Michael Butcher

Impact of Alpha Blockers, 5-alpha Reductase Inhibitors and Combination Therapy on Sexual Function

Medical treatments for lower urinary tract symptoms due to benign prostatic hyperplasia are frequently associated with changes in sexual function. While these medications are generally well-tolerated and have both reduced and delayed more invasive surgical options, the ramifications of long-term chronic use are largely unknown. Sexual side effects of these medications are frequently either reported as part of a short-term initial drug study or have inflexible endpoints that are not able to gauge more subtle changes in sexual performance. This review will delineate the currently known effects of these medications on sexual function and will consider mechanisms of dysfunction.

A Review of Pathophysiology and Management Options for Delayed Ejaculation

INTRODUCTION Delayed ejaculation (DE) is a poorly defined disorder that entails the delay or absence of orgasm that results in personal distress. Numerous causes of DE exist, and management must be tailored to the specific etiology to maximize treatment success. Management strategies include psychological and sexual therapy, pharmacotherapy, and penile vibratory stimulation. AIM This article intends to review the pathophysiology and treatment options for DE discussed in the literature to date. METHODS A review of the literature was performed to identify and evaluate the existing data on treatment success for the various forms of DE management. MAIN OUTCOME MEASURES Each treatment option was evaluated for method of administration, data supporting its success for DE, and potential risks or side effects. RESULTS Different psychosexual therapy strategies have been described for DE but with limited data to describe efficacy. There is no medication for DE approved by the United States Food and Drug Administration. The quality of evidence supporting the off-label use of medications for DE is low. However, there are numerous medications reported in the literature suggested to treat the condition. Cabergoline and bupropion are the two most commonly used. In addition, penile vibratory stimulation has been described as an adjunct treatment option for DE. CONCLUSION There are different treatment options reported for DE, all with limited evidence supporting their efficacy. Identifying the etiology of the DE is important to appropriately target therapy. A multimodal approach combining psychosexual therapy with medications and/or penile vibratory stimulation will likely provide the best outcomes.

How is delayed ejaculation defined and treated in North America

Delayed ejaculation (DE) is an uncommon disorder that is difficult to treat because it is poorly understood. The aim was to evaluate the current opinion and clinical management of DE by practitioners in sexual medicine. Members of the Sexual Medicine Society of North America (SMSNA) were invited by email to participate in a web‐based survey. The questionnaire consisted of eight questions pertaining to DE. Questions addressed patient volume, qualification of patient bother, ranking of etiologies, perceived success, treatments used, quantification of symptom resolution, and broad characterization of practitioner type. A total of 94 respondents completed the survey with 73% of those being urologists. Fifty‐nine percent of the respondents saw ≤ 2 patients a month with DE and 89% of practitioners felt that DE was moderately or severely bothersome to the patients. Etiology was felt to be from medications and psychological factors primarily. Despite treatment modality, ‘seldom’ success was obtained for 49% of the time and ‘never’ for 11%. Carbergoline was the most common selected medication for DE. Academic and private urologists reported ‘never’ or ‘seldom’ success with sexual counseling compared to other practitioners, respectively (p = 0.008 and p = 0.001). Respondents who saw ≤ 2 patients per month often reported normalization of hypogonadism ‘never’ or ‘seldom’ corrected DE (p = 0.047). Delayed ejaculation is still a poorly understood disorder with inconsistent practice patterns seen among members of the SMSNA. A better understanding of this vexing disorder is needed with efforts placed on research and practitioner education.

Delayed Ejaculation: Medical and Psychological Treatments and Algorithm

Delayed ejaculation (DE) is a challenging disorder to treat. Many clinicians are not comfortable dealing with DE due to a lack of treatment approaches supported by evidence-based medicine. In this review, we discuss the most common treatments and the latest studies that support each DE treatment. The goal of our review is to help clinicians identify and treat patients who present with this disorder. An integrative approach using medications, penile vibratory stimulation, and sexual counseling is important for successful treatment of DE. We propose an algorithm for DE treatment to help guide clinicians. However, an individualized treatment plan should be developed for each unique case due to the multifactorial etiology of DE.

Two Fungal Infections of Inflatable Penile Prostheses in Diabetics

Abstract Introduction Penile prosthesis infections have decreased since the introduction of antibiotic‐coated implants. Infections that do occur can be from more rare and virulent organisms than the traditional skin flora historically implicated. Aim In this report, we present two cases of inflatable penile prosthesis (IPP) infection from C andida organisms in insulin‐dependent diabetic patients. Methods Case report with literature review. Main Outcome Measures Resolution of the two cases. Results Both patients were found to have insulin‐dependent diabetes. Both patients also presented with infection of the device with Candida species, with the implant pump adherent to their scrotal skin. Conclusions This report supports the emerging literature that the flora of IPP infections is changing. We suggest considering adding antifungal agents to antibiotic coatings, dips, or washout solutions at the time of penile prosthesis surgery in diabetic patients. Cotta BH, Butcher M, Welliver C, McVary K, and Köhler T. Two fungal infections of inflatable penile prostheses in diabetics. Sex Med 2015;3:339–342.

MP56-09 INTERMEDIATE OUTCOMES OF CONCURRENT TACHOSIL GRAFTING WITH INFLATABLE PENILE PROSTHESIS PLACEMENT

INTRODUCTION AND OBJECTIVES: Intralesional (IL) injection of CCH is the first FDA approved pharmacotherapy for the treatment of men with PD. This analysis was conducted to define the outcome of IL CCH in our program. METHODS: Study population included men with PD, had stable disease for >3 months, met the other label criteria and underwent IL CCH. Men received up to 8 injections of CCH divided into 4 treatment cycles. Curvature assessments were done at baseline, between cycles 2 and 3 and after cycle 4. Traction therapy was used as our modeling technique to standardize the mechanical therapy. Patient demographics, PD factors and IL CCH complications were recorded. Multivariable analysis (MVA) was used to explore predictors of improvement. Two definitions were used: >10 and >25% improvement. RESULTS: To date, 69 subjects have completed baseline and the mid-treatment assessments (mean age1⁄455 10 years). 25 of these subjects also completed the end of treatment assessment. As baseline, the mean duration of PD was 20.5 20 months. 62% had dorsal curvature, 18% had an hourglass deformity, and 6% had tapering. Mean curvature was 44 20 , and decreased at mid-treatment to 40 20 (p1⁄40.01). For the 25 men who completed the end of treatment assessment, their baseline curvature was 49 23 , and decreased at end of treatment to 44 23 (p1⁄40.12). Three categories of curvature change were created: 00improvement00 (>10 ); 00no change00 ( 10 change), and 00worsened00 (>10 ). After 4 IL CCH injections: 33% improved, 54% had no change, and 13% worsened. After 8 IL CCH injections: 36% improved, 48% no change, and 15% worsened. On univariable analysis, only degree of baseline curvature (r1⁄40.4, p1⁄40.01) was positively correlated to improvement. On multivariable analysis, predicting improvement, baseline curvature remained the only significant predictor of improvement (OR1⁄41.04; 95% CI 1.01-1.07, p1⁄40.04). For improvement defined as >25%, after 4 IL CCH injections, 32% improved and after 8 48% improved. While clinically significant, this difference (between 4 and 8 injections) did not reach statistical significance (p1⁄40.21). There were no significant predictors of improvement of >25% at mid-treatment assessment in either univariable or multivariable analyses. CONCLUSIONS: These data reflect our clinical experience, which is quite different to those presented in the IMPRESS trials. Approximately one third of men significantly improve their penile curvature and it appears that maximum response occurs after 4 injections of CCH.

The Effect of LUTS/BPH and Treatments on Ejaculatory Function.

As men age, there is an increased incidence of lower urinary tract symptoms (LUTS), often from benign prostatic hyperplasia (BPH) which can adversely affect sexual function. There are many different treatments for these symptoms; however, many of the treatments also affect sexual quality of life, specifically in the realm of ejaculation. Our paper will review the medications, surgical procedures, minimally invasive procedures, and even investigational procedures used to treat LUTS/BPH and the effect they have on ejaculation. The aim of this paper is to help practitioners counsel patients more effectively on treatment options when ejaculation is a concern.