Patrick Teloken

REPORT: Obesity, Dyslipidemias and Erectile Dysfunction: A Report of a Subcommittee of the Sexual Medicine Society of North America

Because of increasingly sedentary lifestyles and diets higher in saturated fats, obesity and dyslipidemias are common and increasing in prevalence in Westernized countries. Longitudinal population-based studies clearly demonstrate that dyslipidemias and obesity, as well as factors such as hypertension, diabetes, and smoking, are major risk factors for atherosclerosis. Both clinical and animal models of endothelial dysfunction confirm that atherosclerosis leads to increased cerebrovascular and cardiovascular morbidity. Clinical studies with hypolipidemic agents demonstrate that hydroxy-3-methylglutaryl coenzyme A reductase inhibitors can decrease the risk of vascular morbidity. An increasing body of evidence from animal models demonstrates that hypercholesterolemia and atherosclerosis are risk factors for the development of erectile dysfunction (ED). This causal relationship between obesity and dyslipidemias with the development of ED in humans still needs further definition with convincing peer-reviewed scientific studies. The challenge for the future will be to define the benefit of controlling obesity and dyslipidemias on the development of ED and improvement of erectile function.

ORIGINAL RESEARCHORIGINAL RESEARCH—PEYRONIE'S DISEASE: Peyronie's Disease Following Radical Prostatectomy: Incidence and Predictors

INTRODUCTION Both prostate cancer and Peyronies disease (PD) are prevalent in men after their fifth decade of life. The evidence to support or refute a link between radical prostatectomy (RP) and PD is limited. AIMS To define the incidence of PD in men who had RP and determine possible predictors of PD development after RP. METHODS A review of a prospectively built sexual medicine database, years 2002-2008, looking at subjects who had RP as a monotherapy for localized prostate cancer. We identified and characterized subjects who developed PD within 3 years after RP and compared them with subjects who did not. MAIN OUTCOME MEASURES The incidence of PD among men who attended a sexual medicine clinic after they had RP, predictors of PD development after RP. RESULTS The study population included 1,011 subjects, and PD incidence in this population was 15.9%. Mean time to develop PD after RP was 13.9 +/- 0.7 months. Mean curvature magnitude was 31 + 17 degrees. On univariate analysis, younger age (mean age of 59 + 7 in men with PD vs. 60 + 7 years in men without PD, P = 0.006) and white race (vs non-white, 18% vs. 7%, P < 0.001) were predictive of PD development after RP, but post-op erectile function was not a predictor of PD development. On multivariate analysis, younger age (odds ratio (OR) = 1.3, for 5-year decrease in age) and white race (OR = 4.1, vs. non-white) remained independent significant predictors. CONCLUSIONS Men presenting with sexual dysfunction after RP have higher PD incidence then the general population. Therefore, they should be routinely evaluated for PD. Younger men and men of white race are at increased risk for PD. Prospective controlled studies are needed to elucidate the incidence of PD following RP and to conclude if RP has a causative role in the pathogenesis of PD.

Erectile Function Following Prostate Cancer Treatment: Factors Predicting Recovery

Prostate cancer represents the most common nonskin malignancy encountered in men, and the excellent long-term survival achieved in the majority of patients has allowed more attention to be given to the side effects associated with its treatment. Erectile function is one of the main concerns of patients when considering treatment options for prostate cancer. Not surprisingly, post-treatment sexual function is closely related to outcome satisfaction and has long-lasting effects on quality of life. Radical prostatectomy is currently the most commonly employed therapy for prostate cancer. Conflicting rates of erectile dysfunction have been reported after surgery, owing not only to different surgical techniques but also because of dissimilar patient populations and definitions. Providing accurate information to individual patients in regards to their chances of recuperating the ability to have intercourse after treatment is important not only because it allows patients to make informed decisions but also because it has the potential to reduce treatment dissatisfaction. This article mainly focuses on discussing predictors of erectile function after radical prostatectomy. Patient factors, surgical aspects, including comparisons between open, laparoscopic, and robotic approaches, and postoperative management issues that impact sexual outcomes are evaluated. Prediction models combining multiple factors are described. The definition and chronology of erectile function recovery and impact of sexual function on quality of life after surgery are also discussed. Teloken PE and Mulhall JP. Erectile function following prostate cancer treatment: Factors predicting recovery. Sex Med Rev 2013;1:91-103.

1398 ORGASM PROFILES IN MEN ON ANDROGEN DEPRIVATION THERAPY (ADT) FOR PROSTATE CANCER

men who (i) were diagnosed with HG (ICD-9 257.2) by an experienced sexual medicine physician or were at risk for HG because of risk factors (prior chemotherapy) and had low or low normal serum total T (TT) levels (ii) had 2 early morning total TT levels (iii) had hormone testing conducted at a single laboratory and (iv) had DXA scans. Patient records were reviewed for demographics, comorbidities, serum hormone profiles and DXA results. BMD t-Scores (t) -2.5 defined osteoporosis (OPO); while t scores 1 t 2.5 defined osteopenia (OPE). RESULTS: 164 men met all inclusion criteria. Mean age was 56 14 years. 84% were Caucasian. Comorbidities included: 20% history of chemotherapy, 10% diabetes, 9% hematologic malignancy, 3% severe alcohol use ( 20 drinks/week), 2% corticosteroid use, 2% on anti-convulsant medicine, and 1% hyperthyroidism. Mean TT level 280 115 (range 11-691) ng/dL, mean free T (FT) 59 24 (range 0-130) pg/mL and mean E 21 9 (range 0-46) pg/mL. The distribution of men across TT quartiles was: 20% TT 200, 43% 200-299, 28% 300-399, 9% 400. 51% of all men had BMD loss (42% OPE; 9% OPO). OPE and OPO rates for various TT cutoffs is presented in the table. The percent of subjects by E cut-offs: 6% E 10; 52% E 10-20; 42% E 20. OPE/OPO rates in patients with T/E ratio 10 35%/11% , for ratio 10 52%/6%. CONCLUSIONS: Half of this patient population had evidence of BMD loss, with 9% demonstrating OPO. Men with TT levels greater than the classic 300 ng/dl cut-off continue to have a significant incidence of BMD loss. Given the high prevalence of BMD loss in this population, DXA screening should be considered in men presenting with HG.

PREDICTORS OF RESPONSE TO SILDENAFIL CITRATE FOLLOWING RADIATION THERAPY FOR PROSTATE CANCER

Introduction. Phosphodiesterase type 5 inhibitor (PDE5) use is a treatment strategy for prostate cancer patients with post-radiation therapy (RT) erectile dysfunction (ED). Aim. To define the predictors of sildenafil response in men treated with RT for prostate cancer. Main Outcome Measures. International Index of Erectile Function (IIEF). Methods. Patients were enrolled prospectively if they met the following criteria: (i) either a three-dimensional conformal external beam (EBRT) or brachytherapy (BT) with or without androgen deprivation (AD) for prostate cancer; (ii) self-reported ability to have sexual intercourse prior to RT; (iii) experienced onset of ED following RT; (iv) candidates for sildenafil citrate use; (v) followed-up periodically; and (vi) completed the IIEF at least 12 months after RT. Failure to respond to sildenafil was defined as IIEF-erectile function (EF) domain score of 24 months was 17. Successful response to sildenafil occurred in 68% of men at 12 months after RT, 50% at 24 months, and 36% at 36 months. Onmultivariable analysis, predictors of failure to respond to sildenafil were: older age, longer time after RT, AD > 4 months duration, and RT dose > 85 Gy. Modality of radiation delivery was not predictive of sildenafil failure. Conclusions. A steady decrease in sildenafil response was seen with increasing duration after RT. Several factors were predictive of sildenafil failure. Teloken PE, Parker M, Mohideen N, and Mulhall JP. Predictors of response to sildenafil citrate following radiation therapy for prostate cancer. J Sex Med 2009;6:1135–1140.