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European Urology Feb 2014Priapism is defined as a penile erection that persists beyond or is unrelated to sexual interest or stimulation. It can be classified into ischaemic (low flow), arterial... (Review)
Review
CONTEXT
Priapism is defined as a penile erection that persists beyond or is unrelated to sexual interest or stimulation. It can be classified into ischaemic (low flow), arterial (high flow), or stuttering (recurrent or intermittent).
OBJECTIVE
To provide guidelines on the diagnosis and treatment of priapism.
EVIDENCE ACQUISITION
Systematic literature search on the epidemiology, diagnosis, and treatment of priapism. Articles with highest evidence available were selected to form the basis of these recommendations.
EVIDENCE SYNTHESIS
Ischaemic priapism is usually idiopathic and the most common form. Arterial priapism usually occurs after blunt perineal trauma. History is the mainstay of diagnosis and helps determine the pathogenesis. Laboratory testing is used to support clinical findings. Ischaemic priapism is an emergency condition. Intervention should start within 4-6h, including decompression of the corpora cavernosa by aspiration and intracavernous injection of sympathomimetic drugs (e.g. phenylephrine). Surgical treatment is recommended for failed conservative management, although the best procedure is unclear. Immediate implantation of a prosthesis should be considered for long-lasting priapism. Arterial priapism is not an emergency. Selective embolization is the suggested treatment modality and has high success rates. Stuttering priapism is poorly understood and the main therapeutic goal is the prevention of future episodes. This may be achieved pharmacologically, but data on efficacy are limited.
CONCLUSIONS
These guidelines summarise current information on priapism. The extended version are available on the European Association of Urology Website (www.uroweb.org/guidelines/).
PATIENT SUMMARY
Priapism is a persistent, often painful, penile erection lasting more than 4h unrelated to sexual stimulation. It is more common in patients with sickle cell disease. This article represents the shortened EAU priapism guidelines, based on a systematic literature review. Cases of priapism are classified into ischaemic (low flow), arterial (high flow), or stuttering (recurrent). Treatment for ischaemic priapism must be prompt in order to avoid the risk of permanent erectile dysfunction. This is not the case for arterial priapism.
Topics: Humans; Male; Penile Erection; Priapism; Risk Factors; Sympathomimetics; Treatment Outcome; Urologic Surgical Procedures, Male; Urology
PubMed: 24314827
DOI: 10.1016/j.eururo.2013.11.008 -
Andrology Nov 2020For a large proportion of patients with spinal cord injury, sexuality and reproduction are important issues. However, sparse data exist regarding available treatment...
BACKGROUND
For a large proportion of patients with spinal cord injury, sexuality and reproduction are important issues. However, sparse data exist regarding available treatment options for this patient population.
OBJECTIVES
We sought to review performance and safety rates of all currently available treatment options for erectile dysfunction in spinal cord injury men.
MATERIALS AND METHODS
A systematic literature review without time restrictions was performed using PubMed/EMBASE database for English-, Italian-, German-, and Spanish-language articles. Articles' selection was performed according to the PRISMA guidelines. Relevant papers on erectile dysfunction in spinal cord injury patients were included in the final analyses.
RESULTS AND DISCUSSION
Overall, 47 studies were eligible for inclusion in this review. Of these, most evidence dealt with phosphodiesterase 5-inhibitors and intracavernous drug injection. Both treatment options are associated with high levels of performance and with patients/partners' satisfaction; side effects are acceptable. Overall, penile prostheses and vacuum erection devices are in general less approved by spinal cord injury patients and are correlated with increased rates of complications in comparison with phosphodiesterase 5-inhibitors and intracavernous drug injection. Sacral neuromodulation, transcutaneous electrical nerve stimulation, and intraurethral suppositories have been poorly studied, but preliminary studies did not show convincing results.
CONCLUSION
The best treatment options for erectile dysfunction in spinal cord injury patients emerged to be phosphodiesterase 5-inhibitors and intracavernous drug injection. The choice of erectile dysfunction treatment should be based on several aspects, including residual erectile function, spinal cord injury location, and patients' comorbidities. Future studies assessing the applicability of less well-studied treatments, as well as evaluating innovative options, are needed in this specific population.
Topics: Erectile Dysfunction; Humans; Injections; Male; Patient Satisfaction; Penile Erection; Penile Prosthesis; Phosphodiesterase 5 Inhibitors; Prosthesis Implantation; Recovery of Function; Spinal Cord Injuries; Treatment Outcome; Vacuum; Vasodilator Agents
PubMed: 32741129
DOI: 10.1111/andr.12878 -
The Journal of Sexual Medicine Feb 2021Males born with bladder exstrophy-epispadias complex generally have a shorter phallus, split corpora with dorsal curvature, and a scarred and flattened glans, so...
BACKGROUND
Males born with bladder exstrophy-epispadias complex generally have a shorter phallus, split corpora with dorsal curvature, and a scarred and flattened glans, so substitution phalloplasty is often required.
AIM
The aim of this study was to review the techniques, complications, and outcomes of substitution phalloplasty in bladder exstrophy-epispadias complex patients to determine the ideal surgical procedure and gauge the risks and benefits for the patient.
METHODS
A systematic review of the literature was performed using PubMed/MEDLINE and the Cochrane Library with the following terms: ("phalloplasty"); (("epispadias") OR ("bladder exstrophy") OR ("cloacal exstrophy")). We included only full-text articles reporting data about techniques and outcomes of substitution phalloplasty in patients with bladder exstrophy-epispadias complex.
OUTCOMES
To determine whether patients with bladder exstrophy-epispadias complex might benefit from substitution phalloplasty.
RESULTS
We selected 7 studies involving 47 patients. All the studies were characterized by a low level of evidence and a heterogeneous approach during treatment and outcome assessment. The free radial forearm flap was the most commonly performed technique (89%) with an overall complication rate of 15%. Urethroplasty was performed in 22 of 47 (47%) patients, and in most cases (20/22) a "tube-within-the-tube" technique was performed simultaneously with the phalloplasty (20/47). Urethroplasty complications were recorded in 12 of 22 (54%) patients with 6 fistulae and 6 stenoses. A penile prosthesis was implanted in 32 of 47 (68%) patients and complications occurred in 8 of 32 (25%) patients with 6 erosion. Aesthetic, sexual, and psychological outcomes were satisfactory, but none of the studies used validated instruments for the final assessment.
CLINICAL IMPLICATIONS
It was not possible to formulate any recommendations based on a high level of evidence regarding substitution phalloplasty in patients with bladder exstrophy-epispadias complex.
STRENGTH & LIMITATION
To our knowledge, this is the first review to address bladder exstrophy-epispadias complex patients only. The limitations are mainly represented by the small number of cases because of the rarity of this disease and by the fact that no studies used validated instruments.
CONCLUSION
Substitution phalloplasty in patients with bladder exstrophy-epispadias complex can achieve good functional, aesthetic, psychological, and sexual outcomes. It requires multiple procedures and carries a high complication rate. Multicentric studies including the assessment of patients by means of a validated questionnaire which investigates both sexual function and psychosexual satisfaction are required. Berrettini A, Sampogna G, Gnech M, et al. Substitution Phalloplasty in Patients With Bladder Exstrophy-Epispadias Complex: A Systematic Review of Techniques, Complications, and Outcomes. J Sex Med 2021;18:400-409.
Topics: Bladder Exstrophy; Epispadias; Humans; Male; Penile Prosthesis; Surgical Flaps; Urethra
PubMed: 33223423
DOI: 10.1016/j.jsxm.2020.10.007 -
BJU International Apr 2015To systematically review the management of sexual dysfunction due to central nervous system (CNS) disorders. (Review)
Review
OBJECTIVE
To systematically review the management of sexual dysfunction due to central nervous system (CNS) disorders.
PATIENTS AND METHODS
The review was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified independently by two reviewers using electronic searches of MEDLINE and OVID (from January 2004 to August 2014) and hand searches of reference lists and review articles.
RESULTS
In patients with CNS disorders, neuro-urological assessment is recommended for both genders before starting any treatment for sexual dysfunction. For men, blood sexual hormones evaluation is the main investigation performed before phosphodiesterase type 5 inhibitors (PDE5Is) treatment, whereas there is no consensus on routine laboratory tests for women. PDE5Is are the first-line medical treatment for men, with the most robust data derived from patients with spinal cord injury assessed by validated questionnaires, mainly the International Index of Erectile Function-15. There is no effective medical treatment for sexual dysfunction in women. Sacral neuromodulation for lower urinary tract dysfunction may improve sexual dysfunction in both genders.
CONCLUSIONS
Although sexual dysfunction is a major burden for patients with CNS disorders, high-evidence level studies are rare and only available for PDE5Is treating erectile dysfunction. Well-designed prospective studies are urgently needed for both genders.
Topics: Central Nervous System Diseases; Clinical Trials as Topic; Electric Stimulation Therapy; Erectile Dysfunction; Female; Humans; Male; Neurologic Examination; Neurotransmitter Agents; Penile Prosthesis; Phosphodiesterase 5 Inhibitors; Sexual Dysfunction, Physiological
PubMed: 25599613
DOI: 10.1111/bju.13055 -
International Journal of Clinical... Aug 2008Priapism is a urological emergency which is commonly classified into low-flow and high-flow priapism. Immediate intervention is required for low-flow cases as the... (Review)
Review
INTRODUCTION
Priapism is a urological emergency which is commonly classified into low-flow and high-flow priapism. Immediate intervention is required for low-flow cases as the development of ischaemia ultimately leads to long-term erectile dysfunction. Stuttering or recurrent priapism is less well understood. This subtype is characterised by short-lived painful erections and is commonly encountered in patients with sickle cell disease.
METHODS
A systematic review of the treatment options available for stuttering priapism is presented combined with our own experience in managing this condition over a period of 25 years.
RESULTS
Although numerous medical treatment options have been reported, the majority are through small trials or anecdotal reports.
CONCLUSIONS
Stuttering priapism is a condition which is still not well understood and there is no standardised algorithm for the management of this condition. A multicentre randomised trial is required to evaluate the treatment options.
Topics: Anemia, Sickle Cell; Digoxin; Drug Delivery Systems; Etilefrine; Hormones; Humans; Male; Orchiectomy; Penile Prosthesis; Phosphodiesterase Inhibitors; Priapism; Procyclidine; Pseudoephedrine; Terbutaline; Treatment Outcome
PubMed: 18479367
DOI: 10.1111/j.1742-1241.2008.01780.x -
Sexual Medicine Reviews Jul 2020Erectile dysfunction (ED) is a common and costly urologic condition with increasing prevalence as men age. Cost-effectiveness of ED therapies and whether...
INTRODUCTION
Erectile dysfunction (ED) is a common and costly urologic condition with increasing prevalence as men age. Cost-effectiveness of ED therapies and whether cost-effectiveness varies for different populations of men remains underexplored.
AIM
To review and summarize available published data on the economic evaluation of ED therapies and to identify gaps in the literature that still need to be addressed.
METHODS
All relevant peer-reviewed publications and conference abstracts were reviewed and incorporated.
RESULTS
There are a number of medical and surgical treatment options available for ED. The economic evaluation of phosphodiesterase-5 inhibitors, particularly sildenafil, has been well described. However, minimal research has been conducted to assess the cost-effectiveness of intracavernosal injections, intraurethral suppositories, penile prosthesis surgery, vacuum erection devices, and other emerging therapies in men with different causes of ED.
CONCLUSION
Available economic evaluations of ED therapies are dated, do not reflect present-day physician, pharmaceutical, and device costs, fail to account for patient comorbidities, and may not be generalizable to today's ED patients. Substantial research is needed to evaluate the cost-effectiveness of ED treatments across different patient populations, countries, and reimbursement systems. Rezaee ME, Ward CE, Brandes ER, et al. A Review of Economic Evaluations of Erectile Dysfunction Therapies. Sex Med Rev 2019;8:497-503.
Topics: Cost-Benefit Analysis; Erectile Dysfunction; Health Care Costs; Humans; Male; Penile Prosthesis; Sildenafil Citrate; Urological Agents
PubMed: 31326359
DOI: 10.1016/j.sxmr.2019.06.001 -
Sexual Medicine Reviews Oct 2018The 3-piece inflatable penile prosthesis (IPP) is the gold standard treatment for male erectile dysfunction when other less invasive approaches are contra-indicated or... (Comparative Study)
Comparative Study
BACKGROUND
The 3-piece inflatable penile prosthesis (IPP) is the gold standard treatment for male erectile dysfunction when other less invasive approaches are contra-indicated or unacceptable for the patient. There are currently 2 surgical approaches for IPP implantation: the penoscrotal (PS) and the infrapubic (IP) incision.
AIM
To assess the most recent evidence on the impact of surgical approach for 3-piece IPP implantation in patients with erectile dysfunction.
METHODS
A systematic literature review was performed using the MEDLINE (PubMed) and Cochrane Libraries databases in November 2017 to identify all studies investigating 3-piece IPP with a specified surgical access.
OUTCOMES
The following key words were used in combination: "infrapubic," "transcrotal," "penoscrotal," "peno-scrotal," and "penile prosthesis." Additional references were obtained from the reference lists of full-text manuscripts. We used a narrative synthesis for the analyses of the studies.
RESULTS
22 Studies reporting data on 3-piece IPP implantation with a specified surgical approach were found in the literature. While IPPs are most commonly positioned through a PS incision, the IP approach is a faster procedure. No cases of glans hypoesthesia after IPP placement with an IP approach were reported, and the overall peri-prosthetic infection rate was 3.3% or less. Patient satisfaction rates were higher than 80% in both groups.
CONCLUSIONS
Both the IP and PS approaches are viable and effective strategies for a 3-piece IPP placement, and result in high satisfaction rates. To date there is no evidence that an incision strategy may reduce infection rates. Penile sensory loss following an IP approach remains a virtual risk. It is recommended that the surgeon executing the implant have knowledge of both accesses and be capable of tailoring the incision strategy for complex cases. The chosen method should be based on the patient's specific anatomy, surgical history, and surgeon experience. Palmisano F, Boeri L, Cristini C, et al. Comparison of Infrapubic vs Penoscrotal Approaches for 3-Piece Inflatable Penile Prosthesis Placement: Do We Have a Winner? Sex Med Rev 2018;6:631-639.
Topics: Erectile Dysfunction; Humans; Male; Penile Implantation; Penile Prosthesis
PubMed: 29730314
DOI: 10.1016/j.sxmr.2018.03.007 -
International Journal of Impotence... Jan 2021Successful treatment of erectile dysfunction (ED) is associated with improvements in quality of life; however, treatment utilisation is sub-optimal. The aim of this...
Successful treatment of erectile dysfunction (ED) is associated with improvements in quality of life; however, treatment utilisation is sub-optimal. The aim of this systematic review was to identify the rates of ED treatment utilisation and the barriers and enablers men experience when using treatment. We searched: MEDLINE, Embase, the Cochrane library; AMED; HMIC; HTA; CINAHL; PsychARTICLES; PsychINFO up to August 2018. Data on rates of treatment utilisation and barriers and enablers of utilisation were extracted and summarised. Fifty studies were included. Discontinuation rates ranged from 4.4 to 76% for phosphodiesterase type 5 inhibitors, 18.6 to 79.9% for intracavernosal injections, and 32 to 69.2% for urethral suppositories. In relation to those with a penile prosthesis, 30% discontinued having sex due to, e.g. device complications, lack of partner or a loss of sexual interest. Most research included in the current review examined barriers to treatment utilisation and therefore focussed on reasons for discontinuing treatment. However, a small number explored factors that men found helpful with regards to treatment utilisation. The most prevalent barriers to utilisation were treatment ineffectiveness, side effects, the quality of men's intimate relationships and treatment costs. With regards to treatment enablers, the most salient finding was that men who reported side effects to a healthcare professionals (HCPs) were significantly less likely to discontinue treatment. There were limitations in methodology in that the studies did not use validated measures of treatment utilisation or barriers and enablers and no study used psychological theory to inform the examination of factors that influenced treatment utilisation. This review identifies a number of influential factors relating to ED treatment utilisation and highlights the importance of men's beliefs with regards to ED and its treatment. Beliefs are potentially modifiable and therefore the findings of this review highlight important considerations for HCPs with regards to supporting men to make better use of treatment.
Topics: Erectile Dysfunction; Humans; Male; Phosphodiesterase 5 Inhibitors; Quality of Life; Sexual Behavior; Sexual Partners
PubMed: 32231275
DOI: 10.1038/s41443-020-0249-1 -
The Journal of Sexual Medicine Oct 2020Modern-day penile prostheses use infection retardant coating to decrease rates of postoperative infection, subsequently reducing explantation and revision rates as well....
Impact of Antimicrobial Dipping Solutions on Postoperative Infection Rates in Patients With Diabetes Undergoing Primary Insertion of a Coloplast Titan Inflatable Penile Prosthesis.
BACKGROUND
Modern-day penile prostheses use infection retardant coating to decrease rates of postoperative infection, subsequently reducing explantation and revision rates as well. The Coloplast Titan models are dipped into antimicrobial solutions right before implantation, and the components used for dipping can be tailored toward the patient.
AIM
To compare infection, explantation, and revision rates among different dipping solutions used before implantation for patients with diabetes receiving a Coloplast Titan implant.
METHODS
We systematically reviewed 932 patients with diabetes receiving a primary penile implant across 18 different centers from the period April 2003 to August 2018. Of those patients, 473 received a Coloplast device, whereas 459 received an AMS device. Data regarding the type of antimicrobial solution used before implantation were recorded for 468 patients receiving a Coloplast Titan, including whether or not they suffered a postoperative infection and if they underwent explantation and/or revision. Outcome rates were compared using Fisher's exact and Pearson's chi-square tests, and logistic regression modeling was performed to account for covariates.
OUTCOMES
The main outcome measures of this study were postoperative infection, explantation, and revision rates.
RESULTS
Of the total 932 patients reviewed, 33 suffered a postoperative infection. Of 468 patients receiving Coloplast implants, there was a 3.4% infection rate. The most commonly used antibiotic combination before dipping was vancomycin + gentamicin (59.0%). There was a significantly lower rate of postoperative infection, explantation, and revision when vancomycin + gentamicin was used than those associated with the use of all other dipping solutions ([1.4% vs 6.4%; P = .004], [1.1% vs 8.3%; P < .001], and [2.5% vs 12.5; P < .001], respectively). After adjusting for age, body mass index, preoperative blood glucose level, and hemoglobin A1c, the use of other dips was an independent predictor of postoperative infection (odds ratio: 0.191; P = .049). The inclusion of rifampin in the dipping solution trended toward being a significant risk factor for infection (P = .057). Including antifungals in the dipping solution did not affect infection (P = .414), explantation (P = .421), or revision (P = .328) rates.
CLINICAL IMPLICATIONS
Vancomycin + gentamicin was the most efficacious combination of antibiotics used for dipping in terms of preventing postoperative infection and subsequent explantation and revision.
STRENGTHS AND LIMITATIONS
Data were sampled across multiple institutions providing a large sample that may be more representative of the population of interest. A key limitation of the study was its retrospective nature, which prevented us from controlling certain variables.
CONCLUSION
The use of rifampin did not provide the same type of protection, possibly representing a shift in resistance patterns of common bacteria responsible for device infection. Towe M, Huynh LM, Osman MM, et al. Impact of Antimicrobial Dipping Solutions on Postoperative Infection Rates in Patients With Diabetes Undergoing Primary Insertion of a Coloplast Titan Inflatable Penile Prosthesis. J Sex Med 2020;17:2077-2083.
Topics: Diabetes Mellitus; Gentamicins; Humans; Male; Penile Implantation; Penile Prosthesis; Retrospective Studies
PubMed: 32807707
DOI: 10.1016/j.jsxm.2020.07.009 -
Minerva Urologica E Nefrologica = the... Oct 2020We aimed to summarize evidences about the efficacy of available treatments for erectile disfunction after robotic assisted radical prostatectomy (RARP).
INTRODUCTION
We aimed to summarize evidences about the efficacy of available treatments for erectile disfunction after robotic assisted radical prostatectomy (RARP).
EVIDENCE ACQUISITION
A systematic literature review searching on PubMed (Medline), Scopus, and Web of Science databases was performed in December 2019. PRISMA guidelines were followed. Population consisted of patients with erectile disfunction after RARP (P), conservative and surgical intervention were considered of interest (I). No comparator was considered mandatory (C). Outcomes of interest were the recovery of erectile function after conservative treatments and sexual function after surgical treatments (O).
EVIDENCE SYNTHESIS
Eleven studies were included. Seven studies focused on the use of phosphodiesterase-5 inhibitors (PDE5i) alone (five studies) or associated with other treatments (two studies). All the studies confirmed the efficacy of PDE5i, while the most promising association is with vacuum pump erectile devices. Two studies investigated topical treatments, namely low intensity extracorporeal shock wave therapy and alprostadil. Low intensity extracorporeal shock wave therapy may be a promising option in patients in whom nerve-sparing surgery was performed. The use of alprostadil could be an effective alternative to intracorporeal injection in those who underwent non-nerve-sparing surgery. One study focused and confirmed the efficacy of penile implants. Furthermore, one study reported the efficacy of a multi-modal treatment with preoperative medication, showing the benefits of a multimodal approach.
CONCLUSIONS
Penile rehabilitation with PDE5i is effective after nerve sparing RARP. The association of PDE5i with vacuum devices could led to a faster recovery. A multimodal approach with preoperative specific care seems to be effective to fasten erectile function recovery.
Topics: Erectile Dysfunction; Humans; Male; Penile Prosthesis; Phosphodiesterase 5 Inhibitors; Postoperative Complications; Prostatectomy; Prostatic Neoplasms; Robotic Surgical Procedures
PubMed: 32748616
DOI: 10.23736/S0393-2249.20.03780-7