Mikkel Fode

Penile rehabilitation after radical prostatectomy: what the evidence really says

The pathophysiology of erectile dysfunction after radical prostatectomy (RP) is believed to include neuropraxia, which leads to temporarily reduced oxygenation and subsequent structural changes in penile tissue. This results in veno‐occlusive dysfunction, therefore, penile rehabilitation programmes focus on tissue oxygenation. Animal studies support the use of phosphodiesterase type 5 inhibitors (PDE5Is) after cavernous nerve damage but results from human studies are contradictory. The largest study to date found no long‐term effect of either daily or on‐demand PDE5I administration after RP compared with placebo. The effects of prostaglandin and vacuum erection devices are questionable and high‐quality studies are lacking. Better documentation for current penile rehabilitation and/or better rehabilitation protocols are needed. One must be careful not to repeat the statement that penile rehabilitation improves erectile function after RP so many times that it becomes a truth even without the proper scientific backing.

Neglected Side Effects After Radical Prostatectomy: A Systematic Review

INTRODUCTION A series of previously neglected sexually related side effects to radical prostatectomy (RP) has been identified over the recent years. These include orgasm-associated incontinence (OAI), urinary incontinence in relation to sexual stimulation (UISS), altered perception of orgasm, orgasm-associated pain (OAP), penile shortening (PS), and penile deformity. AIM The aim of this article is to conduct a systematic review of the literature regarding the above-mentioned side effects. METHODS A predefined search strategy was applied in a thorough search of Medline, Web of science, and the online Cochrane library. The PRISMA guidelines for systematic reviews were followed, and protocol as well as search strategies was registered at http://www.crd.york.ac.uk/Prospero/ (RN: CRD42012003165). MAIN OUTCOME MEASURE The main outcome measure was incidence rates for the relevant side effects. RESULTS A total of 43 articles were included. OAI and UISS are experienced by 20-93% of RP patients at least a few times after surgery. Although these issues are associated to postoperative daytime incontinence, previous transurethral resection of the prostate (TURP) is the only known predicting factor. Alterations of orgasmic function are experienced by approximately 80% after RP. Erectile dysfunction seems to play an important role in waning orgasmic function. OAP is only experienced by a subset of the patients with reported rates varying between 3% and 19%. Sparing of the tips of the seminal vesicles has been shown to double the risk of OAP. PS occurs in 15-68% of RP patients. Nerve sparing and preservation of erectile function may help preserve penile length. With regard to all side effects, studies indicate that they are reduced over time. CONCLUSIONS The sexually related side effects summarized in this review are common after RP. Meanwhile, it is difficult to predict which patients are at risk. Daytime incontinence, previous TURP, a lack of nerve sparing, and erectile dysfunction are all associated with the above-mentioned sexually related side effects.

Penile vibratory stimulation in the recovery of urinary continence and erectile function after nerve-sparing radical prostatectomy: a randomized, controlled trial

To examine the effect of penile vibratory stimulation (PVS) in the preservation and restoration of erectile function and urinary continence in conjunction with nerve‐sparing radical prostatectomy (RP).

Idiopathic partial thrombosis of the corpus cavernosum: Aetiology, diagnosis and treatment

Abstract Idiopathic partial thrombosis of the corpus cavernosum (IPT) is a rare cause of perineal pain involving thrombosis within the proximal corpora cavernosa. This article clarifies the aetiology and makes recommendations on diagnosis and treatment. Three cases are described and a systematic review of the literature is presented. Magnetic resonance imaging (MRI) scans of the penis conducted for reasons other than IPT were also reviewed, to compare the normal anatomy of the corpora cavernosa with that of IPT patients.Twenty-nine IPT cases were identified, including the three described here. All patients presented with perineal pain and in all cases the thrombus was located in the proximal part of the corpora cavernosa.IPT has been associated with haematological diseases, drugs, prior priapism, sexual activity, bicycle riding and aeroplane flights. A fibrous septum within the corporeal tissue has been identified with advanced imaging modalities. Ultrasound, computed tomography and MRI have proven useful in the diagnosis. Both surgical and medical treatments have been attempted and the results have usually been good. However, two cases of surgical treatmenthave resulted in erectile dysfunction. It is suggested that ITP is based on the development of penile thrombosis and/or priapism in the presence of a pre-existing fibrous septum in the corpora cavernosa. MRI should be used to confirm the presence of a thrombus and a septum. First choice of treatment is pain medication and systemic anticoagulation; more invasive treatments should only be attempted only if this approach fails.

Low-intensity extracorporeal shockwave therapy in the treatment of postprostatectomy erectile dysfunction: a pilot study

Abstract Objective: The objective was to investigate the effect and feasibility of low-intensity extracorporeal shockwave therapy (LI-ESWT) as a treatment for erectile dysfunction (ED) after bilateral nerve-sparing radical prostatectomy (RP). Materials and methods: Patients who had undergone robot-assisted bilateral nerve-sparing RP more than a year before entering this pilot study, had no preoperative ED and were suffering from mild to severe postoperative ED were invited to participate. Six treatments were given over a 6 week period, using the Duolith® SD1 T-Top machine. The effect of the treatment was evaluated 1 month (t1) and 1 year (t2) after the final treatment. The main outcome measure was changes in the five-item International Index of Erectile Function (IIEF-5) scores. Results: Eighteen patients were included in the study. However, two patients breached the protocol and consequently 16 patients were included in the analysis at t1 and 15 patients were included in the analysis at t2. At baseline the median age was 62 years (range 51 to 70 years) and the median time since surgery was 24 months (range 12 to 54 months). The median preoperative IIEF-5 score was 25 (range 22 to 25) and the median baseline IIEF-5 score was 9.5 (range 5 to 20). The median change in IIEF-5 scores was +3.5 (range –1 to 8; p = 0.0049) and +1 (range –3 to 14; p = 0.046) at t1 and t2, respectively. No severe side-effects were reported. Conclusions: LI-ESWT may improve erectile function after bilateral nerve-sparing RP. Based on these results, further studies in patients with ED after nerve-sparing RP are justified.

European Association of Urology Position Statement on the Role of the Urologist in the Management of Male Hypogonadism and Testosterone Therapy

Testosterone is a crucial sex hormone important for the health and development of men of all ages. It plays a role in the integrity and maintaining the function of several systems and organs. Testosterone deficiency is linked to a number of signs and symptoms potentially affecting every man in his complexity and masculinity, and is therefore of strong urological interest. For this reason, urologists should attach importance to the need for knowledge, vocational education, and training in this specific area.

Low-intensity shockwave therapy for erectile dysfunction: is the evidence strong enough?

Erectile dysfunction (ED) affects ∼30% of all men above the age of 40 years and its prevalence steadily increases with age. Current nonsurgical treatment options, including phosphodiesterase type 5 inhibitors (PDE5I), provide temporary relief but have failed to provide a permanent improvement of the condition. Low-intensity extracorporeal shockwave therapy (Li-ESWT) is noninvasive and uses acoustic waves, which can pass through tissue and be focussed to target specific areas or organs to induce the desired effects. The use of Li-ESWT has previously been described in other disease contexts, such as ischaemic heart disease, bone fractures, and burns, in which it improves neoangiogenesis; similar principles seem to apply in the erectile tissue. The major potential advantage of the treatment, therefore, is the possibility to restore natural erectile function. Thus, Li-ESWT is the only currently marketed treatment for ED that might offer a cure, which is the most desired outcome for most men with ED. Li-ESWT has also been suggested to improve the effect of PDE5I in nonresponders, reducing the need for more invasive treatments. Several single-arm trials have shown benefit of Li-ESWT on patient-reported erectile function scores, but data from randomized trials are conflicting, and many questions remain to be answered before we can routinely offer this treatment to patients. Thus, the search for the true clinical value of Li-ESWT for ED represents a dynamic and continuing field of enquiry.

The use of exercise interventions to overcome adverse effects of androgen deprivation therapy

Androgen deprivation therapy (ADT) induces severe hypogonadism and is associated with several adverse effects that negatively affect health and quality of life in patients with prostate cancer. ADT changes body composition characterized by an increase in fat mass and a reduction in muscle mass and strength. Insulin sensitivity is also diminished and population-based studies indicate an increased risk of diabetes mellitus and cardiovascular disease in men receiving ADT. Particularly the first 6 months of treatment seem to hold an additional risk of new cardiovascular events for patients with already existing cardiovascular disease. In this initial phase of ADT, metabolic changes are also most prominent. In addition, ADT increases the rate of bone loss and fracture risk. Currently available evidence supports the use of exercise interventions to improve physical function and mitigate ADT-induced fatigue. Some studies also indicate that exercise might moderate ADT-related changes in body composition. However, beneficial effects of exercise interventions on other ADT-related conditions have not been conclusively proven. Trials investigating the effects of ADT on fracture risk and development of diabetes mellitus and cardiovascular disease are still warranted. Furthermore, studies investigating safety and effects of physical activity in men with bone metastases are lacking.

Luteinizing Hormone-Releasing Hormone Agonists are Superior to Subcapsular Orchiectomy in Lowering Testosterone Levels of Men with Prostate Cancer: Results from a Randomized Clinical Trial

Purpose: Recent evidence suggests that reaching the lowest achievable levels of testosterone with androgen deprivation therapy delays disease progression and increases overall survival in men with advanced prostate cancer. The aim of this analysis was to compare posttreatment serum testosterone levels between patients undergoing subcapsular orchiectomy and patients treated with the luteinizing hormone‐releasing hormone agonist triptorelin. Materials and Methods: In this randomized clinical trial we included 58 consecutive hormone naïve men diagnosed with advanced prostate cancer at Herlev and Gentofte University Hospital, Herlev, Denmark from September 2013 to March 2015. Followup was 48 weeks. Participants were randomly assigned 1:1 to subcapsular orchiectomy or triptorelin 22.5 mg given as 24‐week depot injections. Androgen status was measured by liquid chromatography‐tandem mass spectrometry prior to treatment and after 12, 24 and 48 weeks. Between group differences in achieved hormone levels were analyzed by longitudinal Tobit regression. Results: Triptorelin injections resulted in 29% lower testosterone levels (95% CI 17.2–41.7) compared to subcapsular orchiectomy (p <0.001). A significantly higher proportion of men receiving triptorelin had testosterone levels less than 20 ng/dl at 12 and 48 weeks compared to men undergoing orchiectomy (97% vs 79% and 100% vs 87%, respectively, p <0.05). There was no detectable difference in the adrenal androgen reduction between the treatment groups. Conclusions: The use of 24‐week depot triptorelin injections results in significantly lower testosterone levels compared to subcapsular orchiectomy. To our knowledge this is the first randomized study to demonstrate a difference in treatment effect between surgical and medical castration on testosterone levels.

Low-Intensity Extracorporeal Shockwave Therapy in Sexual Medicine: A Questionnaire-Based Assessment of Knowledge, Clinical Practice Patterns, and Attitudes in Sexual Medicine Practitioners

Introduction Low-intensity extracorporeal shockwave therapy (LI-ESWT) has emerged as a treatment option for male sexual dysfunction. However, results have been contradictory. Aim To investigate the knowledge, practice patterns, and attitudes regarding LI-ESWT among experts in sexual medicine. Methods A study-specific questionnaire was handed out at the 18th Congress for the European Society for Sexual Medicine. Participants were queried on their knowledge about LI-ESWT and about their use of the equipment. Main Outcome Measures Descriptive data on the knowledge of LI-ESWT and perception of treatment effects. Results One hundred ninety-two questionnaires were available for analysis. Most respondents were physicians (79.7%) and most of these specialized in urology (58.9%). Overall, 144 of 192 (75%) reported that they were familiar with LI-ESWT in sexual medicine. Twenty-seven (14.1%) had performed the treatment. Of the 117 non-users who were familiar with LI-ESWT, 37 sometimes referred patients for the treatment. Nevertheless, 103 of 144 (71.5%) stated that they considered LI-ESWT an effective treatment for erectile dysfunction (ED) and 10 of 144 (6.9%) considered it an effective treatment for Peyronie disease. Of participants who regarded LI-ESWT an effective ED treatment, 91.2% would consider the treatment specifically for vasculogenic ED and 81.6% would combine it with phosphodiesterase type 5 inhibitors. Most participants (83.7%) regarded LI-ESWT as safe. A urology background (odds ratio = 2.4; 95% CI = 1.3–4.8; P = .0093) and working in a private setting (odds ratio = 2.8; 95% CI = 1.5–5.3; P = .0084) were significant predictors of familiarity with LI-ESWT in sexual medicine and of being an LI-ESWT user. Likewise, urologists were significantly more likely than non-urologists to consider the treatment effective (odds ratio = 2.8; 95% CI = 1.1–7.1; P = .033). Conclusion LI-ESWT is well known among experts in sexual medicine and the treatment is perceived as safe and effective against vasculogenic ED when combined with phosphodiesterase type 5 inhibitors. The treatment is mainly offered by urologists. Fode M, Lowenstein L, Reisman Y. Low-Intensity Extracorporeal Shockwave Therapy in Sexual Medicine: A Questionnaire-Based Assessment of Knowledge, Clinical Practice Patterns, and Attitudes in Sexual Medicine Practitioners. Sex Med 2017;5:e94–e98.