Giulia Castagna

Is erectile dysfunction a reliable proxy of general male health status? The case for the International Index of Erectile Function-Erectile Function domain.

INTRODUCTION Erectile dysfunction (ED) has emerged progressively as a sentinel marker of cardiovascular disease (CVD). The correlation between ED and the burden arising from multiple comorbid conditions has been incompletely analyzed. AIM Assess whether erectile function, defined with the International Index of Erectile Function-Erectile Function (IIEF-EF) domain score, is associated with health-significant comorbidities scored with the Charlson comorbidity index (CCI). METHODS Clinical and hemodynamic variables of the last 140 consecutive patients who underwent penile color Doppler ultrasonography for new-onset ED were considered. Patients were assessed with a thorough medical and sexual history. Health-significant comorbidities were scored with the CCI. MAIN OUTCOME MEASURE Descriptive statistics and either linear or logistic regression models tested the association among IIEF-EF, hemodynamic parameters, and CCI, which was included in the model both as continuous and categorized variable (0 vs. ≥1). RESULTS Complete data were available for 138 patients (98.6%) (mean age 46.6 years [standard deviation 13.0]; range 21-75 years). CCI was 0, 1, and ≥2 in 94 (68.1%), 23 (16.7%), and 21 (15.25%) patients, respectively. Of all, 35 patients (79.5%) did not have a CVD comorbidity. Mean IIEF-EF was 13.7 (9.3). ED severity was no ED, mild, mild to moderate, moderate, and severe in 12 (9.1%), 28 (20.2%), 12 (9.1%), 23 (16.2%), and 63 (45.5%) patients, respectively. At multivariable linear regression analysis, CCI significantly worsened with increased age (β=0.33; P=0.001) and decreased IIEF-EF values (β=-0.25; P=0.01). At logistic regression analysis, age (odds ratio [OR]: 1.05; P=0.004) and IIEF-EF (OR: 0.95; P=0.04) emerged as significant predictors of categorized CCI. CONCLUSIONS Severity of ED, as objectively interpreted with IIEF-EF, accounts for a higher CCI, which may be considered a reliable proxy of a lower general male health status regardless of the etiology of ED.

One Patient Out of Four with Newly Diagnosed Erectile Dysfunction Is a Young Man—Worrisome Picture from the Everyday Clinical Practice

INTRODUCTION Erectile dysfunction (ED) is a common complaint in men over 40 years of age, and prevalence rates increase throughout the aging period. Prevalence and risk factors of ED among young men have been scantly analyzed. AIM Assessing sociodemographic and clinical characteristics of young men (defined as ≤ 40 years) seeking first medical help for new onset ED as their primary sexual disorder. METHODS Complete sociodemographic and clinical data from 439 consecutive patients were analyzed. Health-significant comorbidities were scored with the Charlson Comorbidity Index (CCI). Patients completed the International Index of Erectile Function (IIEF). MAIN OUTCOME MEASURE Descriptive statistics tested sociodemographic and clinical differences between ED patients ≤ 40 years and >40 years. RESULTS New onset ED as the primary disorder was found in 114 (26%) men ≤ 40 years (mean [standard deviation [SD]] age: 32.4 [6.0]; range: 17-40 years). Patients ≤ 40 years had a lower rate of comorbid conditions (CCI = 0 in 90.4% vs. 58.3%; χ(2) , 39.12; P < 0.001), a lower mean body mass index value (P = 0.005), and a higher mean circulating total testosterone level (P = 0.005) as compared with those >40 years. Younger ED patients more frequently showed habit of cigarette smoking and use of illicit drug, as compared with older men (all P ≤ 0.02). Premature ejaculation was more comorbid in younger men, whereas Peyronies disease was prevalent in the older group (all P = 0.03). At IIEF, severe ED rates were found in 48.8% younger men and 40% older men, respectively (P > 0.05). Similarly, rates of mild, mild-to-moderate, and moderate ED were not significantly different between the two groups. CONCLUSIONS This exploratory analysis showed that one in four patients seeking first medical help for new onset ED was younger than 40 years. Almost half of the young men suffered from severe ED, with comparable rates in older patients. Overall, younger men differed from older individuals in terms of both clinical and sociodemographic parameters.

Serum Sex Steroids Depict a Nonlinear U-Shaped Association with High-Risk Prostate Cancer at Radical Prostatectomy

Purpose: To assess the association between preoperative serum total testosterone (tT), 17β-estradiol (E2), sex hormone–binding globulin (SHBG), and tT–E2 ratio values with high-risk prostate cancer (as defined by the National Comprehensive Cancer Network practice guidelines) at radical prostatectomy. Experimental Design: Serum E2, tT, and SHBG were dosed the day before surgery (7:00–11:00 am) in a cohort of 724 candidates to radical prostatectomy. Restricted cubic spline functions tested the association between predictors (i.e., model 1: age, body mass index, and serum tT, E2, and SHBG levels; model 2: tT–E2 values instead of tT and E2 levels) and high-risk prostate cancer. Results: Low-, intermediate-, or high-risk prostate cancer was found in 251 (34.7%), 318 (43.9%), and 155 (21.4%) patients, respectively. Patients in the high-risk class showed the lowest tT, E2, and tT–E2 ratio values (all P ≤ 0.02). At univariate analysis, only age, tT, E2, and tT–E2 ratio values were significantly associated with high-risk prostate cancer (all P ≤ 0.006). At multivariate analyses considering model 1 variables, age (P = 0.03), serum tT (all P < 0.001), and E2 (all P ≤ 0.01) were associated with high-risk prostate cancer; only tT–E2 ratios achieved independent predictor status for high-risk prostate cancer (all P < 0.001) when considering model 2. Both the lowest and the highest tT, E2, and tT–E2 values depicted a nonlinear U-shaped significant association with high-risk prostate cancer. Conclusions: These data showed that preoperative serum sex steroids are independent predictors of high-risk prostate cancer, depicting a nonlinear U-shaped association. Clin Cancer Res; 18(13); 3648–57. ©2012 AACR.

Delay in Seeking Medical Help in Patients with New‐Onset Erectile Dysfunction Remained High Over and Despite the PDE5 Era—An Ecological Study

INTRODUCTION It is common knowledge among researchers that erectile dysfunction (ED) is an important sentinel marker of cardiovascular and overall mens health. AIM Determine whether the delay of time between ED onset and seeking medical help (DSH), considered as a proxy of awareness of the importance of ED for overall mens health, has shortened during the phosphodiesterase type 5 inhibitors (PDE5) era. METHODS Complete data from 619 patients seeking first medical help for new-onset ED as their primary disorder between July 2000 and July 2010 were analyzed (i.e., DSH, ED severity as defined by the International Index of Erectile Function-erectile function [IIEF-EF] domain score, patients awareness of any PDE5, and Charlson Comorbidity Index [CCI]). Analysis of variance tested DSH throughout the 10-year time frame. Cox regression models tested the association between predictors and DSH. MAIN OUTCOME MEASURES Assess if DSH has shortened throughout PDE5 era. Evaluate potential predictors of DSH. RESULTS Overall, mean DSH was 30.2 months (median 12.0; range 5-300 months). DSH shortened throughout the analyzed 10-year period (F = 1.918; P = 0.047), with a significant drop only from year 2009 (DSH up to year 2008 vs. from year 2009: 31.0 months [12.0] vs. 7.5 months [6.0], respectively; P < 0.001). Age, CCI, educational status, and ED severity did not significantly change over time. As a whole, 560 patients (90.5%) were aware of PDE5 at the time of their first office visit. PDE5 awareness emerged as an univarible and multivariable predictor of a shortened DSH. Conversely, DSH was not clearly associated with age, CCI, educational status, or ED severity. CONCLUSIONS Delay in seeking medical help in new-onset ED patients remained high over the PDE5 era, with a significant drop only from the year 2009. PDE5 awareness emerged as an independent predictor of shortening of this delay.

Is erectile dysfunction a reliable indicator of general health status in men

Abstract Introduction: Erectile dysfunction (ED) is a common risk factor in men and its incidence increases with age. Ageing and older men frequently have comorbidities such as cardiovascular diseases (CVD), diabetes mellitus (DM), hypertension, chronic obstructive pulmonary disease and dyslipidaemia; likewise, they concurrently refer to a clinician for impairments in sexual function, mostly for ED. The association of ED and other organic, multi-organic or even systemic diseases is widely described, with a specific emphasis on the fact that they often share common pathophysiological factors and mechanisms. Thus we reviewed previous reports assessing the role of ED as a sentinel marker of overall men’s health. Discussion: ED is considered an important sentinel marker for CVD. Numerous studies have highlighted the predictive role of ED for subsequent CV events in patients with a silent history of coronary artery disease. Indeed, ED might be considered as a clinical manifestation of a generalised vascular disease, and it should provoke clinicians to check for CVDs in those patients complaining of impaired erectile function. This concept appears to be even more important for men with DM, where ED has already been shown to have a significant predictive ability for major vascular complications. Moreover, data from large population-based studies showed that ED is a significant predictor of all-cause mortality, in addition to CV outcomes. The severity of erectile function is assessed with the International Index of Erectile Function-Erectile Function domain score, and this has emerged as a proxy for men’s general health status, as assessed with the Charlson Comorbidity Index score. Conclusions: Patients complaining of ED should be evaluated with a comprehensive medical and sexual history, and a thorough physical examination, regardless of their age, considering ED as an opportunity to screen for the presence of health-threatening concomitant comorbidities.

Prevention and management of post prostatectomy erectile dysfunction

Sexual dysfunction is common in patients with prostate cancer (PC) following radical prostatectomy (RP). Review the available literature concerning prevention and management strategies for post-RP erectile function (EF) impairment in terms of preoperative patient characteristics, intra and postoperative factors that may influence EF recovery, and postoperative treatments for erectile dysfunction (ED). A literature search was performed using Google and PubMed database for English-language original and review articles, either published or e-published up to July 2013. The literature still demonstrates a great inconsistency in the definition of what is considered normal EF both before and after RP. Thus, using validated psychometric instruments with recognized cut-offs for normalcy and severity during the pre- and post-operative evaluation should be routinely considered. Therefore, a comprehensive discussion with the patient about the true prevalence of postoperative ED, the concept of spontaneous or pharmacologically-assisted erections, and the difference between “back to baseline” EF and “erections adequate enough to have successful intercourse” clearly emerge as key issues in the eventual understanding of post-RP ED prevention and promotion of satisfactory EF recovery. Patient factors (including age, baseline EF, comorbid conditions status), cancer selection (non- vs. uni- vs. bilateral nerve-sparing), type of surgery (i.e., intra vs. inter vs. extrafascial surgeries), surgical techniques (i.e., open, laparoscopic and robotically-assisted RP), and surgeon factors (i.e., surgical volume and surgical skill) represent the key significant contributors to EF recovery. A number of preclinical and clinical data show that rehabilitation and treatment in due time are undoubtedly better than leaving the erectile tissue to its unassisted postoperative fate. The role of postoperative ED treatment for those patients who received a non-nerve-sparing RP was also extensively discussed. Optimal outcomes are achieved mainly by the careful choice of the correct patient for the correct type of surgery. Despite a plethora of potential rehabilitative approaches, they should be only considered as “strategies”, since incontrovertible evidence of their effectiveness for improving natural EF recovery is limited. Conversely, numerous effective therapeutic options are available for treating post-RP ED.

Metabolic syndrome in white European men presenting for primary couple's infertility: investigation of the clinical and reproductive burden.

Despite complex interactions between obesity, dyslipidemia, hyperinsulinaemia, and the reproductive axis, the impact of metabolic syndrome on human male reproductive function has not been analysed comprehensively. Complete demographic, clinical, and laboratory data from 1337 consecutive primary infertile men were analysed. Health‐significant comorbidities were scored with the Charlson Comorbidity Index (categorised 0 vs. 1 vs. 2 or higher). NCEP‐ATPIII criteria were used to define metabolic syndrome. Semen analysis values were assessed based on the 2010 World Health Organisation (WHO) reference criteria. Descriptive statistics and logistic regression models tested the association between semen parameters and clinical characteristics and metabolic syndrome. Metabolic syndrome was found in 128 (9.6%) of 1337 men. Patients with metabolic syndrome were older (p < 0.001) and had a greater Charlson Comorbidity Index of 1 or higher (chi‐square: 15.6; p < 0.001) compared with those without metabolic syndrome. Metabolic syndrome patients had lower levels of total testosterone (p < 0.001), sex hormone‐binding globulin (p = 0.004), inhibin B (p = 0.03), and anti‐Müllerian hormone (p = 0.009), and they were hypogonadal at a higher rate (chi‐square: 32.0; p < 0.001) than patients without metabolic syndrome. Conversely, the two groups did not differ significantly in further hormonal levels, semen parameters, and rate of either obstructive or non‐obstructive azoospermia. At multivariate logistic regression analysis, testicular volume (OR: 0.90; p = 0.002) achieved independent predictor status for WHO pathological semen concentration; conversely, age, Charlson Comorbidity Index scores, metabolic syndrome, and inhibin B values did not. No parameters predicted normal sperm morphology and total progressive motility. Metabolic syndrome accounts for roughly 9% of men presenting for primary couples infertility. Although metabolic syndrome patients have a lower general male health status, semen analysis values seem independent of the presence of metabolic syndrome.

A minimum of 1-year follow-up for MiniArc single incision slings compared to Monarc transobturator slings: An analysis to evaluate durability of continence and medium-term outcomes

To compare efficacy and safety of two commercially available single incision slings (SIS) and trans‐obturator vaginal tapes (TOT), namely MiniArc™ and Monarc™ slings, and report the results at 5‐year follow‐up.

Sexual and bladder comorbidity in women.

Sexual dysfunction in women is defined as disorders of sexual desire, arousal, orgasm, and/or sexual pain, which result in significant personal distress and may have a negative effect on a womans health and an impact on her quality of life. A comprehensive understanding of the anatomic, neurobiologic, and psychologic mechanisms behind womens sexual function and dysfunction is of paramount importance. This chapter reviews the most frequent comorbid conditions related to urinary tract symptoms (thus including symptoms related to overactive bladder syndrome and urinary incontinence) and sexual dysfunction in women. Likewise, it considers the different disorders from the point of view of daily clinical practice.

MP46-09 PREVIOUS INCONTINENCE SURGERY AND SURGICAL VOLUME PREDICT SOCIAL CONTINENCE AND SURGICAL REVISION: RESULTS OF A LARGE MULTI-INSTITUTIONAL STUDY.

circumference, 4) 100% circumference. A stricture was defined as clinically significant if it required intervention such as urethroplasty, direct visual internal urethrostomy, or dilation. Patients with less than 1 month follow up were excluded for stricture rate analysis. RESULTS: A total of 55 males with a history of AUS cuff erosion were identified. The mean patient age was 73.6 ( 9.4). The mean device age was 50.5 months (range 1-160). Of the cohort, 47 were initially implanted at our institution and 8 elsewhere. An associated infection was noted in 20 patients. Of 55 patients, 13 (24%) had a prior history of AUS erosion. Of the 55 patients, 21 were in group 1, 13 in group 2, 7 in group 3, 5 in group 4, and the degree of erosion was not documented in 9. The median follow up after erosion in these patients was 9 months. Four patients did not have sufficient follow up to assess stricture rate (less than 1 month). The median length of catheterization was 30 days after removal of the AUS. The degree of erosion did not correlate with a longer period of catheterization (p1⁄40.5). Of the patients with follow up, the overall rate of stricture in this cohort was 25%. The degree of erosion did not correlate with the risk of stricture occurrence (p1⁄40.8). However, in the circumferential erosion group (n1⁄45), 2 underwent a urethroplasty at the time of cuff removal. An infected and eroded cuff did not appear to correlate with a higher risk of stricture formation (p1⁄40.7) CONCLUSIONS: Erosion of the AUS cuff into the urethra leads to a urethral stricture in 25% of patients. However, the degree of erosion, prolonged urinary extravasation, or associated infection did not correlate with development of a urethral stricture.