Ian Eardley

An update on new oral PDE5 inhibitors for the treatment of erectile dysfunction

The management of erectile dysfunction (ED) has been revolutionized by the discovery of phosphodiesterase 5 (PDE5) inhibitors, which have been commercially available for more than a decade and are the first-line therapeutic option for men with ED. Sildenafil, vardenafil and tadalafil were approved by the European Medicine Agency and the US FDA for the treatment of ED on the back of their high efficacy rates and favorable safety profiles. However, despite the fact that more than 50 million patients with ED worldwide have been successfully treated with one of these PDE5 inhibitors, some men—most notably those with severe neurologic damage, diabetes mellitus or severe vascular disease—are resistant to the currently available drugs and require more-invasive treatments, such as intracavernosal injection therapy. Partly as a consequence of this, research into alternative therapeutic approaches continues, including the development of new PDE5 inhibitors, centrally acting pharmaceutical agents, and application of molecular technologies such as gene therapy and stem cell therapy.

Sexual function impairment after high energy pelvic fractures: evidence today.

PURPOSEnSexual dysfunction has been associated with pelvic fractures, especially in patients with concomitant urethral injuries. A critical review of the existing literature was performed focusing on the reported definitions of sexual dysfunction, its reported incidence, the presence of related risk factors, the methods of assessing sexual function, the timing of this assessment and its management.nnnMATERIALS AND METHODSnThe PubMed® search engine was used in July 2010 to retrieve articles using the terms pelvic fracture and sexual function in their title or abstract, published in the English language, from 1989 onward. The references of the selected publications were also evaluated for potential relevant studies according to set selection criteria.nnnRESULTSnBased on 23 original articles the data of 1,462 patients, with a mean age of 37.7 years (range 15 to 92), were analyzed. The overall mean reported incidence of sexual dysfunction was 35.9% in men and 39.6% in women. Various methods were applied for the evaluation of sexual dysfunction, and were questionnaire based in 22 of the 23 studies. Important factors associated with sexual dysfunction were age, pelvic fracture pattern, presence of urogenital injury and injury severity score.nnnCONCLUSIONSnMale and female patients were equally affected by sexual dysfunction following pelvic blunt trauma. Limited consensus exists in the definition of sexual dysfunction, the methods and timing of assessment, as well as its management. The existing literature offers limited evidence regarding sexual dysfunction in females, as for both genders in the absence of urogenital initial trauma.

Medical therapy for premature ejaculation.

Premature ejaculation (PE) is a common male sexual dysfunction. Advances in PE research have been hampered owing to a nonstandardized definition of PE, until the definition by the International Society of Sexual Medicine (ISSM) in 2009. Once the diagnosis of PE is established through a thorough history, a variety of medical therapies is available, including tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), centrally acting opiates, phosphodiesterase 5 inhibitors and topical desensitizing creams. Most of these treatments increase the intravaginal ejaculation latency time (IELT) and patient satisfaction scores, with the most convincing evidence for SSRIs and topical creams. Daily SSRIs such as paroxetine, although efficacious, do have a substantial and prolonged side effect profile. Dapoxetine, which is a on-demand SSRI, is the only licensed drug for the treatment of PE, increasing IELT by a factor of 2.5 to 3 with limited and tolerable side effects. In the near future, the topical aerosol PSD502 is due to be licensed for the treatment of PE, increasing IELT by up to a factor of 6 but having minimal local and negligible systemic side effects.

The impact of surgical treatment for penile cancer – Patients' perspectives

PURPOSE OF THE RESEARCHnPenile cancer is a rare but highly treatable condition. Whilst over 80% survive for over five years, treatment can have a significant impact on quality of life. There has been little research conducted to date on mens experiences of treatment for penile cancer. The Patients Experiences of Penile Cancer study (PEPC) aimed to redress this shortfall by exploring mens experiences of surgical treatment for penile cancer.nnnMETHODS AND SAMPLEnThe study used a narrative history design in which data were collected using one-on-one semi-structured interviews. Maximum variation sampling was used to acquire the widest possible range of experiences. Twenty-seven interviews of around one hour were conducted with men with an average age of 63 years at diagnosis (range = 41-82). The data were analysed using constant comparison analysis.nnnKEY RESULTSnThe physical impact of surgery was inter-connected with broader events in the lives of the men experiencing treatment. These experiences cover urinary function, sexual function and sexual relationships, healing and recovery, masculinity, mental well-being, coping and support.nnnCONCLUSIONnA key area for the development of care is to devise and evaluate procedures for ensuring that men are well-informed about the extent and potential consequences of their treatment. Mens experiences of penile cancer surgery will be informed by a complex web interlaced with their broader lives, making it difficult for health professionals to judge how surgery will impact on a men presenting to them. Further research is required to ascertain the most appropriate strategies for rehabilitation of men experiencing penile cancer surgery.

Masculinities, humour and care for penile cancer: a qualitative study

AIMnTo explore how men with penile cancer construct humour in relation to their diagnosis and treatment.nnnBACKGROUNDnFunctionalist, relief and incongruity theories attempt to account for humour, but there is a dearth of empirical evidence in nursing care. This is particularly so in relation to a condition like penile cancer where some nurses think that humour in their interactions with patients would be inappropriate.nnnDESIGNnThe study employed a participative, mixed-qualitative-methods design.nnnMETHODnFocus groups and patient-conducted interviews were both used during a one-day pilot workshop in March 2011. The data were initially analysed using framework analysis. This paper explores the theme of humour in depth.nnnFINDINGSnHumour helped participants make light of their condition, which meant that they could laugh about the consequences of treatment (laughing about urination) and build rapport with health professionals (humour with health professionals). Nevertheless, the use of humour was less important than the treatment of their cancer (humour discounted) and there was a fear that they would be subject to ridicule because of their condition (fear of ridicule).nnnCONCLUSIONnThe findings suggest a combination of functionalist, relief and incongruity theories of humour; the emotions these men experience are contained (functionalist) and released (relief) through humorous interaction, and the potential for comedy lies in an incongruity between what is expected socially and the experiences of these men, for example, around expectations that men use urinals in public toilets. Nurses should continue to use humour to build rapport with patients, should they judge this to be appropriate, although they may want to avoid jokes about sexual and urinary functioning until after treatment.

Engaging men with penile cancer in qualitative research: reflections from an interview-based study

AIMnTo explore the challenges of engaging men with penile cancer in qualitative interview research.nnnBACKGROUNDnQualitative interviewing offers an ideal tool for exploring mens experiences of illness, complementing and providing context to gendered health inequalities identified in epidemiological research on men. But conducting interviews with men can be challenging and embarking on a qualitative interview study with males can feel like a daunting task, given the limited amount of practical, gender-sensitive guidance for researchers. Reflecting on a researchers experience of conducting qualitative research on men with penile cancer, this paper explores the potential challenges of interviewing this group, but also documents how engagement and data collection were achieved.nnnREVIEW METHODSnThis is a reflective paper, informed by the experiences of a male researcher (KW) with no nurse training, who conducted 28 interviews with men who had been treated for penile cancer. The researchers experiences are reported in chronological order, from the methodological challenges of recruitment to those of conducting the interview.nnnIMPLICATIONS FOR PRACTICE/RESEARCHnThe paper offers a resource for the novice researcher, highlighting some advantages and disadvantages of conducting qualitative interview research as a nurse researcher, as well as recommendations on how to overcome challenges.nnnCONCLUSIONnEngaging men with penile cancer in qualitative interview raises practical, methodological, ethical and emotional challenges for the researcher. However, when these challenges are met, men will talk about their health. Methodological procedures must enable an open and ongoing dialogue with clinical gatekeepers and potential participants to promote engagement. Support from colleagues is essential for any interviewer, no matter how experienced the researcher is.

A case-control study: are urological procedures risk factors for the development of infective endocarditis?

To evaluate the association between urological procedures and the development of infective endocarditis (IE), as there are case‐reports linking urological procedures to IE but evidence of a causal relationship is lacking and no major guidelines advise prophylaxis to prevent development of IE during transurethral urological procedures. No case‐control study has been undertaken to examine the relationship between urological procedures and the development of IE.

The accuracy of magnetic resonance imaging (MRI) in predicting the invasion of the tunica albuginea and the urethra during the primary staging of penile cancer

To assess the accuracy of magnetic resonance imaging (MRI) in predicting invasion of the tunica albuginea (TA) and the urethra during the primary staging of penile cancer.

The evaluation of apomorphine for the treatment of erectile dysfunction.

Introduction: Erectile dysfunction (ED) is a common condition affecting men. Apomorphine is one of the oral medications that has been used in the management of ED, though over recent years, its use in the management of ED has dwindled. Areas covered: The authors review the evidence available for the use of apomorphine in the management of ED. A Medline search was performed searching for the articles related to the use of apomorphine in the treatment of ED from 2000 to present. The article reviews the erectogenic properties of apomorphine and evaluates its efficacy, suitability and tolerability in management of patients with ED. Expert opinion: Apomorphine SL is more effective than placebos in treating ED and is generally well tolerated in the sublingual formulation, causing tolerable side effects. Newer nasal-spray formulations provide faster efficacy. Its efficacy in patients with multiple co-morbidities is more limited. However, it is not as effective as PDE5-I in the treatment of ED. Its most significant strength is its safety profile. It may have a niche in the treatment ED in patients who have failed treatment with, or are intolerant to other well-established pharmacological treatment for ED (e.g., PDE5-Is). Apomorphine is not a first-line treatment option for patients with ED, especially as it is no more widely available in the western world.

Bacteraemia during Transurethral Resection of the Prostate: What Are the Risk Factors and Is It More Common than We Think?

The aim of this work was to investigate the microbial causes, incidence, duration, risk factors and clinical implications of bacteraemia occurring during transurethral resection of the prostate (TURP) surgery to better inform prophylaxis strategies. An ethically approved, prospective, cohort study of patients undergoing TURP was conducted. Clinical information and follow-up details were collected using standardized data collection sheets. Blood was obtained for culture at 6 different time points peri-procedure. Standard of care antibiotic prophylaxis was given prior to surgery. Bacteriuria was assessed in a pre-procedure urine sample. Histopathology from all prostate chips was assessed for inflammation and malignancy. 73 patients were consented and 276 blood samples obtained. No patients developed symptomatic bacteraemia during the procedure, 17 patients developed asymptomatic bacteraemia (23.2%). Enterococcus faecalis and Pseudomonas aeruginosa were the most common organisms cultured. 10 minutes after the start of the TURP, the odds ratio (OR) of developing bacteraemia was 5.38 (CI 0.97–29.87 p = 0.05), and 20 minutes after the start of the procedure, the OR was 6.46 (CI 1.12–37.24, p = 0.03), compared to before the procedure. We also found an association between the development of intra-operative bacteraemia and recent antibiotic use (OR 4.34, CI 1.14–16.62, p = 0.032), the presence of a urinary catheter (OR 4.92, CI 1.13–21.51, p = 0.034) and a malignant histology (OR 4.90, CI 1.30–18.46, p = 0.019). There was no statistical relationship between pre-operative urine culture results and blood culture results. This study shows that asymptomatic bacteraemia is commonly caused by TURP and occurs in spite of antibiotic prophylaxis. Our findings challenge the commonly held view that urine is the primary source of bacteraemia in TURP-associated sepsis and raise the possibility of occult prostatic infection as a cause of bacteraemia. More work will be needed to determine the significance of transient bacteraemia in relation to more serious complications like infective endocarditis and malignancy.