectile Function values increased significantly when compared with pre-operative values (P < 0.001 and 0.040 respectively). Testicular size increased after varicocelectomy, but this increase was nonsignificant till the end of study (P = 0.054). We concluded that varicocelectomy is clearly related to improvement of premature ejaculation and testicular hormonal function in varicocele patients.

Metabolic syndrome and prostate abnormalities in male subjects of infertile couples

No previous study has evaluated systematically the relationship between metabolic syndrome (MetS) and prostate-related symptoms and signs in young infertile men. We studied 171 (36.5 ± 8.3-years-old) males of infertile couples. MetS was defined based on the National Cholesterol Education Program Third Adult Treatment Panel. All men underwent hormonal (including total testosterone (TT) and insulin), seminal (including interleukin-8 (IL-8), seminal plasma IL-8 (sIL-8)), scrotal and transrectal ultrasound evaluations. Because we have previously assessed correlations between MetS and scrotal parameters in a larger cohort of infertile men, here, we focused on transrectal features. Prostate-related symptoms were assessed using the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and the International Prostate Symptom Score (IPSS). Twenty-two subjects fulfilled MetS criteria. In an age-adjusted logistic ordinal model, insulin levels increased as a function of MetS components (Wald = 29.5, P < 0.0001) and showed an inverse correlation with TT (adjusted r = -0.359, P< 0.0001). No association between MetS and NIH-CPSI or IPSS scores was observed. In an age-, TT-, insulin-adjusted logistic ordinal model, an increase in number of MetS components correlated negatively with normal sperm morphology (Wald = 5.59, P< 0.02) and positively with sIL-8 levels (Wald = 4.32, P < 0.05), which is a marker of prostate inflammation, with prostate total and transitional zone volume assessed using ultrasound (Wald = 17.6 and 12.5, both P < 0.0001), with arterial peak systolic velocity (Wald = 9.57, P = 0.002), with texture nonhomogeneity (hazard ratio (HR) = 1.87 (1.05-3.33), P < 0.05), with calcification size (Wald = 3.11, P< 0.05), but not with parameters of seminal vesicle size or function. In conclusion, in males of infertile couples, MetS is positively associated with prostate enlargement, biochemical (sIL8) and ultrasound-derived signs of prostate inflammation but not with prostate-related symptoms, which suggests that MetS is a trigger for a subclinical, early-onset form of benign prostatic hyperplasia.

Pharmacology for the treatment of premature ejaculation

Male sexual response comprises four phases: excitement, including erection; plateau; ejaculation, usually accompanied by orgasm; and resolution. Ejaculation is a complex sexual response involving a sequential process consisting of two phases: emission and expulsion. Ejaculation, which is basically a spinal reflex, requires a tight coordination between sympathetic, parasympathetic, and somatic efferent pathways originating from different segments and area in the spinal cord and innervating pelvi-perineal anatomical structures. A major relaying and synchronizing role is played by a group of lumbar neurons described as the spinal generator of ejaculation. Excitatory and inhibitory influences from sensory genital and cerebral stimuli are integrated and processed in the spinal cord. Premature ejaculation (PE) can be defined by ≤1-min ejaculatory latency, an inability to delay ejaculation, and negative personal consequences. Because there is no physiological impairment in PE, any pharmacological agent with central or peripheral mechanism of action that is delaying the ejaculation is a drug candidate for the treatment of PE. Ejaculation is centrally mediated by a variety of neurotransmitter systems, involving especially serotonin and serotonergic pathways but also dopaminergic and oxytocinergic systems. Pharmacological delay of ejaculation can be achieved either by inhibiting excitatory or reinforcing inhibitory pathways from the brain or the periphery to the spinal cord. PE can be treated with long-term use of selective serotonin-reuptake inhibitors (SSRIs) or tricyclic antidepressants. Dapoxetine, a short-acting SSRI, is the first treatment registered for the on-demand treatment of PE. Anesthetics applied on the glans penis have the ability to lengthen the time to ejaculation. Targeting oxytocinergic, neurokinin-1, dopaminergic, and opioid receptors represent future avenues to delaying ejaculation.

Elevated body mass index correlates with higher seminal plasma interleukin 8 levels and ultrasonographic abnormalities of the prostate in men attending an andrology clinic for infertility

BACKGROUND

Obesity is associated with a systemic, low-grade inflammatory state. Although the relationship between obesity and semen parameters or prostate diseases has been previously investigated, the association between body mass index (BMI), prostate inflammatory diseases and color- Doppler ultrasound (CDU) of the male genital tract (MGT) has been poorly studied.

AIM

To evaluate the association between BMI and CDU features of the MGT, signs and symptoms of prostate inflammation, semen parameters.

MATERIALS/SUBJECTS AND METHODS

We studied 222 men seeking medical care for couple infertility. According to the World Health Organization classification, subjects were divided into 3 groups: normal weight (no.=131, BMI=18.5-24.9 kg/m2), overweight (no.=71, BMI=25.0-29.9 kg/m2), obese (no.=20, BMI≥30.0 kg/m2). All patients underwent simultaneous testosterone evaluation and seminal analysis, including interleukin 8 (sIL-8), along with scrotal and transrectal CDU, before and after ejaculation. Prostatitis symptoms were evaluated by National Institutes of Health- Chronic Prostatitis Symptom Index questionnaire.

RESULTS

After adjusting for age and testosterone levels, higher BMI was significantly related to higher prostate volume and several CDU features of the prostate, including macro-calcifications, inhomogeneity, higher arterial peak systolic velocity (the latter adjusted also for blood pressure), but not with abnormalities of testis, epididymis, seminal vesicles. Furthermore, higher BMI and BMI class were significantly related to higher sIL-8, a reliable surrogate marker of prostate inflammatory diseases, even after adjustment for age. Conversely, no associations among BMI, clinical symptoms of prostatitis or semen parameters were observed.

CONCLUSIONS

Subjects with higher BMI might develop CDU and biochemical signs suggestive of prostate inflammation, although not clinically overt.

Does varicocelectomy improve gonadal function in men with hypogonadism and infertility? Analysis of a prospective study

Varicocele in infertile males is associated with Leydig cell dysfunction and hypogonadism. The effect of varicocelectomy on serum testosterone level is not yet established. We analysed 200 heterosexual infertile men diagnosed to have clinical varicocele they were divided into two groups: group 1 (100 men) had microsurgical varicocelectomy, and group 2 (100 patients) underwent assisted reproduction procedures. All participants had semen analysis, serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and total testosterone (TT), measured both at recruitment time and 6 months later. In group 1, the mean TT level increased significantly after varicocelectomy (1.644 ± 0.029 to 2.461 ± 0.0198 ng/dL, P < 0.0001) and testicular size correlated with the mean change in TT (P = 0.001). No similar change was found in group 2. Out of the 100 patients in group 1, 78 had postoperative normalization of TT unlike only 16 men in group 2.