Deformity stabilization and improvement in men with untreated Peyronie's disease.

OBJECTIVE: To define predictors of the deformity stabilisation and improvement in men with untreated Peyronie's disease (PD). PATIENTS AND METHODS: The study population consisted of patients with PD-associated uniplanar curvature, who opted for no treatment and were followed for at least 12 months. All patients had deformity assessment (DA) performed on initial presentation and at follow-up. Stabilisation of PD was defined as no change between DAs (±10°), while improvement and progression were defined as ≥10° change. Patients were subdivided into different groups based on time to presentation: ≤6 months (A), 7-12 months (B), and 13-18 months (C). Multivariable analysis was used to define predictors of stabilisation and improvement. RESULTS: In all, 176 men met the inclusion criteria. The mean age was 54 years, with a mean (sd) PD duration of 9 (12) months and mean curvature of 42 (27)°. In all, 67% of the entire population had no change in deformity over time, 12% improved with a mean (sd) change of 27 (14)°, and 21% worsened with a mean (sd) change of 22 (11)°. On multivariate analysis, predictors of stabilisation included: time to presentation of >6 months (odds ratio [OR] 2.4, P < 0.01), per decade increase in age (OR 1.5, P < 0.05), and age (r = 0.32, P < 0.05). Predictors of improvement included: time to presentation of ≤6 months (OR 4.1, P < 0.001), and per decade decrease in age (OR 2.1, P < 0.01). CONCLUSIONS: In men with uniplanar curvature, PD stabilisation and improvement rates change with time-to-presentation and patient age. These data may aid in counselling patients with PD.

Metabolic and cardiovascular outcomes of fatherhood: results from a cohort of study in subjects with sexual dysfunction.

INTRODUCTION: Previous cross-sectional and longitudinal studies reported a negative correlation between fatherhood and testosterone (T) levels, likely due to a centrally mediated downregulation of the hypothalamic-pituitary-gonadal axis. Moreover, epidemiological data indicate that fatherhood might affect metabolic and cardiovascular outcomes, although different results have been reported. Up to now, no studies have evaluated these associations in a population of men seeking treatment for sexual dysfunction (SD). AIM: To explore biological and clinical correlates of number of children (NoC) and its possible associations with forthcoming major cardiovascular events (MACE) in a sample of men with SD. METHODS: A consecutive series of 4,045 subjects (mean age 52 ± 13.1 years old) attending the Outpatient Clinic for SD was retrospectively studied. A subset of the previous sample (N = 1,687) was enrolled in a longitudinal study. MAIN OUTCOME MEASURES: Information on MACE was obtained through the City of Florence Registry Office. RESULTS: Among patients studied, 31.6% had no children, while 26.3% reported having one child, 33.4% two, and 8.8% three or more children. Although fatherhood was negatively related with follicle-stimulating hormone levels and positively with testis volume, we found a NoC-dependent, stepwise decrease in T plasma levels, not compensated by a concomitant increase in luteinizing hormone. NoC was associated with a worse metabolic and cardiovascular profile, as well as worse penile blood flows and a higher prevalence of metabolic syndrome (MetS). In the longitudinal study, after adjusting for confounders, NoC was independently associated with a higher incidence of MACE. However, when the presence of MetS was introduced as a further covariate, the association was no longer significant. CONCLUSIONS: This study supports the hypothesis that bond maintenance contexts and fatherhood are associated with an adaptive downregulation of the gonadotropin-gonadal axis, even in a sample of men with SD. Moreover, our data suggest that NoC predicts MACE, most likely because of an unfavorable, lifestyle-dependent, parenthood-associated behavior.

[Anorectal foreign bodies--only a surgical question?]. / Anorektale Fremdkörper--eine rein chirurgische Fragestellung?

Treatment of anorectal foreign bodies is a frequent surgical and proctologic question. However, psychiatric implications of paraphilias are rarely discussed. Since the liberalisation of sexual behaviour in the 1970s, the reported number of severe complications due to paraphilias is increasing, and sexuality is performed until higher age. We describe the case of an 88 year old man who had undergone laparotomy for removal of foreign bodies. The initial diagnosis of a dementia with inappropriate sexual behaviour could not be confirmed as the paraphilia existed since his youth. Etiologic, diagnostic and therapeutic implications of the case are discussed.

The implications of increasing age on erectile dysfunction.

Erectile dysfunction (ED) has long been correlated with psychological well-being. More recently, an understanding has developed of ED being, in some cases, a vascular condition of the penile artery. Given the narrowness of the penile artery, a small amount of atherosclerosis may result in ED before any other manifestations are evident, making ED a useful marker for other vascular conditions with potentially greater clinical implications. In light of this, possible underreporting of ED takes on added significance. A questionnaire regarding ED prevalence and management was distributed for self-administration to men in the waiting room of primary care clinics; the data were analyzed with a focus on the relationship between ED and age. The study had a remarkable response rate of >95%. The prevalence of ED in the ≥70-year age-group was 77%, compared with 61% in the 40- to 69-year age-group (p = .0001). ED correlated linearly with age (R(2) = .80, p < .0001). Among those who had ED, more than half had not discussed it with any provider; the likelihood of discussing ED did increase with the reported severity of symptoms (p < .0001). Older men had more severe ED than younger men (p < .0001). Furthermore, 72% of men with a history of ED were never treated. Younger men were more likely to be treated than older men (p = .004). Given the potential implications of underreporting ED, and the willingness of the men in this study to complete the questionnaire, further work may be merited on new models for ED assessment and follow-up.

Erectile function and sexual satisfaction before and after penile prosthesis implantation in radical prostatectomy patients: a comparison with patients with vasculogenic erectile dysfunction.

INTRODUCTION: Patients with erectile dysfunction (ED) after radical prostatectomy (RP) may benefit from penile prosthesis (PP) implantation after failure of less invasive treatments. Aim. To assess surgical outcomes and satisfaction after PP implantation in RP patients and compare the results with those in patients with vasculogenic ED (controls). METHODS: A database of 415 consecutive PPs (January 1996-December 2008) was used to collate data on preimplantation ED treatments, surgical complications, satisfaction, and International Index of Erectile Function (IIEF) scores before and 3 months after implantation. The results for 90 post-RP implants (79 primary, 11 secondary) and 131 implants for vasculogenic ED were compared. MAIN OUTCOME MEASURES: The main outcome measures of this study are intra- and postoperative complications and IIEF domain scores. RESULTS: Mean follow-up of RP patients was 37.6 ± 26.8 months. Mean interval between RP and PP implantation was 31.5 ± 28.7 months. Nearly all primary implants (96.2%) were inflatable (3-piece, 70.1%; 2-piece, 24.1%). There was no significant difference between groups in terms of rates of infection (1.1%), mechanical failure (3.3%), and other surgical complications requiring revision surgery (migration, auto-inflation) (4.4%). For primary implants, the mean preimplantation IIEF score (all items) was significantly lower in RP patients than in controls (14.7 ± 5.9 vs. 22.6 ± 10.8, P = 0.003), chiefly because of significantly lower scores for erectile function, intercourse satisfaction, and orgasmic function. After PP implantation in RP patients, the scores for all domains improved, but the total score remained significantly lower than in controls (63.1 ± 7.0 vs. 68.5 ± 6.9, P = 0.005). The orgasmic function score was significantly lower (P < 0.001). Overall satisfaction rate was 86.1% in RP patients and 90.7% in controls (P = 0.3). CONCLUSIONS: PP implantation after RP is associated with low morbidity and high satisfaction. It improves the scores for all IIEF domains and, in particular, erectile function. Fibrosis of the retropubic space may require a second incision for reservoir placement or implantation of a 2-piece PP.

What is the definition of a satisfactory erectile function after bilateral nerve sparing radical prostatectomy?

INTRODUCTION: Different cut-offs of the erectile function (EF) domain of the International Index of Erectile Function (IIEF) have been used as definition of postoperative EF recovery. AIM: To test the correlation between patient satisfaction and IIEF-EF domain score cut-offs. MAIN OUTCOME MEASURE: The IIEF was used to evaluate EF and satisfaction before and after bilateral nerve sparing radical prostatectomy (BNSRP). METHODS: The study included 165 consecutive patients treated with retropubic BNSRP at a single institution. All patients had normal preoperative EF (IIEF-EF ≥ 26) and reached an IIEF-EF ≥ 17 following surgery. Complete data included EF, intercourse (IS), and overall satisfaction (OS) assessed by the corresponding domains of the IIEF administered prior and after surgery. Patients were divided into three groups according to the highest IIEF-EF score reached postoperatively, namely 17-21 (group 1), 22-25 (group 2), and ≥ 26 (group 3). One-way analysis of variance was used to compare IIEF-OS and IIEF-IS domain scores at the time the EF end point was reached. The same analyses were repeated separately in those patients with a complete EF recovery after surgery (group 3). RESULTS: Mean preoperative IIEF-OS and IIEF-IS domain score was 8.4, 8.8, 8.7 and 11.6, 11.8, 11.9 in group 1, 2, 3, respectively (all P ≥ 0.3). After a mean follow-up of 26.7 months, mean postoperative IIEF-OS and IIEF-IS domain scores assessed at the time of EF recovery were comparable for patients reaching an IIEF-EF of 22-25 and for patients scoring postoperatively ≥ 26 (8.1, 8.1, and 10.6, 11.4; all P ≥ 0.3). However, mean IIEF-OS and IIEF-IS domain scores of these patients were significantly higher as compared to patients reaching an IIEF-EF domain score < 22 (6.3 and 8.4, respectively; all P ≤ 0.006). Similar results were achieved considering only those patients (group 3) who had complete EF recovery after surgery. CONCLUSIONS: We demonstrated that in preoperatively fully potent patients treated with BNSRP a lower satisfaction is expected when an IIEF-EF cut-off of 17 is used. Conversely, no difference was found using a cut-off of 22 or 26. Therefore, our results support that a cut-off of IIEF-EF ≥ 22 might represent a reliable score for defining EF recovery after BNSRP.

Summary of the recommendations on sexual dysfunctions in men.

INTRODUCTION: Sexual health is an integral part of overall health. Sexual dysfunction can have a major impact on quality of life and psychosocial and emotional well-being. AIM: To provide evidence-based, expert-opinion consensus guidelines for clinical management of sexual dysfunction in men. METHODS: An international consultation collaborating with major urologic and sexual medicine societies convened in Paris, July 2009. More than 190 multidisciplinary experts from 33 countries were assembled into 25 consultation committees. Committee members established scope and objectives for each chapter. Following an exhaustive review of available data and publications, committees developed evidence-based guidelines in each area. Main Outcome Measures. New algorithms and guidelines for assessment and treatment of sexual dysfunctions were developed based on work of previous consultations and evidence from scientific literature published from 2003 to 2009. The Oxford system of evidence-based review was systematically applied. Expert opinion was based on systematic grading of medical literature, and cultural and ethical considerations. RESULTS: Algorithms, recommendations, and guidelines for sexual dysfunction in men are presented. These guidelines were developed in an evidence-based, patient-centered, multidisciplinary manner. It was felt that all sexual dysfunctions should be evaluated and managed following a uniform strategy, thus the International Consultation of Sexual Medicine (ICSM-5) developed a stepwise diagnostic and treatment algorithm for sexual dysfunction. The main goal of ICSM-5 is to unmask the underlying etiology and/or indicate appropriate treatment options according to men's and women's individual needs (patient-centered medicine) using the best available data from population-based research (evidence-based medicine). Specific evaluation, treatment guidelines, and algorithms were developed for every sexual dysfunction in men, including erectile dysfunction; disorders of libido, orgasm, and ejaculation; Peyronie's disease; and priapism. CONCLUSIONS: Sexual dysfunction in men represents a group of common medical conditions that need to be managed from a multidisciplinary perspective.

The female factor: predicting compliance with a post-prostatectomy erectile preservation program.

INTRODUCTION: Early post-radical prostatectomy (RP) erectile preservation (EP) therapy may be critical to preserve erections after surgery. AIM: To assess if pre-RP female sexual function predicts of partner compliance with an EP protocol. MAIN OUTCOME MEASURES: Compliance, defined as use of localized penile EP therapy (intracavernosal injections [ICIs], vacuum erection device [VED], or alprostadil) at 3 and 6 months after RP. METHODS: Records of patients enrolled in our EP program from April 2007 to June 2008 were reviewed. Before surgery, patients completed the Sexual Health Inventory for Men (SHIM) and their female partners completed the Female Sexual Function Index (FSFI) questionnaire. Prior to surgery, patients were advised to take sildenafil 25 mg every nightly and use a 250-µg alprostadil suppository three times/week. At 1 month, additional daily use of a VED was encouraged. All patients unable to achieve erections sufficient for penetration were encouraged to initiate ICI of Trimix (phentolamine, papaverine, and PGE1) twice weekly after 3 months following surgery. Data were analyzed using binary logistic regression analysis holding all input variables constant. RESULTS: Twenty-nine patients had preoperative SHIM>7 and pre-RP partner FSFI data available. After a 4-week follow-up, compliance with alprostadil suppository declined and both ICI and VED usage increased. At 6 months, six (25.0%) patients had return of natural erectile function and 22 (91.7%) were achieving assisted erections. Higher preoperative partner FSFI scores were associated with greater compliance to the localized penile therapy component of our EP protocol (risk ratio 3.8, P=0.05). CONCLUSIONS: Preoperative female sexual function correlated with greater partner compliance with the localized component of our EP protocol. Consideration of a female partner's preoperative sexual function in predicting patient erectile function recovery after RP is warranted. Future studies are necessary to determine the clinical significance of this factor.

[Sexual dysfunction and its consequences in patients with cardiovascular diseases]. / Sexuelle Funktionsstörungen bei Herzkranken und die Folgen.

PURPOSE: Due to the high prevalence of sexual disorders in men and women with cardiovascular disease, the associations between sexual dysfunction, depression, anxiety, quality of life and partnership were investigated. Studies examining impairments to certain aspects of psychological health and interpersonal life in cardiac patients are still lacking. The SPARK (Sexuality of Patients in Rehabilitation of Cardiovascular Diseases) investigation is the first study which explores these relevant associations in German rehabilitation patients. METHODS: Five rehabilitation centers for cardiovascular diseases took part in our cross-sectional study. Associations between sexual dysfunction and depression, anxiety, quality of life and partnership were tested using z-tests (resulting parameter prevalence rate ratio, PRR) and via multiple binary logistic regressions controlling for age and severity of cardiovascular disease as possible confounders (resulting parameter odds ratio, OR). RESULTS: Sexual function could be assessed in 261 men and 75 women (sexual activity during the previous month; for detailed flow chart see Fig. 1). In total, 43.1% of female patients reported a sexual dysfunction, while 20.2% of male patients stated to have at least moderate erectile dysfunction (ED). The proportion of self-assessed sexual problems is shown in Fig. 2. Women with a sexual dysfunction were impaired to a significantly higher extent compared to women without sexual dysfunction with regard to their quality of partnership (PRR 13.0; p=0.019; OR 25.42, confidence interval, CI, 2.5-254.9), anxiety (PRR 3.2; p=0.053; OR 4.43, CI 1.2-16.4) and psychological quality of life (PRR 2.4; p=0.115; OR 6.08, CI 1.6-22.9). Men with ED reported significantly stronger depression (PRR 3.6; p=0.003; OR 3.63, CI 1.5-8.8) and anxiety (PRR 2.4; p=0.008; OR 2.88, CI 1.4-5.9) compared to men without ED. For detailed information see Tables 1 and 2. CONCLUSION: Due to the high proportion of men and women with cardiovascular disease reporting sexual disorders, depression and anxiety, screening for these disorders should be an integral part of comprehensive rehabilitation programs. In particular, the diagnosis and treatment of psychiatric comorbidity seem to be necessary from a tertiary preventive perspective.

Methodology of a randomized clinical trial of symptom management strategies in patients receiving chronic hemodialysis: the SMILE study.

Despite the high prevalence of pain, sexual dysfunction, and depression in patients on chronic hemodialysis, these symptoms are often unrecognized and under-treated by renal providers. This report describes the rationale and methodology of the SMILE study (Symptom Management Involving End-Stage Renal Disease), a multi-center, randomized clinical trial comparing the effectiveness of two strategies for implementing treatment for these symptoms in patients receiving chronic hemodialysis. Approximately 250 patients from nine outpatient dialysis units will participate. Over a 2-12 month observational phase, participants complete monthly surveys characterizing their pain, sexual dysfunction, and depression. Following this observational period, subjects are randomized to one of two study arms to receive a 12-month intervention. In one study arm (feedback intervention), patients continue to complete the same three symptom surveys, and the presence and severity of the symptoms reported on these surveys is mailed to the patient's renal provider along with evidence-based algorithms outlining treatment options for these symptoms. Decisions on treatment are left at the discretion of the provider. Patients randomized to the other study arm (management intervention) also continue to complete the same monthly symptom surveys and are evaluated by a symptom management nurse trained in the management of these symptoms. This nurse then discusses the patient's symptoms with the renal provider, provides specific recommendations for treatment, and facilitates the implementation of treatment. The primary endpoints are changes in scores on pain, erectile dysfunction, and depression surveys. This report describes the rationale and methodology of this clinical trial.

Priapus is happier with Venus than with Bacchus.

INTRODUCTION: The relationship between alcohol consumption and erectile function is still not completely clarified. AIM: Aims of the present study are to explore a number of biological and clinical correlates of alcohol consumption in a sample of men consulting for sexual dysfunction, and to verify possible associations with the incidence of major adverse cardiovascular events (MACEs). METHODS: A consecutive series of 1956 (mean age 55 ± 11.9 years old) attending our outpatient clinic for sexual dysfunction was retrospectively studied. A subset of the previous sample (N = 1687) was enrolled in a longitudinal study. MAIN OUTCOME MEASURES: Different clinical, biochemical, instrumental (penile Doppler ultrasound [PCDU]), and intrapsychic (Middlesex Hospital Questionnaire [MHQ]) were evaluated. We considered alcohol abuse more than three drinks per day. RESULTS: Among the patients studied 81% reported no or mild (<4 drinks/day) alcohol consumption whereas 14.3% and 3.9% declared a moderate (4-6 drinks/day) or severe (>6 drinks/day) alcohol abuse, respectively. After adjustment for confounders, both moderate or severe alcohol abuse was associated with low perceived partner's sexual desire, worse couple relationship, and smoking abuse. Furthermore, moderate and severe alcohol abuse was associated with low prolactin and thyroid-stimulating hormone levels, as well as an increase in triglycerides and total cholesterol levels. Penile blood flow was reduced in moderate and severe alcohol drinkers even after adjustment for confounders. In the longitudinal study, after adjusting for confounding factors, any kind of alcohol abuse was independently associated with a higher incidence of MACE (hazard ratio = 2.043 [1.059-3.943]; P < 0.0001). CONCLUSIONS: Our findings demonstrate that, in subjects consulting for erectile dysfunction, severe alcohol consumption is associated with a worse sexual function and a higher incidence of MACE.

Diagnostic tests for male erectile dysfunction revisited. Committee Consensus Report of the International Consultation in Sexual Medicine.

INTRODUCTION: The Committee on "Clinical Evaluation and Scales in Sexual Medicine" of the third International Consultation in Sexual Medicine reviewed current practice and new developments in the field of physiological testing in male erectile dysfunction (ED). AIM: To provide an overview of current practice and new developments in the field of diagnostic testing in male ED. METHODS: The Pubmed literature was reviewed. RESULTS: Since the 1980s of the last century, a broad array of specialized physiological tests has been used for assessing ED. The notion that ED often is an (early) symptom of generalized cardiovascular disease and the introduction of oral pharmacological therapies that are effective irrespective of etiology has reduced the application of the "classical" tests to a minimum and has shifted the scope toward tests with demonstrated reliability in cardiovascular medicine. CONCLUSIONS: (i) The clinical utility of specialized tests in the evaluation of male ED is limited to a small minority of men; (ii) the scope of physiological testing has shifted toward tests with demonstrated reliability in cardiovascular medicine.

Considerations for diagnostic criteria for erectile dysfunction in DSM V.

INTRODUCTION: The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., text revision (DSM-IV-TR) criteria for erectile disorder have been criticized as multiple grounds including that the criteria lack precision, that the requirement of marked distress is inappropriate, and that the specification of etiological subtypes should be deleted. AIM: The goal of this manuscript is to review evidence relevant to diagnostic criteria for erectile disorder published since 1990. METHOD: Medline searches from 1990 forward were conducted using the terms erectile disorder and impotence. Early drafts of proposed alterations in diagnostic criteria were submitted to advisors. MAIN OUTCOME MEASURE: Evidence regarding modification of criteria for DSM V diagnostic criteria for erectile dysfunction was judged by whether existing data justified the adoption of precise criteria which would lead to homogenous groups for research. Another outcome measure was whether data exist to reliably differentiate fluctuations in normal function from pathological states. RESULTS: The literature review revealed a large literature concerning erectile disorder but minimal evidence concerning an operational definition for this disorder. CONCLUSIONS: It is recommended that erectile disorder be precisely defined in order to clearly differentiate alterations in normal function from a condition requiring medial intervention and to facilitate clinical research. It is specifically proposed that erectile dysfunction be defined as failure to obtain and maintain an erection sufficient for sexual activity or decreased erectile turgidity on 75% of sexual occasions and lasting for at least 6 months. It is also recommended that erectile disorder be defined independently of distress.

Psychobiological correlates of women's sexual interest as perceived by patients with erectile dysfunction.

INTRODUCTION: We have recently reported that the perceived loss of a partner's sexual desire is independently associated with an increased incidence of major cardiovascular events in patients with erectile dysfunction (ED). No study has ever evaluated the specific impact of men's perception of women's sexual desire on male sexual function and lifestyle attitudes in ED subjects. AIM: To evaluate the clinical correlates of the perception of a partner's sexual desire [hypoactive sexual desire (HSD)] in a consecutive series of subjects seeking medical care for ED. METHODS: A consecutive series of 2,303 heterosexual male patients (mean age 58.1 ± 10.5) was studied. MAIN OUTCOME MEASURES: Patients were interviewed with the Structured Interview on Erectile Dysfunction (SIEDY) structured interview. They also completed the Middlesex Hospital Questionnaire, a brief questionnaire for the screening of the symptoms of mental disorders. RESULTS: Among the patients studied, 458 (19.9%) reported a mild loss of their partner's desire, 302 (13.1%) a moderate reduction of libido, while 118 (5.1%) complained of a complete absence of sexual interest on the part of their partner. After adjustment for confounding factors, the perceived women's HSD was associated with different sexual, lifestyle, and relational factors. In particular, more extra-marital affairs, a longer and more hostile couple relationship, as well as a stressful job and both alcohol and smoking abuse were all significantly associated with perceived women's HSD. In addition, the perceived women's moderate to severe HSD was significantly associated with severe ED and less frequent sexual intercourse. Finally, partner HSD was significantly associated with a stepwise increase of free-floating anxiety and depressive symptoms (adj. r = 0.081, P < 0.05 and 0.158, P < 0.0001, respectively). CONCLUSIONS: Perceived sexual interest (éros) on the part of the woman can be seen for men not only as a fun and enjoyable behavior, but also a safe strategy for improving a man's overall health and life expectancy.

Physical activity and PDE5 inhibitors in the treatment of erectile dysfunction: results of a randomized controlled study.

INTRODUCTION: Physical activity (PhA) has proven to be a protective factor for normal erectile function in numerous epidemiological studies. AIM: The aim of this study was to establish if PhA could have a therapeutic role in the treatment of erectile dysfunction (ED). METHODS: This was a randomized, open-label study. A total of 60 patients complaining of ED were studied. Patients were assessed at baseline and after 3 months of study treatment. At baseline, patients were randomized to receive phosphodiesterase type 5 inhibitor (PDE5i) alone (group A) or PDE5i plus regular (≥3 hours/week), aerobic, non-agonistic PhA (group B). MAIN OUTCOME MEASURES: All subjects completed the International Index of Erectile Function (IIEF-15) questionnaire and performed total testosterone (TT). RESULTS: Mean PhA was 3.4 hours/week in group B vs. 0.43 in group A; mean energy expenditure in group B was 1,868 kcal/ week or 22.8 metabolic equivalent (MET)/week. IIEF restoration of ED occurred in 77.8% (intervention group) vs. 39.3% (control) (P < 0.004). The IIEF-15 score resulted in statistical improvement in intervention group in all the domains but one (orgasm): erectile function 24.7 vs. 26.8 (P = 0.003); confidence (Q15) 3.53 vs. 4.07 (P = 0.006); sexual desire 6.46 vs. 7.18 (P = 0.028); intercourse satisfaction 9.85 vs. 11.25 (P = 0.001); total satisfaction 7.17 vs. 8.07 (P = 0.009); total score 56.2 vs. 61.07 (P = 0.007). TT was statistically similar in the two groups; separate analysis in each group showed statistical increase in group B 4.24 vs. 4.55 (P = 0.012). At multivariate logistic regression analysis, PhA was the only independent variable for normal erection (P = 0.010) (95% confidence interval [CI] 0.036-0.643), higher sexual satisfaction (P = 0.022) (95% CI 0.084-0.821) and normal total IIEF-15 score (P = 0.023) (95% CI 0.85-0.837). CONCLUSION: In this randomized controlled pilot study, PDE5i plus PhA was more effective than PDE5i alone in the treatment of ED.

Effect of sexual function on health-related quality of life mediated by depressive symptoms in cardiac rehabilitation. findings of the SPARK project in 493 patients.

INTRODUCTION: Empirical evidence suggests associations between cardiovascular diseases, sexual functioning, depressive symptoms, and quality of life. However, to date, the interrelation of these constructs has not been examined simultaneously in a structural analysis. AIM: To estimate the prevalence of sexual disorders and depressive symptoms and to examine the association between sexual disorders, depressive symptoms, and quality of life in patients in the rehabilitation of cardiovascular disorders. AIM: A postal survey in five German inpatient rehabilitation centers for cardiovascular diseases was conducted. Prevalence of sexual disorders and depressive symptoms were assessed using psychometrically sound instruments. To analyze complex associations, structural equation modeling was used. MAIN OUTCOME MEASURES: For epidemiological questions, proportions with 95% confidence intervals were calculated. The strength of association in structural equation models was expressed as a standardized regression coefficient. RESULTS: Data from 493 patients were analyzed (response rate 22.7%). At least moderate erectile dysfunction proved to be present in 20.3% of men. The prevalence of female sexual dysfunction lay at 43.1%. At least moderate depressive symptoms were present in 14.4% of men and 16.5% of women. A considerable association between sexual functioning and quality of life was found in both sexes, which was largely mediated by depressive symptoms. Major drawbacks of the study are imprecision of the estimates due to limited sample size and questionable generalizability of the findings due to possible self-selection bias. CONCLUSIONS: Considering the high prevalence of depressive symptoms and their role as a mediating factor between sexual functioning and quality of life, it is recommended to routinely screen for depression in men and women with cardiac disease.

Sexual satisfaction in men with erectile dysfunction: correlates and potential predictors.

INTRODUCTION: Sexual satisfaction is an important treatment objective for men with erectile dysfunction (ED). AIMS: To evaluate potential associations between International Index of Erectile Function (IIEF) satisfaction at study endpoint and a range of baseline, on-treatment, and endpoint variables. METHODS: An exploratory analysis was conducted involving 3,935 subjects with ED randomized to on-demand tadalafil (N = 2,824) or placebo (N = 1,111) in randomized, controlled trials across 28 countries. Patients achieving scores > or =16 on IIEF questions 7, 8, 13, and 14 at study endpoint were operationally defined as satisfied (vs. <16, not satisfied). Multivariate logistic regression and other analyses were conducted to ascertain correlates and potential predictors of improvements in the IIEF-erectile function domain (IIEF-EF). MAIN OUTCOME MEASURES: Satisfaction on the IIEF at study endpoint, on-treatment improvements in IIEF-EF, and endpoint sexual frequency. RESULTS: Patients who were satisfied with sexual function were on average younger and had less severe ED, a shorter history of the condition, and no history of vascular disorders, hypertension, or diabetes mellitus/insulin use at baseline (P < 0.01 vs. not satisfied for each). Satisfied patients were also more likely to experience a > or =4-point increase on the IIEF-EF domain on treatment (adjusted odds ratio [OR] = 22.4; 95% CI = 17.6-28.5; P < 0.0001) or IIEF-EF > or =26 at endpoint (adjusted OR = 41.0; 95% CI = 33.6-50.2; P < 0.0001). Satisfaction emerged as a strong correlate of a > or =4-point increase in the IIEF-EF on treatment; however, as a correlate of endpoint sexual frequency, baseline sexual frequency was stronger than endpoint satisfaction. CONCLUSIONS: Satisfaction is associated with certain baseline, on-treatment, and endpoint variables in ED patients. Further studies are needed to confirm these preliminary findings and explore their meaning for female partners.

Sildenafil citrate 100 mg starting dose in men with erectile dysfunction in an international, double-blind, placebo-controlled study: effect on the sexual experience and reducing feelings of anxiety about the next intercourse attempt.

INTRODUCTION: Sildenafil citrate 50 mg is the recommended starting dose for men with erectile dysfunction (ED); however, most men are later titrated to sildenafil 100 mg for improved efficacy. AIM: Assess the tolerability and efficacy of sildenafil initiated at the 100-mg dose in men with ED. METHODS: Men with ED (score < or =25 on the Erectile Function domain of the International Index of Erectile Function) who had received < or =6 total doses of a phosphodiesterase type 5 inhibitor and none within 4 weeks were randomized to 8 weeks of double-blind, placebo-controlled (DBPC), fixed-dose treatment (50 or 100 mg sildenafil or placebo) followed by 4 weeks of open-label flexible-dose sildenafil (50 or 100 mg). MAIN OUTCOME MEASURES: Efficacy, tolerability, treatment satisfaction, and other end points were measured at baseline and/or the end of the double-blind and open-label phases and compared between placebo and sildenafil initiated at doses of 50 and 100 mg. RESULTS: Improvements in DBPC patient-reported outcomes from baseline were statistically significant for both sildenafil 50 and 100 mg compared with placebo. At the end of DBPC treatment, 56% of men on the 100-mg dose felt no anxiety about the next intercourse attempt compared with 39% in the 50-mg group (odds ratio 2.03; P = 0.0197). Changes in functional scores from baseline were not statistically significant with the 100-mg dose compared with the 50-mg dose in the DBPC. Measures of treatment satisfaction and sexual experience significantly favored the 100-mg dose compared with the 50-mg dose in the DBPC. There was no increase in adverse events with the higher dose. CONCLUSIONS: Sildenafil at 50 mg or 100 mg significantly improved erection quality, treatment satisfaction, anxiety levels, and the sexual experience compared with placebo during DBPC. Sildenafil 100 mg improved the sexual experience and treatment satisfaction, and reduced feelings of anxiety compared with the 50-mg dose.