Andrew T. Gabrielson

Erectile Dysfunction in Young Men—A Review of the Prevalence and Risk Factors

INTRODUCTION Erectile dysfunction (ED) is an important health concern that can significantly affect a mans psychosocial well-being. ED has traditionally been considered a disease of old age; however, contemporary evidence suggests a growing incidence of ED in men younger than 40 years. The process of achieving an erection is multifaceted; there are many potential mechanisms that can be disrupted. It is critical to identify the specific causes of ED before proceeding with potentially costly and invasive therapeutic options. Advances in diagnostic and treatment modalities offer opportunities to identify and manage young men with ED. AIM To provide an update on the prevalence and risk factors of ED in young men and to provide a framework to guide clinicians in identifying and managing the affected young man. METHODS Comprehensive review of the literature pertaining to ED in young men. MAIN OUTCOME MEASURES ED in young men was assessed by outlining the prevalence according to recent epidemiologic studies. The pathophysiology, diagnostic considerations, risk factors, and etiologies were reviewed. RESULTS Large multinational studies have estimated the prevalence of ED in young men to be as high as 30%. Several studies have stratified the etiologies of ED into psychogenic and organic causes. Psychogenic etiologies of ED include depression, anxiety, and partner-related difficulties. These patients tend to experience sudden onset of symptoms, with decreased libido and good quality of spontaneous or self-stimulated erections. Organic etiologies include vasculogenic, endocrinologic, neurogenic, iatrogenic, and structural components. These patients usually experience gradual onset of symptoms and a low to normal libido. Conservative treatments such as phosphodiesterase type 5 inhibitors continue to be the mainstay treatment. CONCLUSIONS ED in young men is an increasingly common condition. A careful diagnostic evaluation should focus on the identification of any underlying etiology to ensure appropriate management of patients. Nguyen HMT, Gabrielson AT, Hellstrom WJG. Erectile Dysfunction in Young Men-A Review of the Prevalence and Risk Factors. Sex Med Rev 2017;5:508-520.

Collagenase Clostridium Histolyticum in the Treatment of Peyronie's Disease: Review of a Minimally Invasive Treatment Option

Peyronies disease (PD) is an inflammatory disorder characterized by an abnormal collagen deposition in the tunica albuginea of the penis, leading to fibrous and non-compliant plaques that can impede normal erection. Although pharmacological treatments are available, only intralesional injection therapy and surgical reconstruction have demonstrated tangible clinical efficacy in the management of this condition. Intralesional injection of collagenase clostridium histolyticum (CCH) has come to the forefront of minimally invasive treatment of PD. In this review, the authors provide an update on the safety, efficacy, and indications for CCH. The efficacy of CCH will be assessed on the basis of improvement in the severity of penile fibrosis, curvature, and pain. Numerous well-designed clinical trials and post-approval studies involving more than 1,500 patients have consistently demonstrated the efficacy and tolerability of CCH in the treatment of PD. CCH significantly decreases penile curvature and plaque consistency, as well as improves quality of life. Post-approval studies continue to demonstrate the efficacy of CCH despite broader inclusion criteria for treatment, such as the case with acute phase disease and atypical plaque deformities (i.e., ventral plaques, hourglass narrowing). CCH continues to be the gold standard for non-surgical management of stable phase PD, in the absence of strong evidence supporting oral therapy agents and ongoing evaluation of extracorporeal shockwave therapy. However, recent studies are beginning to provide precedent for the use of CCH in the management of acute phase and atypical PD.

Nondestructive Diagnosis of Kidney Cancer on 18-gauge Core Needle Renal Biopsy Using Dual-color Fluorescence Structured Illumination Microscopy.

OBJECTIVE To present a novel imaging technique used for rapid, nondestructive histological assessment of renal neoplasias using a dual-component fluorescence stain and structured illumination microscopy (SIM). MATERIALS AND METHODS After Institutional Review Board approval, 65 total biopsies were obtained from 19 patients undergoing partial or radical nephrectomy. Biopsies were stained with a dual-component fluorescent, and optically sectioned SIM images were obtained from the surface of the intact biopsies. Specimens were subsequently fixed and analyzed using hematoxylin and eosin (H&E) histopathologic methods and compared with SIM images. A single, board-certified pathologist blinded to specimens reviewed all SIM images and H&E slides, and determined the presence or absence of neoplasias. Results of blinded diagnosis of SIM were validated against traditional pathology. RESULTS Of the 19 patients, 15 underwent robotic partial nephrectomies and 4 underwent laparoscopic nephrectomies. Indications included clinical suspicion of renal cell carcinoma. In total, 65 biopsy specimens were available for review. Twenty-one specimens were determined to be neoplastic on H&E, whereas 41 represented benign renal tissue. The final sensitivity and specificity of our study were 79.2% and 95.1%, respectively. CONCLUSION SIM is a promising technology for rapid, near-patient, ex vivo renal biopsy assessment. By improving the ability to rapidly assess sufficiency of biopsy specimens and enabling immediate diagnostic capability, SIM aids in more effective biopsy performance, tissue triage, and patient counseling regarding management options. Additionally, because tissue is preserved, effective utilization of downstream diagnostic tests and molecular assessments are possible.

Rethinking active surveillance for prostate cancer in African American men

Active surveillance (AS) is a treatment modality for prostate cancer that aims to simultaneously avoid overtreatment and allow for the timely intervention of localized disease. AS has become the de facto standard of care for most men with low-risk prostate cancer. However, few African American (AA) men were included in the prospective observational cohorts that resulted in a paradigm shift in treatment recommendations from active intervention toward AS. It has been established that AA men have an increased prostate cancer incidence, higher baseline prostate-specific antigen (PSA) values, more aggressive prostate cancer features, greater frequency of biochemical recurrence after treatment, and higher overall cancer-specific mortality compared to their Caucasian counterparts. As such, this has given many physicians pause before initiating AS for AA patients. In the following manuscript, we will review the available literature regarding AS, with a particular focus on AA men. The preponderance of evidence demonstrates that AS is as viable a management method for AA with low-risk prostate cancer as it is with other racial groups.

Role of Penile Prosthesis in Priapism: A Review

Ischemic priapism is a urological emergency that has been associated with long-standing and irreversible adverse effects on erectile function. Studies have demonstrated a linear relationship between the duration of critically ischemic episodes and the subsequent development of corporal fibrosis and irreversible erectile function loss. Placement of a penile prosthesis is a well-established therapeutic option for the management of erectile dysfunction secondary to ischemic priapism, and will be the focus of this review. Review of the current literature demonstrates a growing utilization of penile prostheses in the treatment of erectile dysfunction secondary to ischemic priapism. Unfortunately, there is a paucity of randomized-controlled trials describing the use of prosthesis in ischemic priapism. As a result, there is a lack of consensus regarding the type of prosthesis (malleable vs. inflatable), timing of surgery (acute vs. delayed), and anticipated complications for each approach. Both types of prostheses yielded comparable complication rates, but the inflatable penile prosthesis have higher satisfaction rates. Acute treatment of priapism was associated with increased risk of prosthetic infection, and could potentially cause psychological trauma, whereas delayed implantation was associated with greater corporal fibrosis, loss of penile length, and increased technical difficulty of implantation. The paucity of high-level evidence fuels the ongoing discussion of optimal use and timing of penile prosthesis implantation. Current guidance is based on consensus expert opinion derived from small, retrospective studies. Until more robust data is available, a patient-centered approach and joint decision-making between the patient and his urologist is recommended.

The Impact of Thyroid Disease on Sexual Dysfunction in Men and Women

BACKGROUND Individually, thyroid disease and sexual dysfunction are common conditions that can have a detrimental effect on quality of life. Recent reports have documented an increased prevalence of sexual dysfunction among patients with thyroid disorders. As such, it is important for sexual medicine physicians to be primed on the presentation of patients with overlying sexual and thyroid dysfunction to allow for proper management. AIM To review the available literature exploring the relationship between thyroid disease and sexual dysfunction in men and women. METHODS A PubMed review of existing clinical and pre-clinical studies from 1978 through 2018 was performed. MAIN OUTCOME MEASURES The prevalence, symptomatology, pathophysiology, diagnosis and management of patients with sexual dysfunction in the setting of thyroid disease were reviewed. RESULTS The prevalence of sexual dysfunction in patients with hypothyroid (59-63% and 22-46% in men and women, respectively) and hyperthyroidism (48-77% and 44-60% in men and women, respectively) has been estimated in select populations. Both hypothyroidism and hyperthyroidism were strongly associated with erectile and ejaculatory dysfunction: hypothyroidism with delayed ejaculation, hyperthyroidism with pre-mature ejaculation. Hypothyroidism and hyperthyroidism have been reported to impair libido in men and women; however, evidence of hypothyroidisms impact on male libido is mixed. Hypothyroid and hyperthyroid women demonstrated impairments in desire, arousal/lubrication, orgasm, satisfaction, and pain during intercourse. Mechanistically, hypothyroidism and hyperthyroidism exert effects on circulating sex hormone levels through peripheral and central pathways and can indirectly provoke psychiatric and autonomic dysregulation that can impair sexual function. Correction to euthyroid state was associated with dramatic resolution of sexual dysfunction in both male and female patients with hypothyroidism or hyperthyroidism. CONCLUSION By improving awareness of the link between thyroid disease and sexual dysfunction, sexual medicine physicians may sooner identify patients whose sexual symptoms may be remedied by treating an underlying thyroid disorder. Gabrielson AT, Sartor RA, Hellstrom WJG. The Impact of Thyroid Disease on Sexual Dysfunction in Men and Women. Sex Med Rev 2019;7:57-70.

Chapter 35 – Posttraumatic Stress Disorder and Its Effects on Men’s Sexual and Reproductive Health

Abstract Posttraumatic stress disorder (PTSD) is a complex somatic, cognitive, and behavioral condition that occurs following traumatic events. Patients with PTSD often exhibit intrusive thoughts, nightmares, flashbacks of past traumatic events, hypervigilance, avoidance of reminders of trauma, and sleep disturbance, all of which can lead to significant occupational and interpersonal dysfunction. The constellation of symptoms associated with PTSD has been well documented in the Diagnostic and Statistical Manual of Mental Disorders; however, the effects of PTSD on sexual function have not been well characterized. PTSD can have detrimental effects on intimacy and sexual health that range from decreased sexual desire and impotence to impaired fertility. Therefore, it is critical that physicians appropriately screen patients with PTSD for sexual dysfunction, as well as consider factors such as substance abuse, iatrogenic medication side effects, and avoidance of intimacy and sex due to undertreated psychiatric illness, which can complicate management of these patients. This chapter describes the biology and pathophysiology of PTSD in relation to men’s sexual and reproductive health, with a focus on guiding physicians in the proper management of such difficult patients.

MP46-06 COMPARISON OF ADJUVANT RADIATION THERAPY BEFORE OR AFTER ARTIFICIAL URINARY SPHINCTER PLACEMENT: A MULTI-INSTITUTIONAL ANALYSIS

INTRODUCTION AND OBJECTIVES: Artificial Urinary Sphincter (AUS) remains the gold standard in the management of male stress urinary incontinence following radical prostatectomy. However, the impact of AUS placement before or after adjuvant radiation therapy has limited coverage in the literature. The objective of this study was to determine if the timing of radiation therapy has an impact on AUS outcomes, as well as identify predictors of AUS-related complications. METHODS: A retrospective review was conducted across five academic institutions of men who received AUS placement and adjuvant radiation therapy between 1993 and 2016. A total of 306 men were included in the study. Out of the 306 men, 292 (95.4%) received radiation before AUS placement (Group 1) and 14 (4.6%) men received radiation after AUS placement (Group 2). Collected variables included demographics, type of prostate cancer therapy, and AUS device specifications. Primary endpoints included complication rates, revision rates, and number of pads per day before and after AUS treatment. Bivariate analysis was used to examine the association between pretreatment comorbidities and the incidence of AUS-related complications postoperatively. RESULTS: Median duration of follow-up for the entire cohort was 30 months (range 4-148 months). Group 1 was followed for a median of 29 months (range 4-148 months), while Group 2 was followed for a median of 49 months (range 12-141 months). There was no difference between groups in the percentage of men who experienced postoperative complications (P 1⁄4 0.832). In Group 1, 26.0% of patients experienced postoperative complications while 28.6% of patients in Group 2 experienced postoperative complications. While the number of pads per day decreased significantly from before AUS placement to after AUS placement, there was no significant difference in the average number of pads used per day between Group 1 and Group 2 (P 1⁄4 0.907). The number of pads used per day in Group 1 before AUS placement was 5.24 3.12 which decreased to 1.13 1.31 (P < 0.001). In Group 2, the number of pads used per day before surgery was 6.09 1.97 which decreased to 1.53 0.99 pads per day after AUS placement (P < 0.001). The percentage of men requiring revision in Group 1 was 31.2%, while the percentage of revisions in Group 2 was 14.3%(P 1⁄4 0.028). The median time to revision was 14 months and 18.5 months for Group 1 and Group 2, respectively. The presence of peripheral vascular disease (PVD) and coronary artery disease (CAD) was associated with increased incidence of AUS-related complications (primarily refractory incontinence and cuff erosion) in both Groups (P 1⁄4 0.032). The following factors were not significant: age, race, smoking, hypertension, diabetes mellitus, dyslipidemia, BMI, AUS device specifications, type of radiation therapy. CONCLUSIONS: The timing of radiation therapy does not have a significant impact on complication rates or urinary continence as represented by number of pads used post-AUS placement. There is a non-statistical association between lower revision rates in patients who underwent radiation after AUS placement, as compared to before AUS placement. Patients with pre-existing PVD or CAD may experience more frequent postoperative complications, but this study is underpowered. Further research is needed to confirm these findings.