Are sexually transmitted infections associated with male infertility? A systematic review and in-depth evaluation of the evidence and mechanisms of action of 11 pathogens

Purpose

To systematically review the evidence on the association between sexually transmitted infections (STIs) and male infertility. We sought to answer two questions: Are STIs significantly associated with detrimental changes in semen parameters?; and, is the prevalence of STIs significantly higher in infertile than fertile men?

Materials and methods

PubMed, Scopus and Google Scholar databases were searched (inceptionMarch 2023) following the PRISMA guidelines. Identified original studies in English on the association between STIs and male infertility were included. Data was tabulated/described by pathogen, mechanisms of action, number of studies and their level of evidence.

Results

Seventy out of 903 originally retrieved articles were included in this review. For the detrimental changes in semen parameters (first question), the evidence seems equivocal based on the nearly equal number of studies and similar levels of evidence. The only exception was for Ureaplasma, where the number of studies and levels of evidence supported an association with male infertility. Pertaining to a significantly higher prevalence of STI among infertile compared to fertile men (second question), evidence was insufficient to support/deny a significant association. The two exceptions were Ureaplasma and Mycoplasma, where the number of studies and evidence levels were in favour of an association with male infertility.

Conclusions

Generally, the relationship between STIs and male infertility remains to be uncovered. Our appraisal of the overall state of this relationship shows that the evidence base leaves much to be desired. The exceptions are Ureaplasma and Mycoplasma, where the evidence convincingly suggests their associations with infertility in men.

Testosterone status is not associated with bladder cancer parameters in adult male patients: results of a prospective controlled study

PURPOSE

This controlled study assessed whether there was a correlation between serum total testosterone levels and bladder cancer (BCa) in terms of tumor grade and stage as objective measures in adult men.

MATERIALS AND METHOD

Our prospectively-designed study included 257 patients who were diagnosed with primary BCa and its surgery between January 2017 and January 2020. Hundred and forty patients who had surgery in the same period with TUR for prostate or endoscopic ureteral stone treatment were included in the study as a control group. All patients in the study and control groups were male. The age range of the patients was between 34 and 90 years old. In order to examine groups, fasting blood glucose, lipid profile, albumin, total testosterone, and vitamin D levels of all patients included in the study.

RESULTS

The relationship between tumor aggression and total testosterone level was investigated with a multinomial logistic regression model, where the control group was accepted as a reference, following adjustment for potential confounding variables, including age and serum albumin levels. Testosterone level was not found to be associated with any of the categories that determine tumor aggressiveness (p > 0.05).

CONCLUSION

In the present study, there was no correlation between any categories that determine tumor aggressiveness of BCa and total testosterone levels in adult men. It is obvious that our findings should be supported and further investigations are needed.

Low-intensity extracorporeal shockwave therapy for erectile dysfunction

Objectives: To review the current evidence of clinical effectiveness of low-intensity extracorporeal shockwave therapy (LI-ESWT) treatment for erectile dysfunction (ED).

METHODS

A selective database search using Medical Subject Headings (MeSH) terms 'low intensity extracorporeal shock wave therapy' and 'erectile dysfunction' was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta Analyses (PRISMA) guidelines to review the effectiveness of LI-ESWT for ED. We performed a systematic search of publications using the PubMed and Web of Science databases (January 2010-December 2020) for prospective randomised clinical trials (RCTs). The success rate of LI-ESWT associated with ED were recorded and analysed.

RESULTS

A total of 106 articles were reviewed after searching for the keywords. Overall, 11 RCTs were included in this systematic review. A total of 920 male patients were treated in 11 RCTs. The patients' ages ranged from 18 to 80 years and they had ≥3 months of ED symptoms. Vasculogenic and neurogenic causes were addressed in 81% and 19% of patients, respectively. Of the 920 patients, 348 patients had a statistically significant improvement in their erectile function after LI-ESWT; however, 572 did not have a statistically significant improvement.

CONCLUSIONS

The present review found that LI-ESWT has a role in ED treatment in laboratory studies, but its role in human clinical trials is still controversial. Further good quality studies need to be conducted to properly assess its true potential in ED treatment.

HbA1c over 8.5% is not predictive of increased infection rate following penile prosthesis implant surgery in diabetic patients with erectile dysfunction

Diabetes mellitus is associated with increased risk of erectile dysfunction. Penile prosthesis implantation is an efficient therapeutic option for erectile dysfunction, but not without risk, as infection remains a prominent concern. This study investigates diabetes mellitus as a risk factor for penile prosthesis implantation infection and the relationship between haemoglobinA1c levels and infection rates. All diabetic patients with erectile dysfunction who underwent penile prosthesis implantation surgery between January 2012 and November 2019 at Hamad Medical Corporation, Qatar, were included in this retrospective observational study. A total of 599 diabetic patients with erectile dysfunction had penile prosthesis implantation. Mean age was 59.69 ± 31.19. Penile prosthesis implantation infection rate was 0.83% (5/599), while the mean haemoglobinA1c level was 7.58 ± 1.45 mmol/l (range: 4.1-12.6). A comparison between diabetic patients with penile prosthesis implantation infection and those without infection revealed no significant difference in the level of haemoglobinA1c between the two groups with mean haemoglobinA1c in patients with infected implants 7.14 and 7.59 for noninfected (p = 0.491). Limitations include retrospective single-centre design and low-infection rates reducing sample number. Penile prosthesis implantation infection rate in a large series of diabetic patients was low with no significant association between haemoglobinA1c level and penile prosthesis implantation infection observed.

Vitamin D Supplementation As a Potential therapeutic Mediator in Asthma: Does Dose Really Matter? a Critical Review of the Literature

Around 400 million people across the globe will suffer from asthma in the next 10 years. Although most asthmatics use asthma medications regularly, they occasionally visit the emergency department for aggressive treatment amidst family anxiousness. Vitamin D (VD) not only regulates the expression of genes associated with calcium homeostasis, but also the genes associated with cancers, autoimmune diseases, and infection. VD has also non-genomic activities e.g. it is a potentially safe and effective novel strategy for decreasing the asthma episodes and controlling exacerbations. Our review assessed the dose, serum level, duration of administration and outcomes of VD in cases of asthmas. Although a body of research evidences the effectiveness of VD supplementation in asthma, other studies showed the insignificant response of VD to asthma either with low dose or low achieved serum VD levels. Nevertheless, recent reviews suggest that manipulating VD status holds promise for primary prevention and treatment of asthma. Future research on the relationship between VD and asthma should consider utilizing adequate doses of VD preparations for sufficient duration (likely to be >12 months) aiming to achieve appropriate level of serum VD (25-hydroxyvitamin D) concentration (likely to be at least >40 ng/mL).

Are We missing out the role of oxytocin in overactive bladder syndrome?

Overactive bladder (OAB) is characterized by the storage symptoms of urgency with or without urgency incontinence. Although there is no clear cause of this idiopathic disease, overall prevalence of OAB symptoms in individuals aged 40 years old is more than 15%. Oxytocin, which is one of the most powerful contracting neuropeptide, was also shown to exhibit high intrinsic contractile activity on detrusor muscle. Oxytocin receptor antagonists that inhibit of bladder activity might offer new insights into the treatment of OAB.

Serum testosterone status in men with penile corporoveno-occlusive dysfunction

BACKGROUND AND OBJECTIVES

Vascular abnormalities are the most common factors in patients with erectile dysfunction (ED). There are limited number of case series investigating the etiology of corporoveno-occlusive dysfunction (CVOD). In this study, we evaluated ED patients with vascular etiologies and their serum biomarkers from a large database.

MATERIALS AND METHODS

The current study retrospectively examined the association between serum testosterone levels and basic lab works with Penile Doppler Ultrasonography (PDU) results. We retrieved and reviewed the records of 500 ED patients who had PDU at our institution between January 2012 and November 2018. One-way analysis of variance and Pearson's correlation coefficients were used to compare different parameters between groups (CVOD and penile arterial insufficiency) and between two quantitative variables, respectively.

RESULTS

Sixty patients who met the inclusion criteria were enrolled and examined in this study. Patients' mean age was 52.9 ± 11.5 years, and mean serum testosterone level was 15.57 ± 6.49 nmol/L. Thirty-nine (65%) out of 60 patients had abnormal EDV values (>5cm/sec), while eleven (18.3%) had abnormal PSV values (<35cm/sec). Among the patients with abnormal EDV values, we demonstrated that there was a statistically significant negative correlation between testosterone and CVOD (Pearson's; r = -0.283; p = .028).

CONCLUSIONS

Our findings supported that low serum testosterone level is a risk factor for CVOD and so for ED. Future studies would benefit from larger sample sizes in order to support or refute our findings.

Comparison of the safety and efficacy of the on-demand use of sertraline, dapoxetine, and daily use of sertraline in the treatment of patients with lifelong premature ejaculation: A prospective randomised study

This study compared the safety and efficacy of the on-demand (OD) use of sertraline (50 mg), sertraline (100 mg) and dapoxetine (30 mg), and the daily use of sertraline (50 mg) in the treatment of patients with premature ejaculation (PE). This prospective randomised study involved 120 lifelong PE patients (intravaginal ejaculatory latency time [IELT]: <1 min; Arabic Index of Premature Ejaculation [AIPE] score: < 30) without secondary causes of PE, identified between March 2018 and May 2020. Patients were divided into 4 groups (30 patients per group) and treated for 8 weeks. Assessments were conducted using the AIPE form as a diagnostic tool. Sertraline (50 mg, daily; 196.7 ± 115.5 s) and sertraline (100 mg, OD; 173.3 ± 97.0 s) had similar IELT and AIPE scores. The latter groups had better results in comparison with sertraline (50 mg, OD; 100.5 ± 54.4 s) and dapoxetine (93.7 ± 53.5 s; p < 0.01). Sertraline (100 mg, OD) had a similar efficacy to that of sertraline (50 mg, daily) and was more effective than sertraline (50 mg, OD) and dapoxetine (30 mg, OD). Sertraline (100 mg, OD) can be considered in the treatment of lifelong PE treatment, having tolerable side effects.

Acute prostatitis after prostate biopsy under ciprofloxacin prophylaxis with or without ornidazole and pre-biopsy enema: analysis of 3.479 prostate biopsy cases

Objectives:

To investigate the characteristics of cases of NIH category I acute prostatitis developed after transrectal prostate biopsy and clarifiy the risk factors and preventive factors.

Materials and Methods:

We retrospectively reviewed the medical records of 3.479 cases of transrectal ultrasound-guided needle biopsies performed with different prophylactic antibiotherapy regimens at two different institutions between January 2011 and February 2016. The patients of Group I have received ciprofl oxacin (n=1.523, 500mg twice daily) and the patients of Group II have received ciprofl oxacin plus ornidazole (n=1.956, 500mg twice daily) and cleansing enema combination as prophylactic antibiotherapy. The incidence, clinical features and other related microbiological and clinical data, were evaluated.

Results:

Mean age was 62.38±7.30 (47-75), and the mean prostate volume was 43.17±15.20 (21-100) mL. Of the 3.479 patients, 39 (1.1%) developed acute prostatitis after the prostate biopsy procedure. Of the 39 cases of acute prostatitis, 28/3.042 occurred after the first biopsy and 11/437 occurred after repeat biopsy (p=0.038). In Group I, 22 of 1.523 (1.4%) patients developed acute prostatitis. In Group II, 17 of 1.959 (0.8%) patients developed acute prostatitis. There was no statistical difference between the two groups according to acute prostatitis rates (X2=2.56, P=0.11). Further, hypertension or DM were not related to the development of acute prostatitis (P=0.76, X2=0.096 and P=0.83, X2=0.046, respectively).

Conclusions:

Repeat biopsy seems to increase the risk of acute prostatitis, while the use of antibiotics effective for anaerobic pathogens seems not to be essential yet.

Vitamin D and Male Erectile Function: An Updated Review

Literature support that vitamin-D is important for different systems of the human body including, but not limited to endocrine and immune systems, vasculature and endothelial function of the body. Male erectile function depends on many factors and can be perceived as a health indicator of the body. Epidemiological data have shown that vitamin-D deficiency is also associated with erectile dysfunction. In this review, our aim is to interpret the mechanisms by which vitamin-D might regulate anatomy and physiology of penis. Evidence showed that vitamin-D is needed for an adequate erectile function. Briefly, vitamin-D is crucial for a better healthy body and sexual activity.

Is Hba1c level of diabetic patients associated with penile prosthesis implantation infections?

BACKGROUND AND OBJECTIVES

Diabetes mellitus is an important risk factor for erectile dysfunction (ED). Penile prosthesis implantation surgery is the final solution for diabetic patients with ED, but infections thereof are still a serious risk factor. While some studies suggest that most infections associated with penile prosthesis implantation are associated to high glycated hemoglobin (HbA1c) levels, other research did support such relationship.

MATERIALS AND METHODS

The current study assessed retrospectively, the association between HbA1c level and penile prosthesis surgery infection. We retrieved and reviewed the records of 300 diabetic patients who had penile prosthesis surgery at our Institution (January 2012-November 2016). Patients' mean age was 55.26 ± 10.9 years (31% patients were <50 years of age), and mean HbA1c was 7.60 ± 1.90%.

RESULTS

Infection rate among diabetics was 0.67%. Prevalence of prosthesis infection among patients with HbA1c ≤ 9% was 0.9%, compared with 0% among patients with HbA1c > 9%. Prosthesis infection risk did not significantly increase with higher HbA1c levels, with no meaningful difference in the median or mean level of HbA1c in the infected and non-infected diabetic patients.

CONCLUSION

Findings do not support the use of HbA1c values among diabetic patients who are candidates for penile prosthesis implantation surgery in order to identify and exclude those who might be prone to increased risk of prosthesis infections. Future studies would benefit from larger sample sizes in order to support or refute our findings.

Testosterone therapy has positive effects on anthropometric measures, metabolic syndrome components (obesity, lipid profile, Diabetes Mellitus control), blood indices, liver enzymes, and prostate health indicators in elderly hypogonadal men

To alleviate late-onset hypogonadism, testosterone treatment is offered to suitable patients. Although testosterone treatment is commonly given to late-onset hypogonadism patients, there remains uncertainty about the metabolic effects during follow-ups. We assessed the associations between testosterone treatment and wide range of characteristics that included hormonal, anthropometric, biochemical features. Patients received intramuscular 1,000 mg testosterone undecanoate for 1 year. Patient anthropometric measurements were undertaken at baseline and at each visit, and blood samples were drawn at each visit, prior to the next testosterone undecanoate. Eighty-eight patients (51.1 ± 13.0 years) completed the follow-up period. Testosterone treatment was associated with significant increase in serum testosterone levels and significant stepladder decrease in body mass index, total cholesterol, triglycerides and glycated haemoglobin from baseline values among all patients. There was no significant increase in liver enzymes. There was an increase in haemoglobin and haematocrit, as well as in prostate-specific antigen and prostate volume, but no prostate biopsy intervention was needed for study patients during 1-year testosterone treatment follow-up. Testosterone treatment with long-acting testosterone undecanoate improved the constituents of metabolic syndrome and improved glycated haemoglobin in a stepladder fashion, with no adverse effects.

Vitamin D treatment improves levels of sexual hormones, metabolic parameters and erectile function in middle-aged vitamin D deficient men

BACKGROUND

The associations between serum vitamin D (VD), serum testosterone (TT) and metabolic syndrome are complex and with limited published research, particularly on the effects of VD treatment on sexual hormones, erectile function and the metabolic syndrome.

OBJECTIVES

This study assessed whether a monthly high dose VD treatment for 12 months in VD deficient middle-aged men was associated with: changes in levels of sexual hormones, improvement of diabetes control and metabolic syndrome components, better erectile function [International Index of Erectile Function (IIEF)-5 questionnaire]; and changes in a prostate marker.

MATERIALS AND METHODS

Descriptive research of a prospective study, conducted between October 2014 and September 2015, 102 male patients ≥35 [(±SD: 53.2 ± 10.5), (range 35-64)] years with deficient serum VD level (<30 ng/mL) were included in the study. Participants were followed up for one year, with monitoring at 3-, 6-, 9- and 12-months. At the initial baseline visit, a complete medical examination was conducted, and blood was drawn for laboratory tests for above biochemical and hormonal variables under examination. Participants received an initial VD (Ergocalciferol; oral solution 600 000 IU/1.5 ml), and followed a VD treatment regime thereafter. At the four follow up visits (3, 6, 9 and 12 months), blood was collected, and patients' erectile function was evaluated by IIEF-5 questionnaire.

MAIN OUTCOME MEASURES

During the follow up visits, all the biochemical and hormonal (TT, estradiol and luteinizing hormones, HbA1c, serum lipids profile) were assessed, and patients' erectile function was evaluated by IIEF-5 questionnaire.

RESULTS

Patients' mean age was 53.2 ± 10.4 years. Serum VD exhibited significant increments (p <0.001) from baseline (15.16 ± 4.64 ng/mL), to 3 (31.90 ± 15.99 ng/mL), 6 (37.23 ± 12.42 ng/mL), 9 (44.88 ± 14.49 ng/mL) and 12 months (48.54 ± 11.62 ng/mL), and there was significant stepladder increases in both serum TT level (12.46 ± 3.30 to 15.99 ± 1.84 nmol/L) and erectile function scores (13.88 ± 3.96 to 20.25 ± 3.24) (p <0.001 for both). We also observed significant stepladder decreases in estradiol (87.90 ± 27.16 to 69.85 ± 14.80 pmol/L, p = 0.001), PTH (from 58.52 ± 28.99 to 38.33 ± 19.44 pg/mL, p <0.001) and HbA1c levels (7.41 ± 2.85 to 6.66 ± 1.67%, p = 0.001). Mean BMI significantly decreased from 33.91 ± 6.67 to 33.14 ± 6.35 kg/m² (p = 0.001); and PSA values significantly increased from 0.59 ± 0.30 to 0.82 ± 0.39 ng/mL (p <0.001) at the end of the 12 months' follow-up. There were no changes in LH levels.

CONCLUSION

This study demonstrated that VD treatment improves testosterone levels, metabolic syndrome and erectile function in middle-aged men. More randomized placebo-controlled interventional trials of VD treatment in patients with the metabolic syndrome and low TT could assist in uncovering the putative roles of VD.

RigiScan data under long-term testosterone therapy: improving long-term blood circulation of penile arteries, penile length and girth, erectile function, and nocturnal penile tumescence and duration

BACKGROUND

Late-onset hypogonadism (LOH) presents with low serum testosterone (TT) levels and sexual and nonsexual symptoms. Erectile dysfunction affects a man's self-esteem and as a result partner relationship and quality of life.

OBJECTIVES

To investigate the andrological clinical profile outcomes of testosterone therapy (TTh) in men (n = 88) with symptomatic LOH complaints and symptoms.

MAIN OUTCOME MEASURES

Erectile function was assessed using the International Index of Erectile Function-5 questionnaire at baseline and at 6 and 12 months of TTh. In addition, penile length was measured at baseline and 12 months. We also evaluated nocturnal penile tumescence (NPT, using RigiScan) and blood flow of cavernous arteries (penile Doppler ultrasonography) at baseline and 12 months of TT.

MATERIALS AND METHODS

Eighty-eight LOH men (M_age 51.1 years) with erectile dysfunction, all with serum TT <10.4 nmol/L before TTh. Patients received intramuscular long-acting testosterone undecanoate for 12 months.

RESULTS

Following TTh, in all patients, serum TT levels were restored within 3 months to normal levels. Compared with baseline values, erectile function significantly improved at 6 (mean score increase 1.95) and 12 months (mean score increase 2.16). No significant changes in penile length were observed. NPT significantly improved at 12 months in terms of both the frequency (mean increase 1.27 times) and duration of rigidity (mean increase 5.12 min). As regards the blood flow of the cavernous arteries, we observed a significant improvement (decrease of 1.16 cm/s) and end diastolic velocity of the penile arteries.

CONCLUSION

TTh in men with LOH resulted in improvement of the erectile function, NPT, and to some extent the blood flow of the cavernous arteries.

Is the daily use of vacuum erection device for a month before penile prosthesis implantation beneficial? a randomized controlled trial

Patient concerns about penile length after penile prosthesis (PP) implantation for erectile dysfunction (ED) have significant impact on patients and their partners. In addition, corporal fibrosis is associated with difficult PP implantation. The preoperative use of vacuum erectile devices (VED) is an uncommon physical treatment for such concerns. Therefore, the current randomized controlled study assessed two outcomes: whether pre-operative VED use for a month before surgery would significantly increase flaccid stretched penile length (SPL) on the day of surgery, and facilitate easier corporal dilatation intraoperatively. Fifty-one patients scheduled for PP implantation for ED were randomized to either intervention group (pre-operative VED use; 10-15 min/day for ≥30 days; Group A; n = 25), or control group (no intervention; Group B; n = 26). A research assistant (blinded to the treatment assignments) recorded SPL at baseline (initial consultation) and on day of surgery. The surgeons performing the PP implantation (also blinded to the treatment assignments) provided subjective assessments of the ease of corporal dilatation. Baseline patient characteristics, demographics, and comorbidities were the same in both groups. Baseline measurements (SPL-1) were 10.71 ± 1.28 and 10.87 ± 1.26 cm in Group A and Group B, respectively; and the day of surgery measurements (SPL-2) were 11.50 ± 1.33 and 11.06 ± 1.34 cm in Group A and Group B, respectively. In terms of outcomes: mean SPL increase in Group A was significantly more by a mean of 0.80 ± 0.38 cm (p < 0.05) compared to Group B; and surgeons' subjective report of surgical ease indicated smoother corporal dilatation for Group A compared to Group B. VED use (10-15 min/day during the month prior to PP implantation) was associated with significantly increased SPL on day of surgery, and facilitated easier corporal dilatation intraoperatively. Future studies should examine the long-term outcomes of penile prosthesis implantation after pre-operative use of vacuum erectile devices.

Alteration in the etiology of penile fracture in the Middle East and Central Asia regions in the last decade; a literature review

Penile fracture is a well-recognized, relatively uncommon medical condition and its etiology differs according to geographic area. In this review article, we evaluated literature reported in the past decade, aiming to verify whether there has been any change in the etiology of this condition. A literature review was done for studies published in the past 10 years and focusing on the etiology of penile fracture. Inclusion criteria comprised articles in English language, of sample size more than 10 patients and originating from the Middle East and Central Asia. Data relating to the studied population, etiology of penile fracture, clinical presentation, investigations, management, and outcome was analyzed. One thousand six hundred and twenty-nine patients from 21 original articles were included in the study. The mean age ± standard deviation of the patients was 33.3 ± 3.23 years. Etiologies of penile fracture were vigorous sexual intercourse, manual bending of erect penis, vigorous masturbation, rolling over in bed and blunt trauma in 41%, 29%, 10%, 14% and 6% patients, respectively. Treatment choices were surgery and conservative, in 1580 (95%), 83 (5%) patients, respectively. A higher incidence of complications was found in conservatively treated patients. As a conclusion, in the last 10 years, vigorous sexual intercourse was the commonest etiology of penile fracture in the Middle East and Central Asia regions. Surgery remains the preferred treatment option for patients diagnosed with penile fracture.

The effect of fasting on erectile function and sexual desire on men in the month of Ramadan

PURPOSE

To determine the effect of Ramadan intermittent fasting on erectile function (EF), sexual desire and serum hormone levels.

MATERIALS AND METHODS

Eligible male participants completed the two domains of International Index of Erectile Function (IIEF) questionnaire for EF and sexual desire. They also provided information on any known disease, treatment taking, smoking habits and frequency of sexual intercourse. Frequency of sexual intercourse, two domains of IIEF questionnaire, serum hormone levels, body weight before and four-weeks after the end of month of Ramadan were also recorded.

RESULTS

Overall, 45 men, with a mean age of 37 ± 7.2 years, participated in the study. Frequency of sexual intercourse (P = .046), sexual desire (P = .002), body weight (P = .009) and serum follicle stimulating hormone (FSH) level (P = .016) decreased significantly at the end of month of Ramadan compared to baseline. No statistically significant differences were found on EF (P = .714), serum testosterone (P = .847), luteinizing hormone (P = .876), estradiol (P = .098) and dehydroepiandrosterone sulfate levels (P = .290).

CONCLUSION

Ramadan intermittent fasting might be associated with decrease in sexual desire, frequency of sexual intercourse and serum FSH level.

Extracorporeal transient distal penile corporoglanular shunt in early ischemic priapism treatment

PURPOSE

Ischemic priapism, which is a compartment syndrome, needs urgent treatment in order to nourish corpora cavernosa. As the first step, the aspiration of blood and/or the irrigation of the cavernosal bodies are performed to prevent fibrotic activity and secure erectile capability. While performing aspiration and irrigation, there are some risks of the procedure in which most refrained one is cardiovascular side effects of adrenergic agonists. We aimed to evaluate extracorporeal transient distal penile corporoglanular shunt technique in place of aspiration/ irrigation techniques for early ischemic priapism treatment.

MATERIALS AND METHODS

In this transient shunt technique, a sterile closed system blood collection set (BD Vacutainer, Cat. No.: 367282; NJ, USA), which has two 21G needles, was used. The length of the needle and tubing was 19 mm. (0.75 inch) and 178 mm. (7 inches), respectively. This blood collection set was designed to be used not only for blood collection but can also be used for short term infusions (maximum 2 hours).

RESULTS

Ten patients out of fifteen with early ischemic priapism were successfully treated with this transient shunt technique. The permanent detumescence achieved in the first 10 minutes in nine out of fifteen patients.No additional procedure needed after the disappearance of rigidity in successfully treated patients. The permanent detumescence achieved in the first 10 minutes in nine out of fifteen patients.

CONCLUSIONS

We demonstrated that this extracorporeal transient shunt technique gets some advantages over aspiration and irrigation in early ischemic priapism treatment. Our results indicate thatthe presented technique to be offered for the patients with an ischemic priapism episode of no more than 7 hours.

Erectile dysfunction in qatar: prevalence and risk factors in 1,052 participants-a pilot study

AIM

The aim of this study is to investigate the prevalence of erectile dysfunction (ED) in Qatar and to determine the risk factors associated with it.

MATERIALS AND METHODS

This is a cross-sectional survey study of men attending the outpatient department at Hamad Medical Corporation in Qatar between February 2012 and February 2013. The International Index of Erectile Function (IIEF)-5 questionnaire was used for data collection. In addition to the IIEF-5 score, each participant's medical history was taken, with special emphasis on risk factors for ED, including diabetes mellitus (DM), hypertension (HTN), dyslipidemia, coronary artery disease (CAD), and smoking habits, and on their body mass index.

RESULTS

One thousand fifty-two participants were randomly selected to fill out the IIEF-5 questionnaire. The participants' mean age (±SD) was 41.87 ± 13.24 years. Analysis of replies to the IIEF-5 showed that ED was present in 573 out of 1,052 participants (54.5%). Fifty-six (5%) participants had severe ED, 61 (6%) had moderate ED, 173 (16%) had mild to moderate ED, and 283 (27%) had mild ED. Risk factors for ED that held statistical significance were age (odds ratio [OR] = 2.9, 95% confidence interval [CI] 2.1-4.1, P < 0.001), DM (OR = 2.6, 95% CI 1.7-3.9, P < 0.001), HTN (OR = 1.6, 95% CI 1.1-2.5, P = 0.012), dyslipidemia (OR = 1.5, 95% CI 1.1-2.4, P = 0.024), and CAD (OR = 3.2, 95% CI 1.3-7.5, P = 0.009).

CONCLUSION

We found that the prevalence rate of ED in Qatar is quite similar to the regional reported rates. Overall, we demonstrated that nearly more than half of our participants suffered from ED. Besides age, DM, HTN, CAD, and dyslipidemia were found to be the most important risk factors for ED. Al Naimi A, Majzoub AA, Talib RA, Canguven O, and Al Ansari A. Erectile dysfunction in Qatar: Prevalence and risk factors in 1,052 participants-A pilot study. Sex Med 2014;2:91-95.

The impact of sexual activity on serum hormone levels after penile prosthesis implantation

OBJECTIVES

Penile prosthesis implantation is the final treatment option for patients who have erectile dysfunction. Most of the patients use their penile prosthesis successfully and frequently for penile-vaginal intercourse. Previous literature showed that decrease in sexual activity resulted in decreased serum testosterone levels and vice versa. The aim of this study was to examine the impact of sexual activity on serum sex hormone levels after penile prosthesis usage.

MATERIAL AND METHODS

In this study, we examined sixtyseven patients for their sex hormone changes who had penile prosthesis surgery 2.7 ± 1.5 years ago.

RESULTS

Patients were using their penile prosthesis for sexual activity with a mean of 9.9 ± 5.7 times per month. Dehydroepiandrosterone sulfate was significantly higher compared to pre-surgery results (5.3 ± 2.6 vs 4.5 ± 2.9; p = 0.031). Mean serum total testosterone levels of patients before and after penile prosthesis usage were clinically significant 15.78 ± 4.8 nmol/L and 16.5 ± 6.1 nmol/L, respectively. Mean serum luteinizing hormone levels of patients before and after penile prosthesis usage were 3.98 ± 2.16 IU/L and 5.47 ± 4.76 IU/L, respectively. No statistical significance difference was observed in the mean total and free testosterone, estradiol and luteinizing hormone levels between pre- and post-surgery.

CONCLUSION

This study results demonstrated that sexual activity changed sex hormone levels positively among those men who were implanted penile prosthesis because of erectile dysfunction.

Impact of sexual activity on glycated hemoglobin levels in patients with type 2 diabetes mellitus after penile prosthesis implantation

PURPOSE

To examine the benefits of sexual activity on glycated hemoglobin (HbA1c)in penile prosthesis implanted patients with type 2 diabetes mellitus (DM).

MATERIALS AND METHODS

Sixty-seven male subjects who had HbA1c levels of ≥ 6.5% before and could perform regular sexual activity after the implantations were enrolled. The contribution of sexual activity on glycemic control assessed by HbA1c level as well as age, duration of DM and frequency of sexual activity were evaluated.

RESULTS

Mean age and mean time from the surgery of the study patients was 59.9 years (range,30-82) and 22.6 months (range, 10-63), respectively. The average of penile prosthesis usage for sexual activity was 9.9 times per month (range, 2-28). Compared with the preimplantation, the absolute mean change in HbA1c after penile prosthesis implantation was found as - 0.2% (P > .05). This study also revealed that more sexual activity was associated with more reduction in HbA1c.

CONCLUSION

The present study demonstrated that sexual activity is associated with HbA1c reduction, which is clinically important in patients with type 2 DM after penile prosthesis implantation.

Treatment of penile strangulation by the rotating saw and 4-needle aspiration method: two case reports

INTRODUCTION

The aim of this article was to describe our experience in using rotating saw and also combination of the instrument with 4-needle aspiration.

METHODS

A comprehensive review of the literature was performed using PubMed. "Penile strangulation, -constriction, -incarceration, -entrapment" were used as search terms, and a manual bibliographic review of cross referenced items was performed.

RESULTS

Search results yielded nearly 70 cases of penile strangulation caused by a variety of objects. Various instruments have been described in the literature for their safe removal, each with its own pros and cons.

CONCLUSIONS

Penile strangulation should be accepted as a self-induced priapism and managed as an emergency in order to preserve erectile function and to prevent penile necrosis. Surgical creativity and patience are necessary in order to have a successful outcome.

Withdraw of the ureteroscope causes fragmented ureter stones to disperse

INTRODUCTION

Ureteroscopy has improved from the first use of ureteroscope in the 1970' s. Although the success rate increased in the last years, new treatment techniques are being developed for impacted and large proximal ureter stones (2). Pneumatic lithotripsy has high efficiency with low complication rates. However, in case of steinstrasse and large (> 1 cm) ureter stones, fragmented small stones may obstruct insertion of a ureteroscope after initial lithotripsy. In order to triumph over this issue, multiple ureteroscopic passages and manipulations needed for extraction of these small stones by forceps or basket catheters. The overall incidence of stricture was found upto 14.2% when the fragments were removed with a grasping forceps or a basket. We present our technique to disperse small fragmented stones in order to contact non-fragmented rest stone.

MATERIALS AND METHODS

Ureteral lithotripsy was performed with an 8-9.8F semirigid ureteroscope using a pneumatic lithotripter (Swiss LithoClast, EMS, Nyon, Switzerland). The stone was fragmented into small pieces as small as 2-3 mm. by pneumatic lithotripter. Eventually, these fragmented stones interfered with vision and the lithotripter to get in touch with the rest stone. After fragmenting distal part of the large stone, the ureteroscope was pulled back out of ureter. While pulling back, the operating channel was closed and irrigation fluid was flowing in order not to decrease pressure behind the stones. Simultaneously, a person tilted the operating table to about 30 in reverse Trendelenburg position. When the ureteroscope was out of ureteral orifice, the operating channel was opened and irrigation fluid was stopped. This maneuver aided decreasing pressure in the bladder more rapidly in addition to feeding tube. Stone dust and antegrade fluid flow were easily seen out of the ureteral orifice. Ureteroscope was re-inserted after 30-60 seconds. While reaching the rest of the stone, small stone dust was seen at first. Bigger stones were approximately 3-5 cm distal to the original place of the stone. When the non-fragmented rest stone appeared, there were no blocking fragmented stones. Insertion of the ureteroscope was easy and we could go on with the lithotripsy procedure.

CONCLUSIONS

In comparison to standard position, tilting and rapid decrease in pressure by pulling back the ureteroscope made gravity and negative pressure more effective.

Axial penile rigidity influences patient and partner satisfaction after penile prosthesis implantation

INTRODUCTION

Penile prosthesis implantation is one of the treatment choices that is kept for patients who were not satisfied with other treatments. Although penile prosthesis satisfaction rates are higher, there are some dissatisfied patients. The patients’ reasons are mostly shortness and softness of implanted prosthesis. It was previously demonstrated that penile axial rigidity of more than 500 grams is enough for successful vaginal intromission. To our knowledge, there is no study comparing axial rigidity of penile prosthesis and satisfaction.

OBJECTIVES

The aim of this study was to examine whether axial rigidity of penile prosthesis had impact on patient and partner satisfaction.

MATERIALS AND METHODS

We enrolled one hundred patients who were implanted penile prosthesis before to evaluate their penile axial rigidity. We used Rigidometry (by using the digital inflection rigidometer) to assess the minimal axial pressure to bend the implanted penis.

RESULTS

We demonstrated that mean axial pressure to bend the implanted penis was 984.8 ± 268.7 grams. Overall satisfaction score with the penile prosthesis implant was 4.55 and 4.49 (out of 5) in patients and partners, respectively. In total, seven men were unsatisfied with their implant and reported a mean satisfaction score of 0.6 ± 0.48 (out of 5). All prostheses types showed good and more than 500 grams axial rigidity. The patients with Ambicor type, which were buckled at about 710.5 grams, showed worse satisfaction rates in comparison to other prostheses in two patients. Digital inflection rigidometer results of other penile prosthesis types in unsatisfied patient were 842.0, 872.0, 887.0 and 920 g. in CX700, Titan, Genesis and Titan OTR, respectively.

CONCLUSION

We demonstrated that dissatisfaction rate was highest in Ambicor prosthesis implanted patients. Additionally, patients with 3-piece penile prosthesis were more satisfied than 2-piece or malleable ones, interestingly, although some cases had lower axial rigidity results.

Corticosteroid therapy improves the outcome of semen analysis in an oligozoospermic patient with epididymal sarcoidosis

Sarcoidosis is a multisystem, inflammatory disorder characterized by the presence of noncaseating epithelioid granulomas. Sarcoidosis can involve the genitourinary system by affecting the kidney and genitals. Most characteristic genital lesions proceed to granuloma and can comprise the epididymis, testis, and vas deferens. Few case reports have been published on this rare entity. We report a case in which a man presented with bilateral epididymal sarcoidosis and severe oligospermia. Corticosteroid treatment, which was applied in gradually decreasing doses for 6 months, dissolved the testicular granuloma. Consequently, semen analysis demonstrated a significant increase in the sperm count to within normal limits.

Transient distal penile corporoglanular shunt as an adjunct to aspiration and irrigation procedures in the treatment of early ischemic priapism

Purpose

Ischemic priapism, a compartment syndrome, requires urgent treatment in order to nourish the corpora cavernosa. As the first step, aspiration of blood and irrigation of the cavernosal bodies is performed to prevent fibrotic activity and secure erectile capability. During aspiration, there are risks of cardiovascular side effects of adrenergic agonists. We aimed to evaluate a transient distal penile corporoglanular shunt technique in place of aspiration and irrigation techniques for treatment of early ischemic priapism.

Materials and Methods

A transient distal penile shunt was applied to 15 patients with early ischemic priapism between January 2011 and May 2012. Priapism duration, history, causes, pain, and any prior management of priapism were assessed in all patients. A complete blood count and penile Doppler ultrasonography were performed, which showed attenuated blood flow in the cavernosal artery. A sterile closed system blood collection set, which has two needles and tubing, was used for the transient distal penile shunt.

Results

Ten of 15 patients with early ischemic priapism were successfully treated with this transient shunt technique. No additional procedures were needed after the resolution of rigidity in the 10 successfully treated patients.

Conclusions

The transient nature of this technique is an advantage over aspiration and irrigation in the treatment of early ischemic priapism. Our results indicate that the technique can be offered for patients with an ischemic priapism episode of no more than 7 hours.

Isolated pump erosion of an inflatable penile prosthesis through the scrotum in a diabetic patient

Isolated pump erosion is a rare complication in patients with inflatable penile prosthesis. We describe a case of a diabetic patient who underwent inflatable penile prosthesis implantation with subsequent isolated pump erosion. Repeated attempts of conservative repair of the erosion failed. Finally, the inflatable penile prosthesis was replaced with a malleable one to avoid new pump erosion. In case of isolated pump erosion, replacement of the inflatable penile prosthesis with a malleable one looks to be a good alternative salvage treatment for the patient.

Which is guilty in self-induced penile fractures: marital status, culture or geographic region? A case series and literature review

Penile fracture is a well-recognized and relatively uncommon clinical entity. It was previously reported that the incidence of penile fracture varies according to various geographic regions. In order to determine whether marital status or culture other than geographic region is involved in the etiology of penile fracture in our country, the charts of 122 men diagnosed with penile fracture were retrospectively reviewed. Detailed history including cause, symptoms, country of origin and a single-question self-report of erectile dysfunction was used for all cases. Diagnosis of our cases was mainly based on history and physical examination and ultrasonography. Immediate or delayed surgical repair of penile fracture included a degloving circumferential, and an additional direct incision, if the site of the tear could not be reached via degloving, was performed. The patients were evaluated after 1 week and 1, 3, and 6 months follow-up by penile examination, recording complications, and with a single-question self-report questionnaire after 3 and 6 months. The most common cause of penile fracture was manual bending of the erected penis in 66 out of 122 (54.1%) of our study patients. In our study, we believe that the prime causes of bending the penis are single status and culture, which are influencing factors irrespective of the geographic distribution.

Hemangiopericytoma of kidney: case report and review of the literature

Hemangiopericytoma, which is derived from pericytes, is rarely seen in the kidney and adical nephrectomy with or without chemotherapy is the treatment of choice in most of the cases. We report a fifty-year-old male patient presenting with gross hematuria that radiologic evaluation confirmed due to a solid mass in the right kidney. Its clinical manifestations and radiologic tests were similar to renal cell carcinoma. Radical nephrectomy was performed and the pathological examination revealed the specimen as hemangiopericytoma. No additional treatment was added and the patient remained disease free at the end of the first year follow up after radical nephrectomy.

Distribution of Cajal like cells and innervation in intrinsic ureteropelvic junction obstruction

OBJECTIVES

C-kit positive interstitial cells of Cajal (ICC)-like cells are defined as pacemaker cells in the ureter, which produce and coordinate peristaltic motility. To investigate the changes in ICC-like cells and innervation in segments of intrinsic uretero-pelvic junction (UPJ) obstruction.

MATERIAL AND METHODS

Full thickness specimens obtained from UPJ segments (n = 77) were divided into 3 groups. Group I included 32 intrinsic UPJ obstruction segments, separated into 3 subgroups: Group Ia (proximal), Group Ib (obstruction, intermediate) and Group Ic (distal segments). Group II included 30 normal UPJ segments derived from the nephrectomy specimens. In Group III, 15 UPJ segments of chronic obstruction were analyzed. Formalin fixed, paraffin embedded specimens from UPJs were analyzed immunohistochemically for CD117, S100 and synaptophysin protein expression in nerve plexus and ganglionic cells in the neuromuscular junction.

RESULTS

Group Ib showed significantly decreased (p < 0.05) positive staning with c-kit protooncogene protein (CD117), S100 and synaptophysin proteins compared with Group Ia and Group Ic. ICC-like cells were observed in increased number (p < 0.05) in Group Ia compared to Groups II and III. Group Ib had lower synaptophysin positivity compared to Group II.

CONCLUSIONS

The findings support the hypothesis of decreased innervation in the etiopathogenesis of intrinsic UPJ obstruction. Increased number of ICC-like cells in Group Ia suggests that peristaltic activity is higher in pelvicalyceal region.

Anorectal functions after perineal and retropubic radical prostatectomy - a prospective clinical and anal manometric assessment

INTRODUCTION

The aim of this study is to evaluate the anorectal functions of prostate cancer patients who have undergone radical perineal prostatectomy (RPP) or radical retropubic prostatectomy (RRP) surgery.

MATERIAL AND METHODS

Thirty-seven patients with an indication for radical prostatectomy were included after informed consent. Anorectal manometry was performed before and one month after the surgery in 22 RPP and 15 RRP patients in our clinic. Clinical assessment was evaluated by anorectal functions with anal incontinence scoring (AIS) (Fernandez; no incontinence = 0; maximal incontinence = 12). Patients with a history of anorectal surgery were excluded from the study. The following data were recorded: external anal sphincteric pressure (EASP), internal anal sphincteric pressure (IASP), minimum ano-rectal reflex volume (MARRV) and minimum rectal sensory volume (MRSV).

RESULTS

In the RPP and RRP groups, the mean age was 66 (56-75) and 64.3 (52-73) years, respectively. In the RPP group, EASP and IASP values showed a significant decrease after the surgery. In the RRP group, EASP and IASP were also decreased after the surgery, but without statistical significance. No significant change was seen in MARRV and MRSV of either group. When the scores of AIS were analysed, no significant clinical difference between pre- or post-operative scores was seen in RPP and RRP groups.

CONCLUSIONS

Perineal or retropubic surgery may injure pelvic floor muscles and/or supplying nerves, which likely causes anorectal dysfunction. Although there is a significant decrease in early postoperative EASP and IASP after RPP, it has no clinical significance according to AIS.

Factors affecting the degree of penile deformity in Peyronie disease: an analysis of 1001 patients

Only a few studies have investigated the association between the severity of Peyronie disease (PD) and clinical parameters such as age and associated comorbidities. The aim of this study was to report the relationship between the degree of curvature of the penis and the clinical parameters among patients with PD. A total of 1001 patients with PD were evaluated retrospectively in terms of penile deformity, erectile status, and risk factors for systemic vascular diseases. The degree of curvature was assessed with a protractor during maximum erection in response to a combined injection and stimulation test and/or vacuum device. A modified Kelami classification was used to categorize penile deformities as follows: patients with deformities without curvature (notching, hourglass, and swan neck deformity, group 1), with mild curvature (≤ 30 degrees, group 2), with moderate curvature (31-60 degrees, group 3), or with severe curvature (> 60 degrees, group 4). Chi-square tests, 1-way analysis of variance, and univariate and multiple ordinal regression analyses were used for statistical analysis. Penile deformity without curvature was detected in 12.3% of the patients, whereas the curvature was less than 30 degrees in 39.5%, 30 to 60 degrees in 34.5%, and more than 60 degrees in 13.5% of the patients. Multiple ordinal regression analysis identified age (P = .013), side of deformity (P = .007), erectile dysfunction (P < .0001), and diabetes mellitus (P = .001) as significant independent predictors of the severity of penile curvature. In conclusion, patients' age, side of deformity, erectile function, and diabetes were significantly associated with the degree of curvature.

Is there a correlation between testosterone levels and the severity of the disease in male patients with obstructive sleep apnea?

OBJECTIVES

Obstructive sleep apnea (OSA) is a prevalent disease that can decrease quality of life. The aim of this study was to investigate the relationship between serum testosterone levels and the severity of the disease in patients with OSA.

MATERIAL AND METHODS

Severity of OSA was quantified with apnea-hypopnea index (AHI) which was defined as the total number of apneas and hypopneas per hour of sleep. Thirty-six male patients with mild-to-severe stable OSA and thirty age-matched subjects without OSA were included in this study. Erectile function was assessed by the International Index of Erectile Function (IIEF)-5. The association between severity of OSA and selected comorbidities was evaluated and compared with findings reported in the literature.

RESULTS

Mean serum testosterone levels of OSA and control patients were 462.8 +/- 160.3 ng/dL and 486.9 +/- 163.2 ng/dL, respectively (p > 0.05). There was a significant negative correlation between serum testosterone levels and AHI in patients with OSA (r = - 0,502, p < 0.01). Mean IIEF scores of OSA and control patients were 17.5 +/- 5.9 and 17.4 +/- 4.7, respectively (p > 0.05). Body mass index (BMI) of the OSA patients and control group were as 30.1 +/- 0.8 and 26.9 +/- 0.4, respectively (p < 0.01).

CONCLUSIONS

Serum testosterone levels were negatively correlated with BMI and the severity of OSA. Measuring testosterone level may be an additional helpful indicator in diagnosis of severity and in follow-up of OSA.

Endoscope-assisted radical perineal prostatectomy

Dissection of the bladder neck is particularly important in patients who have previously had prostate surgery due to hyperplasia. We describe an endoscope-assisted radical perineal prostatectomy (RPP) technique that facilitates the dissection of the prostate-vesical junction. The technique was employed in four patients with a history of transurethral prostate resection. Before dissecting the prostate from the bladder neck during RPP, we circumscribed the bladder neck perurethrally with a Collins knife. The remaining of the RPP procedure was performed via the traditional approach. The incision of the prostate-vesical junction with the Collins knife protected the bladder-neck integrity and made the dissection of this junction easier. The final pathologic diagnosis was organ-confined prostate cancer with negative surgical margins. All the patients had continence during a 6-month follow-up. The major advantage of this technique is to precisely locate the prostate-vesical junction under direct vision. Our modified technique may prove to be a simple, less invasive, and oncologically safe method to manage the bladder neck perurethrally.

Combination of vacuum erection device and PDE5 inhibitors as salvage therapy in PDE5 inhibitor nonresponders with erectile dysfunction

INTRODUCTION

Oral phosphodiesterase type 5 inhibitors (PDE5i) have improved treatment options for erectile dysfunction (ED). In case of unresponsiveness to PDE5i, alternative therapies are considered.

AIM

To evaluate whether combination of vacuum erection device (VED) and PDE5i is effective as salvage therapy in subjects with ED in whom PDE5i alone failed.

METHODS

From September 2007 to May 2008, we evaluated 69 men (aged 36-82 years) in whom PDE5i treatment at the highest recommended dose, with at least 4-6 attempts at intercourse during a 3 months period, had failed. The clinical efficacy of combination therapy was evaluated using the International Index of Erectile Function-5 (IIEF-5) questionnaire, Sexual Encounter Profile (SEP)-2, SEP-3, and Global Patient Assessment Scale (GPAS).

MAIN OUTCOME MEASURES

Scores on IIEF-5, SEP-2, SEP-3, and GPAS before and after combination therapy were measured.

RESULTS

After 4 weeks of combination therapy, the mean IIEF-5 score increased significantly over baseline from 9.0 to 17.6 (P < 0.001). Of the 34 subjects with a SEP-2 response of "no" at baseline, 27 (79%) responded "yes" after combination therapy (P < 0.001). Of the 50 subjects with a SEP-3 response of "no" at baseline, 35 (70%) responded "yes" after combination therapy (P < 0.001). Furthermore, of the 42 subjects with a GPAS response of "not at all" or "slightly" improved at baseline, 31 (74%) responded "moderately" or "greatly" improved after combination therapy (P < 0.001). One subject (1.5%) experienced device-related intermittent penile pain, which resolved after 4 days without any action.

CONCLUSIONS

Statistically significant improvements over baseline were seen in IIEF-5, SEP-2, SEP-3, and GPAS measures following 4 weeks of combination therapy of PDE5i and VED. This study supports the use of PDE5i with VED in men in whom PDE5i alone failed. This combination therapy may be offered to patients not satisfied with PDE5i alone before being switched to more invasive alternatives.

Losartan preserves erectile function after bilateral cavernous nerve injury via antifibrotic mechanisms in male rats

PURPOSE

Angiotensin II is a known mediator of smooth muscle vasoconstriction and fibrosis. It up-regulates thrombospondin-1, a major activator of latent transforming growth factor-beta. Transforming growth factor-beta induces vascular fibrosis via intracellular SMAD signaling pathways. We evaluated the effect of treatment with the angiotensin II type 1 receptor antagonist losartan on erectile function in the rat following bilateral cavernous nerve injury.

MATERIALS AND METHODS

A total of 36 adult male rats were divided equally into 6 groups, including group 1-sham surgery with cavernous nerve exposure only plus vehicle, group 2-sham surgery plus oral low dose losartan (10 mg/kg per day), group 3-sham surgery plus high dose losartan (40 mg/kg per day), group 4-bilateral cavernous nerve injury (3-minute crush using a hemostat clamp) plus vehicle, group 5-bilateral cavernous nerve injury plus low dose losartan and group 6-bilateral cavernous nerve injury plus high dose losartan. Seven days following surgery erectile function was measured by electrically stimulating the cavernous nerves and monitoring intracavernous pressure. Penile tissue was collected for Western blot analysis of fibronectin, transforming growth factor-beta, thrombospondin-1, alpha-actin, and phosphorylated and total SMAD2 and SMAD3 expression.

RESULTS

Erectile function was significantly decreased after bilateral cavernous nerve injury compared with that after sham surgery (p <0.01). Low and high dose losartan preserved erectile function after bilateral cavernous nerve injury compared to that in vehicle controls (p <0.01 and <0.05, respectively). Fibronectin, pSMAD2, pSMAD3, transforming growth factor-beta-1, thrombospondin-1 and alpha-actin expression was up-regulated, and total SMAD2 and SMAD3 expression was down-regulated in the penis after bilateral cavernous nerve injury. Each dose of losartan after bilateral cavernous nerve injury significantly attenuated the up-regulated expression of fibronectin (p <0.01), pSMAD2 (p <0.05) and thrombospondin-1 (p <0.05), and up-regulated total SMAD2 (p <0.05).

CONCLUSIONS

These data suggest that fibrotic activators in the penis may cause decreased erectile function after bilateral cavernous nerve injury. Angiotensin II type 1 receptor antagonism may counteract this effect and promote erectile function preservation for conditions associated with penile fibrosis.

The effect of 5 alpha-reductase inhibitors on erectile function

The 5 alpha-reductase inhibitors, which inhibit conversion of testosterone to dihydrotestosterone, are used for miscellaneous clinical applications, including the treatment of benign prostatic hyperplasia and male pattern hair loss, and for possible reduction of the risk of prostate cancer. Erectile dysfunction has been associated with 5 alpha-reductase inhibitors. Overall, reports in the literature suggest rates of erectile dysfunction to be between 0.8%-33% in men using these medications. However, randomized controlled studies report the rates of erectile dysfunction to be between 0.8%-15.8%. The possible risk association is that these medications impact androgen function, which is understood to contribute to normal erectile physiology. The 5 alpha-reductase inhibitors result in a drop in median serum dihydrotestosterone levels by 60%-93% within 2 years, but there is no major change in testosterone levels. In this review, we surveyed studies on erectile dysfunction in patients treated with 5 alpha-reductase inhibitors and critically examined the evidence that associates 5 alpha-reductase inhibitors and erectile dysfunction. We conclude that 5 alpha-reductase inhibitors do not lead to erectile dysfunction to a significant degree, and we support the position that dihydrotestosterone is less relevant than testosterone in erectile function.