Readability, credibility and quality of patient information for hypogonadism and testosterone replacement therapy on the Internet.

The incidence of hypogonadism and use of testosterone replacement therapy (TRT) are rising, while data evaluating the complexity and quality of health-care information available to patients on the Internet for hypogonadism or TRT are lacking. This study focuses on characterizing the readability, credibility and quality of patient-centered information for hypogonadism on the Internet. A Google search was performed to identify top-ranked websites offering patient-centered information on hypogonadism and TRT. Readability was quantified by reading grade level using several validated instruments. Credibility and quality were determined by several additional criteria, including authorship, references, health-care information quality certification and breadth of topic discussion. Twenty of 75 total sites identified (27%) met the inclusion and exclusion criteria and were evaluated. The mean reading grade level was 13.1 (interquartile range 11.7-15.1), with all websites demonstrating reading levels significantly above recommended levels. Less than half (45%) of the sites were neither authored nor reviewed by a physician, 60% contained at least one reference and 40% were certified for displaying quality health-care information. Over half (55%) did not comprehensively discuss management of hypogonadism or mention treatment-associated risks. In conclusion, the majority of patient-centered information available on the Internet regarding hypogonadism or TRT is of poor quality and too complex for the average patient to comprehend. These results highlight a critical shortage in easily accessible, high-quality, comprehensible online patient health-care information on hypogonadism and TRT.

Tramadol for the management of premature ejaculation: a timely systematic review.

Premature ejaculation (PE) represents a common sexual dysfunction and is associated with a negative impact on quality of life and relationships. Recent evidence suggests that on-demand dosing of tramadol is effective at increasing intra-vaginal ejaculatory latency time (IELT) and improving subjective measures of satisfaction. A literature review was performed of journal articles published between January 2000 and July 2014 that matched the keywords 'tramadol' and 'premature ejaculation'. We identified eight relevant articles with the criteria that each article be published in a peer-reviewed journal, represent original work and be written in English. IELT was used as the primary outcome in each of the papers reviewed for efficacy. Additional subjective outcome measures were reviewed where available. Safety was assessed using adverse event data from the individual studies. We found that tramadol in on-demand dosing is effective at lengthening IELT in men with varying degrees of PE and improves patient satisfaction. Tramadol was generally well tolerated, particularly among those taking 25 and 50 mg doses. Although there is a risk of abuse and dependence, these events are rare, particularly at low doses taken intermittently. In conclusion, tramadol is an effective oral therapy for PE that is overall safe and well tolerated.

Tadalafil - a therapeutic option in the management of BPH-LUTS.

BACKGROUND/AIMS: Men with signs of benign prostatic hyperplasia (BPH) may experience lower urinary tract symptoms (LUTS) such as urinary frequency, urgency, intermittence, nocturia, straining, incomplete emptying or a weak urinary stream. The effective management of LUTS suggestive of BPH (BPH-LUTS) requires careful consideration of several factors, including the severity of a patient's symptoms, concurrent or other coexisting medical conditions, the ability to improve symptoms and impact quality of life (QOL), as well as the potential side effects of available treatment options. Several clinical studies have assessed phosphodiesterase type 5 (PDE5) inhibitors in reducing LUTS; however, tadalafil is the only PDE5 inhibitor approved for the treatment of signs and symptoms of BPH, as well as in men with both erectile dysfunction (ED) and the signs and symptoms of BPH. This review examined articles that assessed tadalafil in patients with signs and symptoms of BPH, with or without erectile dysfunction (ED), which led to regulatory approval in the United States and Europe. RESULTS: In dose-ranging and confirmatory studies, results demonstrate that tadalafil significantly improved total International Prostate Symptom Score (IPSS) following 12 weeks of treatment with once daily tadalafil 5 mg. Statistically significant improvements in Benign Prostatic Hyperplasia Impact Index (BII), IPSS subscores, IPSS QOL and International Index of Erectile Function (IIEF) were also observed. Improvement in urinary symptoms occurred regardless of age, previous treatment with an α1 -adrenergic blocker, BPH-LUTS severity at baseline or ED status. CONCLUSIONS: While tadalafil is most frequently recognised as a standard treatment option for men with ED, it also represents a well-tolerated and effective treatment option in men with moderate to severe BPH-LUTS.

The assessment of vascular risk in men with erectile dysfunction: the role of the cardiologist and general physician.

Erectile dysfunction (ED) and cardiovascular disease (CVD) share risk factors and frequently coexist, with endothelial dysfunction believed to be the pathophysiologic link. ED is common, affecting more than 70% of men with known CVD. In addition, clinical studies have demonstrated that ED in men with no known CVD often precedes a CVD event by 2-5 years. ED severity has been correlated with increasing plaque burden in patients with coronary artery disease. ED is an independent marker of increased CVD risk including all-cause and especially CVD mortality, particularly in men aged 30-60 years. Thus, ED identifies a window of opportunity for CVD risk mitigation. We recommend that a thorough history, physical exam (including visceral adiposity), assessment of ED severity and duration and evaluation including fasting plasma glucose, lipids, resting electrocardiogram, family history, lifestyle factors, serum creatinine (estimated glomerular filtration rate) and albumin:creatinine ratio, and determination of the presence or absence of the metabolic syndrome be performed to characterise cardiovascular risk in all men with ED. Assessment of testosterone levels should also be considered and biomarkers may help to further quantify risk, even though their roles in development of CVD have not been firmly established. Finally, we recommend that a question about ED be included in assessment of CVD risk in all men and be added to CVD risk assessment guidelines.

Impact of an educational initiative on applied knowledge and attitudes of physicians who treat sexual dysfunction.

A randomized, blinded, multicenter, controlled study was undertaken to assess the impact of a multiyear continuing medical education (CME) initiative on physician knowledge and behavior in the treatment of erectile dysfunction (ED). The objective of this study was to assess the efficacy of CME and compare applied knowledge and attitude scores of participants in the Consortium for Improvement in Erectile Function (CIEF), to non-CIEF participants. Subjects were selected randomly and contacted anonymously, by mail, email and fax and requested to enroll in this study. A blinded, validated questionnaire and series of standardized patient (SP) case studies and attitude questions were given to CIEF participants, defined as those who showed an interest in learning more about ED and who took at least one CME-certified program on ED from the CIEF website and non-CIEF participants, defined as those who showed interest in learning more about ED and who took at least one CME-certified program on ED from any organization other than CIEF. The primary outcome was a comparison of subjects' scores who participated in at least one CIEF program to non-participants in CIEF programs. Subjects were also compared based on SP case scores, attitude scores, specialty, years in practice, age and gender. Answers were ranked from best to worst and assigned a corresponding value of 10...3, 2, 1 and 0 (10 being the best), assuming that there may be more than one correct answer to each question in clinical practice. SAS version 9.1 analysis of variance model was used by an independent consultant. A total of 120 physicians completed the questionnaire: 87 urologists (UROs) and 33 primary care physicians (PCPs). UROs scored higher on SP cases compared with PCPs (P=0.0039); however, as a result of participating in CIEF programs, PCPs trended toward more comparable scores to UROs; P=0.23 for SP case 2 that was clinically less complex and P=0.19 for SP case 3 that was more complex. In the other two cases, the gap was reduced; however, UROs scored better than PCPs. PCPs in CIEF (n=23) had significantly higher SP case scores compared with non-CIEF PCPs (n=10); 216.6 vs 191.0, respectively (P=0.0437). PCPs in CIEF also showed a significantly greater level in mean attitude scores compared with UROs, 10.82 vs 8.15, respectively (P<0.0001). Both PCPs and UROs scored higher after participating in CIEF ED educational programs than those clinicians who participated in non-CIEF ED educational programs. In addition, clinicians participating in more CIEF programs scored higher than those participating in fewer CIEF programs. As expected, UROs consistently scored better than PCPs, indicating a higher baseline level of knowledge base about ED. However, this educational gap was significantly reduced in PCPs who participated in CIEF programs. The study demonstrated that PCPs who took more CIEF courses were almost as knowledgeable as UROs on the subject of ED. Longitudinal, disease-specific CME initiatives are valuable in that they positively impact the knowledge and thus the behavior of participating physicians, potentially conferring clinical benefits toward patient outcomes.

The efficacy and safety of tadalafil: an update.

OBJECTIVE: To provide an update on the efficacy and safety of tadalafil, a phosphodiesterase-5 inhibitor, in the treatment of erectile dysfunction (ED). PATIENTS AND METHODS: In all, 2102 men (mean age 56 years) with mild-to-severe ED of various causes were randomized to placebo or tadalafil, taken as needed with no food restrictions, at fixed 'on-demand' doses of 10 or 20 mg in 11 randomized, double-blind, placebo-controlled trials lasting 12 weeks. The three co-primary outcomes were changes from baseline in the erectile function domain of the International Index of Erectile Function (IIEF) and the proportion of 'yes' responses to questions 2 and 3 of the Sexual Encounter Profile (SEP). Additional efficacy instruments included a Global Assessment Question (GAQ). RESULTS: Compared with placebo, tadalafil gave significantly better outcomes. Patients receiving either dose of tadalafil had a significant mean improvement of 6.5 and 8.6, respectively, in the IIEF erectile function domain score from baseline (P < 0.001 vs placebo). At both doses the mean success rate for intercourse attempts (SEP-Q3) was 58% and 68%, respectively, compared with 31% in the placebo group (P < 0.001), and 71% and 84% reported improved erections at the endpoint (GAQ), vs 33% on placebo (P < 0.001). Tadalafil was effective up to 36 h after dosing and was effective regardless of disease severity and causes, and in patients of all ages. The most frequent adverse events were headache, dyspepsia, back pain and myalgia. CONCLUSION: Tadalafil was an effective and well-tolerated treatment for ED.

Diagnosis, treatment and prevention of penile prosthesis infection.

The implantation of inflatable penile prostheses for the treatment of erectile dysfunction continues to be widely practiced in the United States and internationally. As third-line therapy for erectile dysfunction, the numbers of implants continue to rise as the population of men treated for erectile dysfunction increases. Complications of penile prosthesis implantation continued to decline as mechanical malfunctions have decreased as a result of re-engineering inflatable penile prostheses. Inflatable penile prostheses from both available vendors continue to be reliable, effective methods for restoring erectile function with high satisfaction rates. The most troublesome complication of these prostheses, however, is not mechanical but rather that of prosthesis infection. Prosthesis infections may result in further surgery, loss of penile tissue, and even the inability to replace penile prosthesis. While standard sterile technique perioperative antibiotics and careful surgical procedures continue to be the cornerstone of penile prosthesis infection avoidance, newer designs of penile prostheses for antibiotic coating have resulted in an improvement in the prevalence and incidents of penile prosthesis infection. For those patients in whom penile prostheses become infected despite adequate prophylaxis, newer techniques of salvage have demonstrated increasing success. Once and still the most dreaded complication of penile prosthesis implantation, prothesis infections can now be avoided by perioperative preparation and antibiotics as well as antibiotic-coated penile prostheses. Treatment of penile prosthesis infections once associated with severe loss of function can often be successful with modern salvage techniques. Implanting urologists must be familiar prophylaxis, avoidance, and treatment of penile prosthesis infections.

Peyronie's disease: surgical management: autologous materials.

Peyronie's disease in men with satisfactory erectile function but with significant penile curvature is often treated with plaque incision or excision and grafting. The advantages and disadvantages of various grafting materials have long been debated. While artificial materials have been used, the inflammatory reaction from these grafts has produced poor results. Dermal, venous and tunica vaginalis grafts require additional operative time to harvest and their quality varies. Packaged grafts of autologous materials provide a readily available, reliable and well-tolerated choice for penile reconstruction for Peyronie's disease. These grafting materials including cadavaric pericardium, mammalian intestinal serosal products and others are easily obtained and provide a resilient yet compliant graft choice that is easy to tailor and suture in place. Host reaction is minimal and the infection risk small. Results of Peyronie's plaque incision/excision and autologous grafting are presented and the surgical procedures employed are outlined. Excellent results can be expected in the hands of the experienced reconstructive surgeon.

Distal penile prosthesis extrusion: treatment with distal corporoplasty or Gortex windsock reinforcement.

Subcutaneous extrusion of penile prosthesis cylinders beneath the glans penis is an unusual but difficult complication of penile prosthesis. Without surgical repair, extrusion, infection, and corporeal fibrosis may ensue. Twenty-eight patients with distal corporeal extrusion were reviewed to identify the optimum treatment outcome for these penile prosthesis complications. Records of 28 men with subcutaneous distal penile prosthesis cylinder extrusion were reviewed. Mean age was 56.2 y. Etiology of erectile dysfunction was diabetes mellitus in 11, vasculogenic in 10, Peyronie's disease in five, radical pelvic surgery in five. Duration of penile prosthesis was 8-72 months (mean 42.6). No patient had penile prosthesis infection or device exposure through the skin. Distal corporoplasty was treated on 18/28 men using cylinder repositioning and direct tunica albuginea repair. Ten men underwent repair using a Gortex windsock. 8/18 corporoplasty and 6/10 windsock patients required glans fixation for treatment of hypermobile glans following cylinder relocation. In two patients with windsock repair, extrusion recurrence occurred 6 and 18 months following surgery and 1/6 had post operative infection requiring prosthesis removal. Mean surgical time for corporoplasty was 52.8 minutes while windsock reconstruction was 89.6 minutes. Distal subcutaneous penile prosthesis cylinder extrusion produces coital pain and predisposes to cylinder exposure and infection. Early repair with or without additional prosthetic materials will return penile prostheses to a normal functioning state. Distal corporoplasty with cylinder repositioning appears to be a simple, low morbidity solution to this difficult dilemma. Outcomes with distal corporoplasty result in better function, less pain, and fewer recurrences than Gortex windsock repair.

Erectile dysfunction in the 21st century: whom we can treat, whom we cannot treat and patient education.

Erectile dysfunction affects 31-52% of American men. Although considerable advances have been made in the diagnosis and treatment of erectile dysfunction in the past decade, more than 80% of men with erectile dysfunction are not treated because they do not seek medical attention or their physicians do not initiate a dialogue about sexual problems during their visits. This despite patients' desires to confront sexual problems and receive treatment. Most subgroups of men can now be effectively treated for sexual dysfunction. Although men with severe cardiac disease may require stabilization of their cardiac condition before treatment, most can successfully return to an active sex life. Some men, however, do not respond to the use of oral agents. These men can be treated with second- and third-line treatment modalities or with the newer concept of combined-modality treatment. Despite excellent treatment alternatives, many men have low libido or hypoactive sexual desire disorder. In the ultimate resolution of a patient's sexual dysfunction, physicians must open a free and sympathetic dialogue and offer a full spectrum of treatment modalities tailored to the individual patient and partner. If initial treatment modalities fail, more invasive alternatives or combination therapy should be offered to cure the patient's erectile dysfunction.

A comparison of dermal and cadaveric pericardial grafts in the modified Horton-Devine procedure for Peyronie's disease.

PURPOSE: Penile curvature due to Peyronie's disease is often treated with plaque incision or excision and grafting. The advantages of various graft materials have long been debated. We studied the outcomes of dermal and cadaveric pericardial grafts after plaque incision or excision for Peyronie's disease. MATERIALS AND METHODS: We retrospectively evaluated all modified Horton-Devine procedures performed between February 1998 and April 2000. Dermal graft harvested from the lower abdomen or commercially available cadaveric pericardium was used to cover the corporeal defect. A followup telephone questionnaire was administered to determine patient satisfaction and function. RESULTS: We reviewed the records of 27 men, including 18 and 9 who received a dermal and pericardial graft, respectively. We successfully contacted 24 patients, including 15 with a dermal and 9 with a pericardial graft, to evaluate satisfaction. Average postoperative followup was 10 months. Of the 24 patients, 22 reported successful coitus and 15 (63%) needed assistance to achieve erection rigid enough for satisfactory coitus. Eight patients reported recurrent curvature, which was minimal and did not hamper sexual function. Overall 11 of the 15 patients with a dermal and 8 of the 9 with a pericardial graft would undergo the surgery again or recommend it to others. CONCLUSIONS: The results of the dermal and cadaveric pericardial grafts were comparable. The minimal preoperative preparation, decreased patient morbidity and pliability of cadaveric pericardium make it an attractive suitable graft substitute in the modified Horton-Devine procedure. Longer followup and larger patient series are needed to confirm the advantages of cadaveric pericardium.

Physician-patient dialogue and clinical evaluation of erectile dysfunction.

Erectile dysfunction affects 31% to 52% of all men. Although considerable advances have been made in the diagnosis and management of erectile dysfunction, the inadequate knowledge of erectile dysfunction by health care providers still precludes them from initiating candid discussions with their patients. This article provides the health care professional with the ability to establish comfortable doctor-patient dialogue and to clinically evaluate erectile dysfunction in a goal-directed manner. The goal of evaluation is to find the appropriate treatment for the individual, dictated primarily by factors like the patients' preferences, comfort, cost, and the availability of treatment modalities.

Penile prosthesis implantation and infection for Sexual Medicine Society of North America.

Penile prosthetics have developed over the past three decades into an effective treatment for erectile dysfunction with high reliability and patient satisfaction rates. The morbidity of these devices is principally limited to mechanical malfunction and the most feared complication of prostheses infection. Most penile prosthesis infections are caused by gram positive skin contaminations such as Staphylococci. The signs and symptoms of these infections may be difficult to identify in early stages, but late infections may lead to tissue loss and poor prognosis for prosthesis replacement. Treatment of penile prosthesis infections is best carried out with a salvage technique including aggressive lavage and prosthesis replacement. The success of this technique is salvage of prosthesis and return to function in more than 80% of cases. While penile prosthesis infection continues to be a dreaded complication, early diagnosis and aggressive surgical treatment may salvage the majority of these implants.

Identifying mRNA subsets in messenger ribonucleoprotein complexes by using cDNA arrays.

Genomic array technologies provide a means for profiling global changes in gene expression under a variety of conditions. However, it has been difficult to assess whether transcriptional or posttranscriptional regulation is responsible for these changes. Additionally, fluctuations in gene expression in a single cell type within a complex tissue like a tumor may be masked by overlapping profiles of all cell types in the population. In this paper, we describe the use of cDNA arrays to identify subsets of mRNAs contained in endogenous messenger ribonucleoprotein complexes (mRNPs) that are cell type specific. We identified mRNA subsets from P19 embryonal carcinoma stem cells by using mRNA-binding proteins HuB, eIF-4E, and PABP that are known to play a role in translation. The mRNA profiles associated with each of these mRNPs were unique and represented gene clusters that differed from total cellular RNA. Additionally, the composition of mRNAs detected in HuB-mRNP complexes changed dramatically after induction of neuronal differentiation with retinoic acid. We suggest that the association of structurally related mRNAs into mRNP complexes is dynamic and may help regulate posttranscriptional events such as mRNA turnover and translation. Recovering proteins specifically associated with mRNP complexes to identify and profile endogenously clustered mRNAs should provide insight into structural and functional relationships among gene transcripts and/or their protein products. We have termed this approach to functional genomics ribonomics and suggest that it will provide a useful paradigm for organizing genomic information in a biologically relevant manner.

Penile prosthesis implantation in the treatment of Peyronie's disease and erectile dysfunction.

Although men afflicted with Peyronie's disease (PD) usually have a number of treatment options, those who also present with erectile dysfunction (ED) arising from unknown or iatrogenic causes are not easily treated. Surgical straightening procedures that have been used to treat PD may not restore erectile function and failure to straighten the penis with surgery may be the result of erectile inadequacy during the post-operative period. This paper discusses penile prosthesis implantation as a surgical option for patients with PD, placing emphasis on the choice of devices and surgical techniques. Several new techniques which hold the promise of high success rates and low morbidity are mentioned. International Journal of Impotence Research (2000) 12, Suppl 4, S122-S126.

Efficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: results of a long-term multicenter study. AMS 700CX Study Group.

PURPOSE: We performed a long-term multicenter study of the AMS 700CX 3-piece inflatable penile prosthesis, focusing on longevity, morbidity and patient satisfaction in men implanted up to 134 months with a median followup of 47.7 months. MATERIALS AND METHODS: We performed a large scale retrospective multicenter study in 2 phases. Phase 1 was a medical record review of 372 men who underwent implantation with the AMS 700CX penile prosthesis from 1987 to 1996 by 7 frequent penile prosthesis implanters. Phase 2 included a structured telephone interview of 207 patients by a neutral observer. RESULTS: For the 372 men in phase 1 mean device mechanical reliability plus or minus standard deviation was 92.1% + or - 3.3% after 3 and 86.2% + or - 4.6% after 5 years. Patient age was 21 to 79 years (mean 57.6 + or - 11.0) at implantation. The etiology of erectile dysfunction was vascular in 27.7% of the cases, Peyronie's disease in 16.9%, diabetes mellitus in 12.9% and radical surgery in 11.6%. Of the men 55.6% received previous treatment for erectile dysfunction. Postoperative infection and device malfunction developed in 3.2% and 17.5% of the cases, respectively. Of the 207 men interviewed in phase 2, 86% still had an AMS 700CX penile prosthesis implanted, including 87.1% with erection suitable for coitus. Currently 79% of those with a device use it at least twice monthly and 88.2% would recommend an implant to a relative or friend. CONCLUSIONS: The AMS 700CX penile implant produced suitable erection and excellent patient satisfaction at long-term followup in the majority of men. Implant reliability is excellent and postoperative morbidity is low.

Replantation of the penis: a patient report.

Replantation of the penis is an unusual case in this country and it is unlikely that most plastic and reconstructive surgeons or urologists will see one during their career. A successful repair of a self-inflicted amputation of the penis is presented. The unique anatomy of the penis pertinent to replantation is reviewed, and current concepts and recommendations in performing replantation of the penis are presented.

Andropause: a misnomer for a true clinical entity.

PURPOSE: A progressive decrease in androgen production is common in males after middle age. The resulting clinical picture has been erroneously named male menopause or andropause. A more appropriate designation is androgen decline in the aging male (ADAM). The syndrome is characterized by alterations in the physical and intellectual domains that correlate with and can be corrected by manipulation of the androgen milieu. We review the epidemiological aspects of aging and endocrinological manifestations of ADAM, and provide recommendations for treatment and monitoring of these patients. MATERIALS AND METHODS: We performed MEDLINE, Pubmed, Current Contents and Pharmaceutical Abstracts searches of relevant peer reviewed publications on andropause, male climacteric, adult hypogonadism and aging. In addition, conference proceedings were researched to provide a more complete review of the literature. Information was scrutinized and collated, and contributory data were reviewed and summarized. RESULTS: ADAM is a clinical entity characterized biochemically by a decrease not only in serum androgen, but also in other hormones, such as growth hormone, melatonin and dehydroepiandrosterone. Clinical manifestations include fatigue, depression, decreased libido, erectile dysfunction, and alterations in mood and cognition. CONCLUSIONS: The onset of ADAM is unpredictable and its manifestations are subtle and variable, which has led to a paucity of interest in its diagnosis and treatment. Urological practice commonly includes a large proportion of men older than 50 years. Therefore, it is important for urologists to recognize the manifestations of and be familiar with evaluations necessary to document ADAM as well as its treatment and monitoring.