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Background: Daily (once a day [OaD]) tadalafil intake is a valuable option for men favoring spontaneous over scheduled sexual intercourse., Aim: The study sought to assess the rate of and the clinical factors associated with spontaneous, medication-free erectile function (EF) recovery after discontinuation of tadalafil 5 mg OaD in a cohort of young men seeking first medical help for psychogenic erectile dysfunction (ED) as their primary complaint., Methods: Data from 96 consecutive patients <50 years of age seeking first medical help for ED and prescribed tadalafil 5 mg OaD were analyzed. Patients completed the International Index of Erectile Function (IIEF) and underwent baseline penile color Doppler ultrasound. Follow-up involved clinical assessments or phone interviews. Spontaneous medication-free EF recovery was defined as IIEF EF domain score >22 after tadalafil discontinuation, prompting cessation of follow-up. Descriptive statistics compared tadalafil OaD responders and nonresponders. Cox regression hazard models explored the association between baseline characteristics and EF recovery risk post-drug discontinuation. Kaplan-Meier analyses estimated EF recovery probability over time., Outcomes: The primary outcome was EF recovery after discontinuation of tadalafil 5 mg OaD., Results: Overall, median age was 39 (interquartile range [IQR], 32-45) years. Of all, 82 (85.4%) patients achieved EF recovery after tadalafil OaD discontinuation, while 14 (14.6%) patients were identified as nonresponders. Median tadalafil usage time (from beginning to discontinuation) was 3 (IQR, 2-11) months. The most common treatment-emergent adverse event was headache in 9 (9.4%) patients. Nonresponders were older (43 [IQR, 42-45] years vs 38 [IQR, 31-44] years; P = .03), had higher body mass index (25.5 [IQR, 23.4-29.9] kg/m2 vs 23.6 [IQR, 21.8-25.9] kg/m2; P = .04), and reported lower baseline IIEF EF domain scores (12 [IQR, 7-15] vs 15 [IQR, 10-22]; P = .02) than responders. Nonresponders and responders did not differ in terms of baseline ED severity, Charlson comorbidity index, smoking, alcohol consumption, regular physical exercise, and color Doppler ultrasound parameters. Upon Cox regression analysis, younger age (hazard ratio, 0.95; 95% confidence interval, 0.92-0.99; P = .01) was associated to EF recovery, after adjusting for baseline ED severity, body mass index, smoking, and Charlson comorbidity index ≥1. The Kaplan-Meier analysis displays the probability of EF recovery over time, indicating rates of 43%, 60%, and 72% at 3-, 6-, and 12-month follow-up intervals, respectively., Clinical Implications: Tadalafil 5 mg OaD is an effective short-term treatment for psychogenic ED, allowing its discontinuation after achieving a normal medication-free EF., Strengths and Limitations: The main limitations are the limited number of participants and the potential neglect of confounding factors., Conclusion: Almost 1 out of 2 young men with primary psychogenic ED who were prescribed with tadalafil 5 mg OaD recovered spontaneous medication-free EF after 3 months of treatment. Overall, the younger the patient was, the higher the chance there was of spontaneous EF recovery after drug discontinuation., (© The Author(s) 2024. Published by Oxford University Press on behalf of The International Society of Sexual Medicine.)

Background: Orgasmic phase disorders in men worsen the burden of erectile dysfunction on sexual satisfaction., Objectives: To investigate the prevalence of and predictors of unreported orgasmic phase disorder in a cohort of men looking for their first urological assessment for new-onset erectile dysfunction in a real-life setting., Materials and Methods: Data from 1107 heterosexual, sexually active men consecutively assessed for new-onset erectile dysfunction were analysed. Throughout a comprehensive medical and sexual history, all patients were asked to self-report any orgasmic phase disorder and to complete the International Index of Erectile Function and the Beck's Inventory for Depression (depressive symptoms scored as Beck's Inventory for Depression ≥11). Men self-reporting orgasmic phase disorder during the interview were excluded from further analyses. The median value of the International Index of Erectile Function-orgasmic function domain was arbitrarily used to categorise men with (International Index of Erectile Function-orgasmic function ≤5) and without unreported orgasmic phase disorder (International Index of Erectile Function-orgasmic function >5). Circulating hormones were measured in every patient. Descriptive statistics and logistic regression models were used to test the association between clinical variables and unreported orgasmic phase disorder., Results: Of 1098 patients with non-self-reporting orgasmic phase disorder, 314 (28.6%) had International Index of Erectile Function-orgasmic function ≤5. Patients with erectile dysfunction + unreported orgasmic phase disorder were older (median [interquartile range]: 58 [44-66] years vs. 51 [40-60] years), had higher body mass index [25.8 (23.7-28.1) kg/m 2 vs. 25.2 (23.3-27.4) kg/m 2 ], higher prevalence of type 2 diabetes (36 [11.5%] vs. 45 [5.7%]) and lower International Index of Erectile Function-erectile function scores (6 [2-10] vs. 18 [11-24]) than men with erectile dysfunction-only (all p < 0.05). Patients with erectile dysfunction + unreported orgasmic phase disorder depicted higher rates of severe erectile dysfunction (75.5% vs. 25%) and Beck's Inventory for Depression ≥11 (22.6% vs. 17.9%) (all p < 0.05). In the multivariable logistic regression analysis, older age (odds ratio: 1.02) and lower International Index of Erectile Function-erectile function scores (odds ratio: 0.83) were independently associated with unreported orgasmic phase disorder (all p < 0.05)., Conclusions: Almost one in three men seeking first medical help for erectile dysfunction depicted criteria suggestive of unreported orgasmic phase disorder. Men with unreported orgasmic phase disorder were older and had higher rates of severe erectile dysfunction and concomitant depressive symptoms. These real-life findings outline the clinical relevance of a comprehensive investigation of concomitant sexual dysfunction in men only complaining of erectile dysfunction to more effectively tailor patient management., (© 2023 The Authors. Andrology published by Wiley Periodicals LLC on behalf of American Society of Andrology and European Academy of Andrology.)

The interrelationship between male sexual desire and erectile dysfunction (ED) has been scantly investigated. Thus, we aimed at investigating the prevalence of and the predictors of unrecognised low sexual desire/interest (uLSD/I) in a cohort of men with new onset ED. Complete data from 1587 men seeking for first medical help for ED between 2010 and 2021 were analysed. Comorbidities were scored with the Charlson Comorbidity Index (CCI). At entrance, all patients were asked to self-report low sexual desire/interest and completed the International Index of Erectile Function (IIEF) and the Beck Depression Inventory (BDI) (depressive symptoms scored as BDI ≥ 11). The IIEF-erectile function (IIEF-EF) domain was categorised according to Cappelleri's criteria. The median value of the IIEF-sexual desire domain (IIEF-SD) was used to dichotomise men with uLSD/I along with ED (IIEF-SD < 7) vs. ED-only (IIEF-SD ≥ 7). Circulating hormones were measured in every patient. Hypogonadism was defined as total testosterone (tT) <3.0 ng/mL. Descriptive statistics and logistic regression models tested the association between clinical variables and uLSD/I. Of 1197 patients not self-reporting LSD/I, 369 (30.8%) had IIEF-SD < 7. Patients with ED + uLSD/I were older [median (IQR) 54(41-63) vs. 49(36-59) years], had lower IIEF-EF [10.5(5-22) vs. 22(11-28)] but higher BDI [6(3-12) vs. 4(1-8)] and lower tT [4.3(3.2-5.7) vs. 4.8(3.2-6.3) ng/mL] compared to ED-only men (all p < 0.05). Overall, ED + uLSD/I men had higher rate of severe ED (49.9% vs. 23.9%), and of BDI ≥ 11 (30.6% vs. 18.2%) (all p < 0.05). At multivariable logistic regression analysis, lower tT (OR: 0.82), lower IIEF-EF scores (OR:0.95) and BDI ≥ 11 (OR:2.51) were independently associated with ED + uLSD/I, after accounting for age (all p < 0.05). Almost 30% of men seeking first medical help for ED-only had also uLSD/I. Men with both conditions were older, had higher rates of severe ED and more depressive symptoms. A detailed investigation of sexual desire should be always included in men self-complaining only of ED., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Conservative and medical treatments are considered the first step in ischemic priapism (IP) management, although there is no clear evidence regarding their efficacy. We conducted a systematic review on behalf of the EAU Guidelines panel on Sexual and Reproductive health to analyse the available evidence on the efficacy and safety of conservative and medical treatment for non-sickle cell disease-related IP. Databases searched for relevant literature investigating efficacy and safety of conservative measures and medical treatment for IP included Medline, EMBASE, Cochrane Libraries and clinicaltrial.gov published up to September 2021. Overall, 41 retrospective, 3 prospective single-arm studies and 3 randomized controlled trials met the inclusion criteria. Intracavernous injection with sympathomimetic (ICIs) agents were the most frequently utilized treatment with efficacy ranging from 0 to 100% of cases. The combination of ICIs with corporeal aspiration with or without irrigation with saline was successful in 70 to 100% of cases. Oral treatment with β2 receptor agonist (e.g., terbutaline) showed mild to moderate efficacy. Conservative methods including ice pack, exercise, cold enema and ejaculation depicted lower effectiveness in resolving priapism (1-55%). Longer time interval from the onset to the resolution of IP was associated with higher rate of erectile dysfunction at follow-up (30-70%), especially after 24 h., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Sleep quality and duration have been investigated for their association with health. Insomnia affects up to one-third of adults and may impact male erectile function. In addition, medical treatments for insomnia (many of which are sedatives) may also affect erectile quality., Objective: To investigate the association of erectile dysfunction (ED) in patients diagnosed with and treated for insomnia., Design, Setting, and Participants: We utilized the IBM MarketScan (2007-2016) Commercial and Medicare Supplemental Databases (v 2.0). Age- and enrollment-matched controls were selected among patients without insomnia diagnosis or treatment., Outcome Measurements and Statistical Analysis: Cox proportional hazard models were used to estimate the risk of incident ED (ie, diagnosis alone, or diagnosis and treatment with phosphodiesterase-5 inhibitors [PDE5i], intracavernous injection (ICI)/urethral suppositories, and penile prosthesis) after the diagnosis or treatment of insomnia while adjusting for relevant comorbidities., Results and Limitations: In total, 539 109 men with an insomnia diagnosis were identified. Of these men, 356 575 were also medically treated for insomnia. The mean (±standard deviation) follow-up times for patients diagnosed with insomnia and those diagnosed with and treated for insomnia were 2.8 ± 1.6 and 3.1 ± 1.8 yr, respectively. Men with insomnia were more commonly smokers and had a higher number of office visits and comorbidities than controls (p < 0.001). On an adjusted analysis, both untreated and treated insomnia were associated with increased risks of ED diagnosis (hazard ratio or HR [95% confidence interval {CI}]: 1.58 [1.54-1.62] and 1.66 [1.64-1.69], respectively; p < 0.001). Similarly, men with treated insomnia had a higher risk of having ED treated with PDE5i (HR [95% CI]: 1.52 [1.49-1.55]; p < 0.001) and ICI (HR [95% CI]: 1.32 [1.14-1.54]; p < 0.001) when compared with controls. A limitation of this study was that a lack of granularity regarding patient clinical characteristics (eg, severity of disease, laboratory data, etc.) is inherent to insurance claims data. In addition, the follow-up was limited and may affect associations at longer time points., Conclusions: In the current report, a consistent association between insomnia and ED diagnosis was identified. Men diagnosed with insomnia only were found to have a higher risk of developing ED. Moreover, men with pharmacological insomnia treatments were more often prescribed treatments for ED. Given the prevalence of insomnia, future studies are warranted to delineate the association of insomnia and its treatment with erectile function., Patient Summary: Insomnia affects up to one-third of adults and impact male erectile function. Men only diagnosed with insomnia were found to have a higher risk of developing erectile dysfunction (ED). Moreover, men with pharmacological insomnia treatments were more often prescribed treatments for ED., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Hyperestrogenism is believed to be harmful to male sexuality. We aimed to investigate the prevalence of and the impact of hyperestrogenism on sexual functioning in a cohort of men seeking medical attention for new-onset erectile dysfunction., Materials and Methods: Data from 547 men seeking first medical help for new-onset erectile dysfunction at a single andrology center were analyzed. Patients were assessed with a thorough medical and sexual history. Comorbidities were scored with the Charlson comorbidity index. All patients completed the International index of erectile function; the International index of erectile function-erectile function domain was categorized according to Cappelleri's criteria. Circulating hormones were measured in every patient. Hyperestrogenism was defined as estradiol levels >42.6 pg/mL (Tan et al., 2015). Descriptive statistics and logistic/linear regression models tested the association between hyperestrogenism and International index of erectile function domains score., Results: Overall, 96 (17.6%) participants had serum estrogen levels suggestive of hyperestrogenism. Men with hyperestrogenism were older (median [interquartile range]: 46 [35-59] vs. 44 [31-56] years; p < 0.001), had a higher rate of comorbidities (Charlson comorbidity index ≥1: 26.0% vs. 7.4%; p < 0.001), and higher serum total testosterone values (5.4 [5.2-8.0] vs. 4.3 [4.1-5.7] ng/mL; p = 0.01) than those with normal estradiol values. A higher prevalence of severe erectile dysfunction (135 [29.9%] vs. 47 [48.9%] men; p = 0.01) and of hypogonadism (22 [4.8%] vs. 6 [6.3%] men; p = 0.004) were found in men with hyperestrogenism. Serum estradiol levels were positively correlated with total testosterone levels (β = 0.26, p < 0.001) but negatively correlated with International index of erectile function-orgasmic function (β = -0.24, p = 0.002) and International index of erectile function-erectile function scores (β = -0.03, p < 0.001). When International index of erectile function scores was used to stratify erectile dysfunction patients, hyperestrogenism (odds ratio 2.44, p = 0.02) was associated with severe erectile dysfunction., Conclusions: One out of five men seeking first medical help for erectile dysfunction showed elevated serum estradiol values suggestive of hyperestrogenism. Hyperestrogenism was associated with health-significant comorbidities, orgasmic function impairment, and erectile dysfunction severity., (© 2023 The Authors. Andrology published by Wiley Periodicals LLC on behalf of American Society of Andrology and European Academy of Andrology.)

Background: Despite the existence of conservative therapies for Peyronie's disease (PD), surgery is commonly utilized for the treatment of bothersome curvatures due to its potential effectiveness, although it carries intrinsic risks and may not universally lead to satisfactory outcomes., Aim: To explore the rate and factors influencing patients' willingness to undergo surgery for PD., Methods: Data were prospectively collected in 5 European academic centers between 2016 and 2020. Data included age, time from PD onset, penile pain, curvature degree, difficulty at penetration, hourglass deformity, erectile dysfunction (ED), and previous treatments. All patients were offered conservative treatments, either medications or injections. Tunical shortening or lengthening procedures were offered as an alternative to conservative treatments, when indicated. Penile prosthesis was offered to those with concomitant ED. Patients' attitudes with surgery were recorded. Logistic regression analyses tested the profile of patients who were more likely to be willing to undergo surgery., Outcomes: Patients' willingness to undergo surgery for PD., Results: This study included 343 patients with a median age of 57.3 years (IQR, 49.8-63.6) and a median penile curvature of 40.0° (IQR, 30.0°-65.0°). Overall, 161 (47%) experienced penetration difficulties and 134 (39%) reported ED. Additionally, hourglass deformity and penile shortening were reported by 48 (14%) and 157 (46%), respectively. As for previous treatments, 128 (37%) received tadalafil once daily; 54 (16%) and 44 (13%), intraplaque verapamil and collagenase injections; and 30 (9%), low-intensity shock wave therapy. Significant curvature reduction (≥20°) was observed in 69 (20%) cases. Only 126 (37%) patients were open to surgery for PD when suggested. At logistic regression analysis after adjusting for confounders, younger age (odds ratio [OR], 0.97; 95% CI, 0.95-1.00; P = .02), more severe curvatures (OR, 1.04; 95% CI, 1.03-1.06; P < .0001), and difficulty in penetration (OR, 1.88; 95% CI, 1.04-3.41; P = .03) were associated with a greater attitude to consider surgical treatment., Clinical Implications: The need for effective nonsurgical treatments for PD is crucial, as is comprehensive patient counseling regarding surgical risks and benefits, particularly to younger males with severe curvatures., Strengths and Limitations: Main limitations are the cross-sectional design and the potential neglect of confounding factors., Conclusions: Patients with PD, having a lower inclination toward surgery, emphasize the need for effective nonsurgical alternatives and accurate counseling on the risks and benefits of PD surgery, particularly for younger men with severe curvatures., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Men with localized invasive penile cancer (PC) can be treated with organ-sparing treatments with different functional and aesthetical outcomes. Thus, the aim of this study is to investigate sexual outcomes in patients with PC confined to the glans that underwent wide local excision (WLE) vs. glansectomy with urethral glanduloplasty., Methods: Complete data from 60 patients with PC were analyzed at our institution from 2017 to 2022. Patients were asked for personal habits and clinical features. PC was assessed with a clinical visit and imaging techniques. At the outpatient follow-up visit or phone call, all patients compiled the Changes in Sexual Function Questionnaire (CSFQ) and the International Index of Erectile Function in its short 5-item form (IIEF-5). Erectile function (EF) impairment was categorized using Cappelleri's criteria., Results: Overall, 34 patients with PC confined to the glans (c ≤ T2N0) were included. Of those, 12 underwent WLE and 22 underwent glansectomy with urethral glanduloplasty. Using multivariable logistic regression, glansectomy (OR: 3.49) and diabetes (OR: 2.33) were associated with erectile disfunction (IEEF < 22). Meanwhile, using multivariable linear regression analysis, younger patients (Coeff: -2.41) and those that underwent glansectomy (Coeff: -7.5) had a higher risk of sexual function impairment, according to the CSFQ., Conclusions: Patients with PC ≤ T2N0 that underwent WLE have better outcomes in terms of sexual functioning than the patients who underwent glansectomy and uretheral gladuloplasty. Further research is needed to clarify the outcomes of penile-sparing surgery, to inform patients in pre-surgical counseling more comprehensively, and to meet their post-operative expectations more effectively.

Background: Phosphodiesterase 5 inhibitor (PDE5i) use has been linked to a number of ocular side effects, such as serous retinal detachment (SRD), retinal vascular occlusion (RVO), and ischemic optic neuropathy (ION)., Aim: We investigated the risk for SRD, RVO, and ION in patients using PDE5is., Methods: We utilized the IBM MarketScan (2007-2021) Commercial and Medicare Supplemental Databases (version 2.0) for this analysis. To estimate overall events risk, Cox proportional hazard models were applied to calculate the hazard ratios (HRs) for erectile dysfunction (ED) diagnosis and the different treatments, adjusting for region, median age, obesity, diabetes mellitus, hyperlipidemia, smoking, hypertension, coronary artery disease, and sleep apnea. Additionally, the same analyses were performed to calculate the HRs for benign prostatic hyperplasia (BPH) diagnosis and the different treatments., Outcomes: HRs for SRD, RVO, and ION., Results: In total, 1 938 262 men with an ED diagnosis were observed during the study period. Among them, 615 838 (31.8%) were treated with PDE5is. In total, 2 175 439 men with a BPH diagnosis were observed during the study period. Among them, 175 725 (8.1%) were treated with PDE5is. On adjusted Cox regression analysis, PDE5i use was not associated with SRD, RVO, ION, and any ocular event when compared with ED diagnosis and other ED treatments. Importantly, as the intensity of ED treatment increased, so did the risk of ocular events. In addition, PDE5i use was not associated with SRD and ION when compared with BPH diagnosis and other BPH treatments. In contrast, in patients with BPH, PDE5i use was associated with RVO (HR, 1.14; 95% CI, 1.06-1.23). Importantly, patients with BPH receiving other medical treatment (ie, 5a reductase/alpha blocker; HR, 1.11; 95% CI, 1.06-1.16) or surgical treatment (HR, 1.10; 95% CI, 1.02-1.19) had a higher risk of RVO., Clinical Implications: We did not observe any consistent association between PDE5i use and any ocular adverse events (SRD, RVO, and ION)., Strengths and Limitations: Because we did not have access to the patients' medical records, we recorded outcome definitions using ICD-9 and ICD-10 coding., Conclusions: Patients using PDE5is for ED or BPH indications did not have an increased risk of ocular events, even when compared with other treatments for ED or BPH., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The atherosclerotic cardiovascular disease risk score is a validated algorithm predicting an individual's 10-year risk of developing acute cardiovascular events (cardiovascular disease). Patients who suffer from arteriogenic erectile dysfunction are susceptible to developing cardiovascular disease in the future., Objectives: To apply the atherosclerotic cardiovascular disease score at a homogenous cohort of men with erectile dysfunction undergoing a dynamic penile colour Doppler duplex ultrasound and explore its predictive ability to identify patients with vasculogenic erectile dysfunction at colour Doppler duplex ultrasound., Materials and Methods: Complete data of 219 patients undergoing colour Doppler duplex ultrasound were analysed. All patients completed the International Index of Erectile Function. The atherosclerotic cardiovascular disease score and Charlson comorbidity index were applied to the entire cohort. Patients were divided into those with normal vs. pathological parameters at colour Doppler duplex ultrasound. Descriptive statistics were used to explore differences between the two groups. Logistic regression models tested the potential role of atherosclerotic cardiovascular disease to predict arteriogenic and/or venogenic erectile dysfunction. Local polynomial smoothing models graphically displayed the probability of pathological colour Doppler duplex ultrasound parameters at different atherosclerotic cardiovascular disease scores., Results: Overall, arteriogenic erectile dysfunction and venous leakage were diagnosed in 88 (40.2%) and 28 (12.8%) patients respectively. The median (interquartile range) atherosclerotic cardiovascular disease score was 7.7 (3.9-14). Patients with pathologic colour Doppler duplex ultrasound were older (59 vs. 54 years, p < 0.001), had higher Body Mass Index (26.5 vs. 25.6 kg/m 2 , p = 0.04), more comorbidities (Charlson comorbidity index ≥ 1) (76.5% vs. 54.4%, p = 0.002) and higher median atherosclerotic cardiovascular disease scores (9.95 vs. 7, p = 0.005), respectively. At logistic regression analysis, a higher atherosclerotic cardiovascular disease risk score was independently associated with arteriogenic erectile dysfunction at colour Doppler duplex ultrasound (odds ratio: 1.03, 95% confidence interval: 1.01-1.08, p = 0.02) after adjusting for Body Mass Index, physical activity, alcohol consumption and severe erectile dysfunction., Discussion: As vasculogenic erectile dysfunction may precede by some years the onset of acute cardiovascular diseases, the rigorous identification of patients with deficient cavernosal arterial blood flow, would definitely allow the implementation of earlier and more effective cardiovascular prevention strategies in men with erectile dysfunction., Conclusions: The atherosclerotic cardiovascular disease risk score represents a reliable tool to identify patients with arteriogenic erectile dysfunction in everyday clinical practice., (© 2023 American Society of Andrology and European Academy of Andrology.)

Concomitant sexual disorders have progressively shown increased prevalence in men at first outpatient presentation. We sought to i) estimate the prevalence of unreported premature ejaculation (PE) in a homogenous cohort of 1258 men seeking first medical help for erectile dysfunction (ED) as their primary compliant; ii) compare the baseline sociodemographic and clinical characteristics of men with only ED(ED-only) compared to those with ED and PE(ED + PE); and, iii) investigate the likelihood of detecting PE among men self-reporting only ED over a 16-year period at a single tertiary-referral centre. Descriptive statistics compared sociodemographic and clinical characteristics between ED-only patients and those with unreported concomitant primary/secondary PE(ED + PE). Logistic regression models predicted the risk of having ED + PE at baseline. Local polynomial regression models graphically explored the probability of reporting PE among ED men with ≤40 vs. 41-60 vs. >60 years over the analysed timeframe. Of all, 932 (74.1%) were ED-only and 326 (25.9%) ED + PE patients, respectively. ED + PE patients were younger, presented with fewer comorbidities, and lower rates of severe ED (all p ≤ 0.04). At multivariable logistic regression analysis, younger age (OR:0.98) and low sexual desire/interest (OR:1.54) were independently associated with ED + PE at first clinical assessment (all p = 0.03). The likelihood of detecting unreported concomitant primary/secondary PE among patients complaining of only ED at first presentation worrisomely increased among younger and middle-aged men over the last 16 years., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Holmium laser enucleation of the prostate (HoLEP) is considered a challenging procedure even for surgeons who have completed the learning curve., Objectives: To assess outcomes and complications following HoLEP performed by a highly experienced surgeon., Design, Setting, and Participants: This was a single-institution prospective study (NCT03583034) performed at a tertiary referral centre that included 243 consecutive patients with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) treated with HoLEP by a single experienced surgeon (>1600 cases)., Outcome Measurements and Statistical Analysis: Patients were assessed using validated questionnaires and uroflowmetry at baseline and several follow-up dates. Intraoperative and postoperative complications were recorded. Kaplan-Meier analysis was used to estimate recovery rates for urinary continence and erectile function. Logistic regression models were constructed to assess predictors of postoperative complications., Results and Limitations: Of the 243 patients, 78 (32.1%) had an indwelling urethral catheter. The median prostate volume (PV) was 87 cm 3 (interquartile range 60-115) and 146 patients (59.8%) had PV >80 cm 3 . At 3-mo follow-up, 219 patients (90.1%) had a peak flow rate >20 ml/s and 182 (74.9%) had no postvoid residual urine. The improvement in subjective symptoms was significant at 1-mo follow-up and was maintained until 12 mo after surgery. Urinary continence recovery was slow, with an estimated rate of 68% (95% confidence interval [CI] 62-74%) at 1 mo and 94% (95% CI 91-97%) at 12 mo after HoLEP. The recovery rate for erectile function was 53% (95% CI 46-61%) at 1 mo and 85% (95% CI 77-90%) at 12 mo. Postoperative complications occurred in 36 patients (14.8%) during their hospital stay, in 34 (14%) within 1 mo following discharge from hospital, and in ten (4.1%) at later follow-up dates. Clinically significant complications (Clavien-Dindo ≥2) were observed in 44 cases (18%) and were more common for patients with an indwelling catheter at baseline (odds ratio 5.05; p = 0.006)., Conclusions: HoLEP is an effective procedure for treating LUTS due to BPE, although it is not devoid of complications and sequelae, even in the hands of a highly experienced surgeon., Patient Summary: Holmium laser treatment of the prostate to reduce its size has positive results for urinary function when performed by an experienced surgeon, even in complex cases, although there can be complications., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

The aim of this study was to study the retinal vessels in patients affected by vasculogenic erectile dysfunction (ED), using dynamic vessel analyzer (DVA). Patients with vasculogenic ED and control subjects were prospectively enrolled to undergo a complete urological and ophthalmologic evaluation, including DVA and structural optical coherence tomography (OCT). The main outcome measures were: (1) arterial dilation; (2) arterial constriction; (3) reaction amplitude (the difference between arterial dilation and constriction); and, (4) venous dilation. Thirty-five patients with ED and 30 male controls were included in the analysis. Mean ± SD age was 52.0 ± 10.8 years in the ED group and 48.1 ± 16.3 years in the control group (p = 0.317). In the dynamic analysis, the arterial dilation was lower in the ED group (1.88 ± 1.50%), as compared with the control group (3.70 ± 1.56%, p < 0.0001). Neither arterial constriction nor venous dilation differed between groups. The reaction amplitude was decreased in ED patients (2.40 ± 2.02%, p = 0.023), compared to controls (4.25 ± 2.20%). In the Pearson correlation analysis, the ED severity, was directly correlated with both reaction amplitude (R = .701, p = 0.004) and arterial dilation (R = .529, p = 0.042). In conclusion, subjects with vasculogenic ED are featured by a significant dysfunction of the retinal neurovascular coupling, which is inversely correlated with ED severity., (© 2023. The Author(s).)

Introduction: Erectile dysfunction (ED) affects between 12.9% and 28.1% of men worldwide, presenting a strong aged-correlated prevalence. Several pharmacological treatments are currently available for ED, which can be classified into oral, injection, and topical/intraurethral therapies., Areas Covered: Extensive research on PubMed/MEDLINE until February 2023 was performed. For each of the aforementioned drug classes, available molecules, and formulations, their efficacy and most common adverse events as well as general guidelines on prescription were investigated and extensively described. A glimpse into future directions regarding ED pharmacotherapy is also present., Expert Opinion: In recent years, there have been significant developments in pharmacological treatments for ED. It is essential for physicians to identify the best treatment option for patients based on their preferences and sexual habits. The treatment approach for ED has shifted from a sequential to a parallel paradigm, where all treatment options are available as first-line therapies. While there are promising regenerative therapies for ED, such as shockwaves and platelet-rich plasma injections, pharmacological treatment is still the most effective option for most patients.

Background: Peyronie's disease (PD) has a huge impact on patients' physical and psychological wellbeing., Objectives: To investigate whether patients' age has an impact on PD symptomatic burden at first presentation., Materials and Methods: Data from 129 consecutive heterosexual patients seeking first medical attention for PD at a single andrological tertiary-referral centre were collected. All patients completed the International Index for Erectile Function (IIEF) and the PD questionnaire (PDQ). Descriptive statistics were used to compare clinical features between younger (≤40years) and older (>40 years) patients. Multivariable linear model assessed the impact of age, the degree of penile curvature and their impact on PDQ (total scores and its domains), after adjusting for PD duration and IIEF-erectile function domain scores., Results: Of 129, 24 (18.6%) patients were ≤40 years old. Young patients presented with a less severe curvature than older patients (median [interquartile ranges] 20° [15-36] vs. 50° [40-80]; p = 0.04). However, younger age was associated with higher psychological and physical symptoms, PDQ-penile pain and PDQ-symptom bother scores (Coeff -0.11, -0.21 and -0.17, respectively) (all p < 0.05). Moreover, the greater the degree of curvature, the higher the PDQ-psychological and physical symptoms and the PDQ-symptom bother scores (Coeff. 0.21 and 0.22, respectively; all p < 0.05)., Conclusion: Around one in five men seeking first medical help for PD is younger than 40 years at presentation in the real-life setting. PD-related distress varies according to patients' age, with younger men presenting with a greater risk of penile pain and symptom bother despite lower curvature., (© 2022 American Society of Andrology and European Academy of Andrology.)

Background: Peyronie's disease (PD) is a fibrosing disorder of the penis resulting in plaque formation and penile deformity that negatively affect sexual and psychosocial function of patients. A multifactorial etiology of PD is assumed with diabetes mellitus (DM) being a potential risk factor., Objectives: The aim of this narrative review was to investigate diabetes role in PD pathophysiology, diagnosis, and treatment., Materials and Methods: A non-systematic narrative review of original articles, meta-analyses, and randomized trials was conducted, including articles in the pre-clinical setting to support relevant findings., Results: Diabetes is one of the most common comorbidity observed in PD patients, with a prevalence of about 11% and a strong association with erectile dysfunction (ED). DM is associated with both a higher risk of developing PD and has also an impact on the outcomes of PD's treatments., Discussion: Evidence from literature underlines that metabolic alterations typical of DM are pivotal factors in the development of PD and resistance to its medical treatment., Conclusion: The role of DM in development of PD is still debated, while its role in PD development is not completely clear, there is a clear impact of DM on PD treatment outcomes., (© 2022 The Authors. Andrology published by Wiley Periodicals LLC on behalf of American Society of Andrology and European Academy of Andrology.)

Background: Penile prosthesis implantation has been associated with overall good functional outcomes. Of relevance, some patients reported higher level of satisfaction and quality of life., Aim: We investigated the profile of the patients who may benefit the most from penile prosthesis implantation., Materials and Methods: Data from a national multi-institutional registry of penile prostheses including patients treated from 2014 to 2017 in Italy (Italian Nationwide Systematic Inventarization of Surgical Treatment for Erectile Dysfunction) were analyzed. All data have been prospectively recorded by 45 surgeons on a dedicated website (www.registro.andrologiaitaliana.it) and revised by a single data manager. Patients' baseline characteristics were recorded. In order to simultaneously evaluate perceived penile prosthesis function and quality of life, all patients were re-assessed at 1-year follow-up using the validated questionnaire Quality of Life and Sexuality with Penile Prosthesis. High quality of life after surgery was defined as a score higher than the 75th percentile in each of the subdomains of the Quality of Life and Sexuality with Penile Prosthesis questionnaire. Logistic regression analysis tested the association between clinical characteristics and high quality of life after penile prosthesis implantation., Results: Follow-up data were available for 285 patients (median age 60 years; interquartile range: 56-67) who underwent penile prosthesis implantation. Erectile dysfunction etiology was organic in 40% (114), pelvic surgery/radiotherapy in 39% (111), and Peyronie's disease in 21% (60) of the cases. Patients showed good overall Quality of Life and Sexuality with Penile Prosthesis scores at 1-year follow-up for functional (22/25), personal (13/15), relational (17/20), and social (13/15) domains. Overall, 27.0% (77) of patients achieved scores consistent with the high quality of life definition. These patients did not differ in terms of median age (60 vs. 62), type of prosthesis (inflatable penile prostheses: 95% in both of the cases), and post-operative complications (10% vs. 14%) than those with lower quality of life score (all p &gt; 0.1). At logistic regression analysis, erectile dysfunction etiology was the only factor independently associated with high quality of life at 1 year after surgery (p = 0.02). Patients treated for Peyronie's disease (odds ratio: 2.62; p = 0.01; 95% confidence interval: 1.20-5.74) were more likely to report better outcomes after accounting for age, post-operative complications, and surgical volume., Conclusion: Penile prosthesis implantation is associated with an overall good quality of life. The subset of patients affected by erectile dysfunction secondary to Peyronie's disease seemed to benefit the most from penile prosthesis implantation in terms of functional outcomes, relationship with their partners and the outside world, and perceived self-image. The systematic use of validated questionnaires specifically addressed at evaluating quality of life and satisfaction after penile prosthesis implantation should be further implemented in future studies to better define the predictors of optimal satisfaction after penile prosthesis implantation., (© 2022 American Society of Andrology and European Academy of Andrology.)

Background: Erectile dysfunction aetiology has been historically identified as organic, psychogenic and mixed., Objectives: To stratify and compare a cohort of patients seeking medical help for erectile dysfunction for the first time according to the newly proposed binary classification of the European Association of Urology guidelines: 'primary organic' versus 'primary psychogenic'., Materials and Methods: Complete data from 2009 consecutive patients presenting for erectile dysfunction were analysed. All patients completed the International Index of Erectile Function at baseline. According to the presence of erectile dysfunction-related risk factors indexed by the European Association of Urology Guidelines on Sexual and Reproductive Health, patients were categorised as having primary organic (≥1 risk factor) or primary psychogenic (0 risk factor) erectile dysfunction. Descriptive statistics compared the two groups. Linear regression analysis tested the association between the number of risk factors and erectile dysfunction severity. Locally estimated scatterplot smoothing method graphically explored the relationship between the number of risk factors for erectile dysfunction and the International Index of Erectile Function domain scores., Results: Median (interquartile range) age at first presentation was 50 (39-61) years. Of all, 1632 (86.2%) and 377 (13.8%) were identified as having primary organic and primary psychogenic erectile dysfunction, respectively. Overall, 1488 (74.1%) patients were >40 years of age; in this subgroup, the most frequent risk factors were age, hypertension (29%), active smoking (42%) and alcohol intake (25.1%). Median (interquartile range) International Index of Erectile Function-erectile function score was 15 (7-22). Primary organic erectile dysfunction patients depicted lower International Index of Erectile Function-sexual desire and International Index of Erectile Function-orgasmic function scores (all p ≤ 0.02), whilst groups did not differ in terms of International Index of Erectile Function-erectile function, International Index of Erectile Function-intercourse satisfaction and International Index of Erectile Function-overall satisfaction scores., Discussion: One out of nine patients complaining of erectile dysfunction depict criteria for primary psychogenic erectile dysfunction. Erectile function severity could be as severe as patients with organic erectile dysfunction. The single-centre-based cross-sectional nature of the study, raising the possibility of selection biases, is our main limitation., Conclusions: One out of nine patients presenting for erectile dysfunction depict criteria suggestive for primary psychogenic erectile dysfunction in the real-life setting. Patients with primary psychogenic and primary organic erectile dysfunction have comparable erectile dysfunction severity, thus outlining the importance of a comprehensive and tailored management work-up in every patient seeking medical help for the first time., (© 2022 American Society of Andrology and European Academy of Andrology.)

Context: The present summary of the European Association of Urology (EAU) guidelines is based on the latest guidelines on male sexual health published in March 2021, with a last comprehensive update in January 2021., Objective: To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health., Evidence Acquisition: A literature review was performed up to January 2021. The guidelines were updated, and a strength rating for each recommendation was included based on either a systematic review of the evidence or a consensus opinion from the expert panel., Evidence Synthesis: Late-onset hypogonadism is a clinical condition in the ageing male combining low levels of circulating testosterone and specific symptoms associated with impaired hormone production and/or action. A comprehensive diagnostic and therapeutic work-up, along with screening recommendations and contraindications, is provided. Erectile dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. Along with a detailed basic and advanced diagnostic approach, a novel decision-making algorithm for treating ED in order to better tailor therapy to individual patients is provided. The EAU guidelines have adopted the definition of premature ejaculation (PE), which has been developed by the International Society for Sexual Medicine. After the subtype of PE has been defined, patient's expectations should be discussed thoroughly and pharmacotherapy must be considered as the first-line treatment for patients with lifelong PE, whereas treating the underlying cause must be the initial goal for patients with acquired PE. Haemospermia is defined as the appearance of blood in the ejaculate. Several reasons of haemospermia have been acknowledged; the primary goal over the management work-up is to exclude malignant conditions and treat any other underlying cause., Conclusions: The 2021 guidelines on sexual and reproductive health summarise the most recent findings, and advise in terms of diagnosis and treatment of male hypogonadism and sexual dysfunction for their use in clinical practice. These guidelines reflect the multidisciplinary nature of their management., Patient Summary: Updated European Association of Urology guidelines on sexual and reproductive health are presented, addressing the diagnosis and treatment of the most prevalent conditions in men. Patients must be fully informed of all relevant diagnostic and therapeutic options and, together with their treating physicians, decide on optimal personalised management strategies., (Copyright © 2021 European Association of Urology. All rights reserved.)

We investigated changes in patterns of reported male SDs at a single academic centre over a 10-year time frame. Comprehensive data of 2013 patients consecutively assessed for the first time by a single Sexual Medicine expert between 2006 and 2019 has been analysed. All patients were assessed with a thorough sexual and medical history. Primary reason for seeking medical help at first assessment was recorded for all patients and categorized as: erectile dysfunction (ED), premature ejaculation (PE), low/reduced sexual desire/interest (LSD/I), Peyronie's disease (PD), and other SDs. Linear and logistic regression models tested the association between different reasons for seeking medical help and the time at first evaluation. Local polynomial regression model explored the probability of reporting different SDs over the analysed time frame. Median (IQR) age at first clinical assessment was 50 (38-61) years. Overall, most patients were assessed for ED (824; 41%), followed by PD (369; 18%), PE (322; 16%), LSD/I (204; 10%) and other SDs (294; 15%). Significant changes in terms of reported SD over the analysed time frame were observed. The likelihood of assessing patients for ED significantly increased up to 2013, with a decrease in the past 5 years (p < 0.001). PE assessment at presentation linearly decreased over time (OR: 0.94; 95% CI: 0.91-0.96; p < 0.001). Patients assessed during the past few years were more likely to report PD (OR: 1.20; 95% CI: 1.15-1.25; p < 0.001) and LSD/I (OR: 1.21; 95% CI: 1.16-1.26; p < 0.001), with a linear increase over the evaluated time frame. Likewise, patients were also more likely to report other SDs (Coeff: 1.06; 95% CI: 1.02-1.10; p = 0.004), with a linear increase over time. These results may reflect real changes in SD incidence, increased public awareness towards different SDs and the possible impact of novel treatments available on the market throughout the same time frame., (© 2020. The Author(s), under exclusive licence to Springer Nature Limited.)

Low-intensity shockwave therapy (Li-ESWT) has been shown to be an effective and safe treatment for vasculogenic erectile dysfunction (ED). We aim to evaluate the effectiveness and safety of LiESWT in treating patients affected from vasculogenic ED who did not respond to oral treatment with Phosphodiesterase 5 inhibitors (PDE5-i). It is a multicentric open-label prospective study, in a cohort of patients non-responders to PDE-5i. Li-ESWT was performed in an outpatient setting by using the following schedule: 3000 shockwaves with an energy of 0.25 mJ/mm 2 and a frequency of 4-6 Hz, twice a week for 3 weeks. International Index of Erectile Function, Erection Hardness Score and Sexual Quality of Life-Male questionnaires, and penile doppler ultrasound (PDU) are the outcome measurements. The Student t-test or Wilcoxon signed-rank test were applied to compare variables, with results considered statistically significant at p < 0.05. 106 (97.2%) completed treatment and performed follow-up visit after 4 weeks. At follow up visit, the mean IIEF-EF increased by 8.6 points (13.47 ± 4.61 vs 22.07 ± 5.27; p < 0.0001). A clinically significant improvement of IIEF-EF was achieved in 75 patients (70.7%). An EHS score ≥ 3, sufficient for a full intercourse, was reported by 72 patients (67.9%) at follow-up visit. 37 (34.9%) patients reported a full rigid penis (EHS = 4) after treatment. Li-ESWT treatment was also able to improve quality of life (SQOL-M: 45.56 ± 8.00 vs 55.31 ± 9.56; p < 0.0001). Li-ESWT significantly increased mean PSV (27.79 ± 5.50 vs 41.66 ± 8.59; p < 0.0001) and decreased mean EDV (5.66 ± 2.03 vs 1.93 ± 2.11; p < 0.0001) in PDU. Combination of Li-ESWT and PDE5-i represents an effective and safe treatment for patients affected from ED who do not respond to first line oral therapy., (© 2020. The Author(s), under exclusive licence to Springer Nature Limited.)

Focal therapy modalities achieved interest in the management of prostate cancer (PCa) over the last a few years. This systematic review was aimed to investigate erectile function after focal therapy for localized PCa. Twenty-six out of 1287 reports were identified through a database systematic search in MEDLINE, EMBASE, and Web of Science, supplemented with hand search, on June 1st, 2020, according to PRISMA guidelines. Focal therapy modalities investigated were cryotherapy, high-intensity focused ultrasound (HIFU), photodynamic therapy (TOOKAD), irreversible electroporation (IRE), and focal radiotherapy (RT) (i.e. brachytherapy or stereotactic RT). Overall, reported sexual function outcomes after these treatment modalities were generally good, with many studies reporting a complete recovery of EF at 1-year follow-up. However, the quality of current evidence is affected both by the lack of well-conducted comparative studies and by a significant heterogeneity in terms of study design, study population, erectile and sexual function assessment modalities.

Patient-reported outcome instruments for erectile function often ask respondents about their experience over the previous 4wk. This is problematic for baseline assessment of patients with prostate cancer (PC) before treatment, as the previous 4wk would probably have involved procedures such as biopsy and considerable anxiety related to their diagnosis. At San Raffaele Hospital, the International Index of Erectile Function (IIEF-6) was used to ask new PC patients about function in both the previous 4wk and 6mo. We compared responses to these two timeframes. IIEF-6 scores were lower for the 4-wk period (median 24 vs 26; p<0.0001) predominately because approximately one in six of patients with good function in the 6-mo time frame had very poor function in the 4wk before completing the questionnaire (adequate erectile function 60% and 51%; absolute difference 9%, 95% confidence interval 8-10%). Results were further confirmed using a comparison group of 5395 patients with PC newly diagnosed at Memorial Sloan Kettering Cancer Center who had similar function in the previous 6mo. Erectile function evaluation for men presenting with PC should involve asking about typical function over a 6-mo period rather than focusing on the previous 4wk. PATIENT SUMMARY: Questionnaires to assess erectile function often ask men about function in the previous 4wk. We found that this underestimates function in new prostate cancer patients and that such men should be asked about typical function over a 6-mo period., (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Current European Association of Urology guidelines suggest investigation of erectile dysfunction (ED) among patients with lower urinary tract symptoms (LUTS) whenever there is a clinical suspicion., Objective: To assess factors predictive of ED, which may drive the need for a clinical assessment in men only presenting for LUTS., Design, Setting, and Participants: Data from 914 men presenting for LUTS at a single-center outpatient clinic and without a previous diagnosis of ED were analyzed., Intervention: All patients completed the International Prostatic Symptom Score (IPSS) and the International Index of Erectile Function-erectile function (IIEF-EF) questionnaires., Outcome Measurements and Statistical Analysis: Logistic regression analyses tested potential predictors of ED and severe ED. The accuracy of the predictive models was assessed, and decision curve analyses (DCAs) tested their clinical benefit., Results and Limitations: The median baseline IPSS score was 12 (7-19). IIEF-EF scores suggestive of unreported ED were observed in 503 (55%) patients; of all, 251 (27%) men showed severe ED. At logistic regression analysis, age (odds ratio [OR]: 1.04; p<0.001), IPSS score (OR: 1.04; p<0.001), diabetes mellitus (OR: 2.37; p=0.02), and smoking history (OR 1.36; p=0.03) were associated with unreported ED, after accounting for body mass index, hypertension, other cardiovascular diseases, and dyslipidemia. The same factors were associated with severe ED (all p≤0.03). The predictive model including these variables showed good accuracy for predicting ED (areas under the curve 0.69 and 0.72, respectively). However, DCAs showed no greater clinical benefit regarding identifying which patients should actually be screened for ED using these variables versus screening all patients with LUTS. Conversely, the net clinical benefit of the tested model was higher when predicting severe ED. As a limitation, we could not check prospectively the clinical impact of detecting ED in LUTS patients., Conclusions: Given the importance of ED in terms of overall men's health, segregating patients to be investigated or not for ED according to the traditional risk factors did not emerge more clinically useful than screening all patients presenting for LUTS., Patient Summary: Lower urinary tract symptoms (LUTS) are frequently associated with erectile dysfunction (ED). Patients presenting for LUTS only in the everyday clinical practice should always be screened for ED and managed accordingly., (Copyright © 2019. Published by Elsevier B.V.)

Over the past few years, an increase use of low-intensity shockwave therapy (LISWT) for the treatment of erectile dysfunction (ED) has been observed. However, many controversies in the scientific literature about its efficacy still exist. We aimed to investigate changes in the pattern of usage and attitudes toward LISWT for ED among experts over the last years. A dedicated online survey was sent to delegates at the Congress for the EAU Section of Andrological Urology (ESAU) in Prague from 31st October to 1st November 2019. The survey captured demographic data, professional background, and the experience and personal knowledge about LISWT. The results were compared with a previous survey conducted in 2016 and investigating the same topics in order to assess changes in the knowledge and opinion on LISWT over time. Overall, 172 and 192 questionnaires were available from 2019 and 2016, respectively. Participants in the 2019 survey were 80 (45.7%) urologists, 52 (29.7%) uro-andrologists, and 34 (19.4%) residents in urology, from 30 different countries. Compared to the past, we observed an increase of respondents who were familiar with LISWT (75 vs. 95%; p < 0.0001) and who performed LISWT in their routine practice (38% in 2019 vs. 14% in 2016; p < 0.0001). Conversely, no changes in terms of overall perception of treatment efficacy were registered over time (68% in 2019 vs. 72% in 2016 considered LISWT as an effective treatment, respectively (p = 0.5)). An increased proportion of physicians had suggested a wider application of LISWT, and some even advocated its use in nonvasculogenic ED (33% in 2019 vs. 5.9% in 2016; p < 0.0001). The awareness and clinical application of LISWT for ED have increased over time, despite the lack of robust evidence in terms of effectiveness. Further research on the benefit of LISWT is needed to guide physicians in the therapeutic management of ED patients., (© 2020. The Author(s), under exclusive licence to Springer Nature Limited.)

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., (© 2020 American Society of Andrology and European Academy of Andrology.)

Background: Erectile dysfunction (ED) is widely considered as an early manifestation of cardiovascular diseases (CVDs), sharing similar risk factors., Aim: Assess rates and predictors of developing CVD and/or hypertension (HTN) over a long-term follow-up period using user-friendly and clinically reliable tools in men presenting with ED but without CVD/HTN or known vascular risk factors at baseline., Methods: Data from 108 patients presenting between 2005 and 2011 with ED were analyzed. All patients were free from CVD and/or HTN (CVD/HTN) at baseline. Patients completed the International Index of Erectile Function (IIEF) at baseline and were followed up every 6 months with clinical assessment or phone interview. Kaplan-Meier analyses estimated the probability of developing CVD/HTN over time. Cox-regression models tested the association between patient baseline characteristics (for example, age, Charlson Comorbidity Index, baseline IIEF-EF, ED severity, alcohol intake, smoking), response to phosphodiesterase type-5 inhibitors (PDE5is), and the risk of developing CVD/HTN., Results: Of all, 43 (40%) patients showed IIEF-EF scores suggestive of severe ED; 37 (39%) and 59 (61%) were nonresponders and responders to PDE5i, respectively. Median (interquartile range) age was 51 (41, 61) years. Median (interquartile range) follow-up was 95 (86-106) months. Overall, the estimated risk of developing CVD/HTN was 15% (95% confidence interval [CI]: 9-27) at 10-year assessment. Men with baseline severe ED had a higher risk of developing CVD/HTN (34%; 95% CI: 17-59, P = .03) at 10 years than patients with mild to moderate ED (5% [95% CI: 2-14]). At the Cox regression analysis, severe ED (Hazard ratio [HR], 4.62; 95% CI: 1.43, 8.89; P = .01) and baseline IIEF-EF score (HR, 0.92; 95% CI: 0.86, 0.99; P = .02) were associated to the risk of CVD/HTN overtime. Conversely, age and nonresponders to PDE5is (HR, 0.92; 95% CI: 0.32, 2.68; P = .9) were not associated to a risk of CVD/HTN over time., Clinical Implications: The use of an easy and user-friendly tool, as the IIEF-EF domain score, would allow to reliably assess which men with ED at first presentation may deserve a different, more specific and detailed cardiologic investigation to prevent inauspicious CV events., Strengths & Limitations: A single-center-based, observational longitudinal study, raising the possibility of selection biases are the main limits., Conclusions: Patients with severe ED and lower baseline IIEF-EF but no vascular risk factors at first presentation have more than 30% risk of developing CVD/HTN in 10-year time. Those patients may benefit from medical preventive strategies to lowering the risk of CV events and HTN. Pozzi E, Capogrosso P, Boeri L, et al. Longitudinal Risk of Developing Cardiovascular Diseases in Patients With Erectile Dysfunction-Which Patients Deserve More Attention?. J Sex Med 2020;17:1489-1494., (Copyright © 2020. Published by Elsevier Inc.)

The efficacy of phosphodiesterase type 5 inhibitors (PDE5i) in patients with erectile dysfunction (ED) and undiagnosed prediabetes (PreDM) has been scantly analysed. We aimed to assess rates of and predictors of response to oral treatment in a cohort of ED men naïve for PDE5i with either normo-glycaemia or PreDM or diabetes mellitus (DM). Complete data from 466 men were analysed. Comorbidities were scored with the Charlson Comorbidity Index (CCI). Patients completed the International Index of Erectile Function (IIEF) at baseline and after 3 months of PDE5i treatment. Treatment response was evaluated using the minimal clinically important difference (MCID) (mild: +2; moderate: +5; severe: +7 from baseline IIEF-EF). PreDM status was defined as for the American Diabetes Association (2015) criteria. Descriptive statistics and logistic regression models tested the association between clinical predictors and MCID response. Overall, 253 (56.7%), 105 (23.5%) and 88 (19.7%) patients had normo-glycaemia (=controls), PreDM and DM, respectively. Diabetic and PreDM men were older, had higher BMI, higher CCI scores and lower total testosterone (tT) (all p < 0.01) compared to controls. Median baseline IIEF-EF was lower both in PreDM (14.0 vs. 18.0; p < 0.05) and DM patients (10.0 vs. 18.0; p < 0.001) than in controls. IIEF-EF improved in all groups after treatment (all p < 0.001), but scores were higher in controls compared to both PreDM and DM men at 3-mos assessment (26.0 vs. 20.0 vs. 17.5, respectively; all p < 0.001). Controls more frequently achieved significant MCID than both PreDM and DM patients (65.3 vs. 22.9 vs. 11.8%, respectively; p < 0.01). Age (p < 0.001), baseline IIEF-EF (p < 0.001), and DM status (p = 0.02) were independently associated with MCID. In conclusion, patients with undiagnosed PreDM depicted lower rates of response to PDE5i than normoglycemic men. These findings suggest that even milder forms of glucose impairment are associated with a poorer PDE5i effectiveness in men with ED.

Background: Erectile dysfunction (ED) is an increasingly common complaint among men aged <40 yr., Objective: To assess clinical factors potentially associated with impaired erectile function (EF) in a cohort of young men seeking first medical help for ED as their primary complaint., Design, Setting, and Participants: Complete sociodemographic and clinical data for 307 consecutive patients aged <40 yr were analysed. Health-significant comorbidities were scored using the Charlson comorbidity index. Patients completed the International Index of Erectile Function (IIEF) and Beck's Inventory for Depression (BDI) and were categorised into two groups: those with impaired EF (IIEF-EF <26) and those with normal IIEF-EF scores., Outcome Measurements and Statistical Analysis: Descriptive statistics and logistic regression analyses were used to test the association between risk factors and impaired EF., Results and Limitations: Overall, 78 patients (25%) had normal and 229 (75%) had impaired IIEF-EF scores. Among ED patients, 90 (29%) had IIEF-EF scores suggestive of severe ED. The two cohorts did not differ in terms of median age, body mass index, prevalence of hypertension, general health status, smoking history, or alcohol use. No differences were reported for serum sex hormones and lipid profiles. Patients with ED reported higher median BDI scores (7, interquartile range [IQR] 3-13) than those with normal EF (5, IQR 1-9). Overall, the higher the BDI score, the lower was the IIEF-EF domain score (odds ratio 1.08, 95% confidence interval 1.02-1.15; p=0.01). The single-centre cohort is the main study limitation., Conclusions: Overall, young men with impaired EF showed comparable clinical characteristics to those with normal IIEF-EF; conversely, young individuals with worse EF had BDI scores suggestive of significant mood deflection., Patient Summary: Young men complaining of erectile dysfunction show significant mood deflection in comparison to patients with normal erectile function. Conversely, the clinical characteristics are similar between the two groups., (Copyright © 2018. Published by Elsevier B.V.)

Introduction: Erectile function (EF) outcomes after radical pelvic surgery vary widely among different studies, partly as a consequence of heterogeneity with regard to the data assessment and reporting methodology., Aim: Review the methodology of data assessment and reporting of studies evaluating EF outcomes after radical prostatectomy (RP), radical cystectomy (RC), and rectal surgery (RS) and provide detailed recommendations to conduct future high-quality research., Methods: The MEDLINE database was searched for randomized clinical trials and open-label prospective or retrospective studies., Main Outcome Measure: The panel reviewed the modality of data assessment and reporting concerning 3 specific areas: preoperative patients assessment, surgical technique description, and postoperative patients management and follow-up., Results: Overall, 280, 36, and 73 studies investigating EF after RP, RC, and RS, respectively, were included. Baseline EF was largely reported (88%) in studies on RP, but only 67% of the studies on either RC or RS assessed EF before surgery. Baseline comorbidities that could impact postoperative EF were reported in 62%, 64%, and 85% of studies on RP, RC, and RS, respectively. The type of surgical approach was provided in all studies, and surgical details relevant to EF (eg, nerve- or organ-sparing surgery) were reported by 86%, 81%, and 62% of studies on RP, RC, and RS, respectively. Conversely, surgeon experience was rarely reported across all studies. Validated tools were commonly used to assess postoperative EF (64% of studies for RP, 78% for RC, and 71% for RS). Only 41%, 17%, and 29% of studies on RP, RC, and RS, respectively, reported a follow-up of at least 2 years. Use of erectile dysfunction treatment after surgery was assessed by only 39%, 17%, and 4.1% of studies on RP, RC, and RS, respectively. Factors potentially influencing EF recovery (eg, urinary or fecal continence, urinary diversion) were commonly reported, but sexual desire after surgery was reported by only 18%, 42%, and 37% of studies on RP, RC, and RS, respectively., Clinical Implications: The use of a shared methodology for the assessment and reporting of data on EF outcomes after pelvic surgery would allow better estimation of EF outcomes after pelvic surgery., Strengths & Limitations: The modality of data assessment and reporting among studies investigating EF outcome after pelvic surgery was systematically investigated to provide recommendations allowing a proper interpretation of data., Conclusion: Studies on EF outcomes after radical pelvic surgery should fulfill specific criteria concerning preoperative patient assessment, reporting of surgical details, and postoperative functional outcome evaluation and management. Capogrosso P, Pozzi EP, Celentano V, et al. Erectile Recovery After Radical Pelvic Surgery: Methodological Challenges and Recommendations for Data Reporting. J Sex Med 2020;17:7-16., (Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The awareness regarding erectile dysfunction (ED) may have increased over the past decade due to the widespread availability of phosphodiesterase type 5 inhibitors and the growing knowledge of a link between ED and men's overall health., Objective: We examined whether the increased awareness of ED has led to observable changes in patient characteristics among first-time assessments for ED., Design, Setting, and Participants: Data was collected from 1586 men seeking their first medical attention for ED at a single academic center during 2005-2017., Intervention: Patients completed the International Index of Erectile Function (IIEF) to assess ED., Outcome Measurements and Statistical Analysis: Local polynomial regression models explored the relationship between patient characteristics and the year of first-time assessment. Linear and logistic regression models estimated the association between the time at first assessment and the investigated outcomes. Restricted cubic splines tested the nonlinearity for continuous variables., Results and Limitations: We observed a nonlinear correlation between age and year of assessment (p=0.0003); the probability that a patient aged <40 yr presented for ED increased from 13.5% in 2006 to 21.7% in 2017 (p=0.002). Patients assessed over the last period were significantly healthier (Charlson Comorbidity Index≥1; odds ratio [OR]: 0.96; 95% confidence interval [CI]: 0.92-0.99, p=0.02). We observed an increase in the rate of smokers (OR: 1.19, 95% CI: 1.14-1.23, p<0.0001) and in regularly physically active men (OR: 1.05; 95% CI: 1.01-1.08, p=0.008) over the same period. No changes were observed in terms of baseline IIEF-Erectile function scores over time. The single center design is the main limitation of the study., Conclusions: Age at first presentation for ED significantly decreased over the past decade. Physicians should carefully assess EF even at younger age groups, suggesting lifestyle modifications and relevant treatments for comorbid conditions as soon as possible., Patient Summary: Patients presenting for erectile dysfunction (ED) are younger than they were 10 yr ago. These findings may suggest an increase in ED awareness. Likewise, this age reduction could represent a worrisome increase in terms of ED incidence in young men., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: The impact of erectile dysfunction (ED) on patients' sexual satisfaction and mood profile could differ across different ages., Aim: To investigate the relationship between erectile function (EF), sexual satisfaction, and mood status among patients seeking medical help for ED., Methods: Data from 765 patients presenting at a single center for ED were analyzed. Patients were categorized as young (≤50 years), middle-aged (>50 and ≤65 years), and old (>65 years) individuals and completed the International Index of Erectile Function (IIEF) and the Beck's Inventory for Depression (BDI)., Main Outcome Measures: The IIEF overall satisfaction and intercourse satisfaction domain scores and the BDI score were used to investigate sexual life satisfaction and depressive symptoms (defined as BDI > 11) across ages and according to ED severity. Linear and logistic regression analyses assessed the relationship between satisfaction scores and the risk of depressive symptoms with age and EF., Results: Median (interquartile range) age at first assessment for ED was 50 (38, 59) years. Compared with older men, young and middle-aged patients showed significantly higher IIEF-OS and IIEF- Intercourse Satisfaction scores for increasing IIEF-EF scores. Older men showed no difference in terms of satisfaction scores for mild ED and normal EF status. At linear regression analysis, both IIEF-EF and age were significantly associated with sexual satisfaction (all P < .0001). The interaction term between age and EF was also significant, suggesting that the older the patients, the higher the feeling of sexual satisfaction for the same EF status (P = .004). Overall, 25% of patients reported depressive symptoms. Logistic regression analysis showed a 40% risk of depressive symptoms for patients <45 years with severe ED compared to a risk <20% for a man >65 years of age with the same EF status., Clinical Implications: Treating older patients with mild ED may not lead to a further improvement in sexual satisfaction as compared with younger patients with the same ED severity. Younger ED patients suffer more from depressive symptoms compared with older men, regardless of ED severity, thus supporting the need for a comprehensive psychological counseling., Strength & Limitations: The single-center design and the lack of the assessment of the impact of ED treatment are the main limits., Conclusions: The clinical management of ED should be tailored according to different ages: younger patients deserve to be investigated and eventually treated for depressive symptoms. Older patients should be counseled for treatment when a sexual satisfaction improvement is expected. Capogrosso P, Ventimiglia E, Boeri L, et al. Should We Tailor the Clinical Management of Erectile Dysfunction According to Different Ages? J Sex Med 2019;16:999-1004., (Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

To investigate the efficacy, tolerability, and patient's preference of alprostadil cream for topical use administered within the urethral meatus versus the standard administration route, in erectile dysfunction (ED) treatment. Seventy-one patients (mean age 59.7 ± 9.0 years) affected by ED were analyzed in this multicenter, randomized, two-administration routes, cross-over trial. All patients received a single dose of alprostadil cream applying the dispenser to the tip of the penis (without contacting the urethral meatus) (Standard administration route or ST.AR) alternating with a single dose of alprostadil cream applying the dispenser within the urethral meatus (New administration route or NEW.AR) separated by a one-week washout period, according to randomization. The primary objective of the study was to evaluate the change in International Index of Erectile Function (IIEF-5) total score from baseline to the control visit by comparing the ST.AR and NEW.AR. Secondary objectives of the study were to compare the different methods of administration by evaluating the change in the Sexual Encounter Profile (SEP-2 and SEP-3) questionnaire score and the Patient Reported Outcomes (PROs) by scoring the Patient Self-Assessment of Erection (PSAE) questionnaire. The treatment safety profile was assessed by analysis of adverse events (AEs). Based on the study findings it is evident that the NEW.AR is more efficacious than the ST.AR in improving IIEF-5 and SEP scores from baseline to control visit (IIEF-5: +3.8 vs +6.3; p < 0.001; positive response to SEP-2: 10 vs 27; p = 0.002) and in terms of PSAE (a significant improvement from the baseline in 31% of patients; p < 0.001). As regards the safety profile, no difference in terms of local and systemic side effects was found.

Objectives: To investigate scores and predictors of patient satisfaction at 1 year after penile prosthesis implantation (PPI) using the validated Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire., Patients and Methods: Analyses were performed for 142 patients prospectively included in the national multicentre registry Italian Nationwide Systematic Inventarization of Surgical Treatment for Erectile Dysfunction (INSIST-ED), which provided 1-year follow-up data. Postoperative patient satisfaction was assessed using the validated QoLSPP tool. Linear logistic regression analyses assessed predictors of QoLSPP total and single domain scores, including age at surgery, erectile dysfunction aetiology, type of prosthesis, surgical approach, surgeon experience and complications. Locally weighted regression methods were used to explore the relationship between surgeon experience and QoLSPP scores., Results: Overall, high median functional, relational, social, personal and total QoLSPP scores were reported at 1 year after PPI. Patients implanted with hydraulic devices had higher functional (23 vs 21.5; P = 0.01) and total scores (68 vs 65.5; P = 0.03) than those with a malleable prosthesis. Surgeon experience emerged as the only independent predictor of higher satisfaction scores, depicting a non-linear association with both QoLSPP total and single domain scores (all P < 0.03). Data suggested that the higher the number of procedures per year, the greater the satisfaction scores, reaching a plateau after l5 procedures/year., Conclusions: This study reports high functional and patient satisfaction scores at 1 year after PPI surgery using a dedicated tool for the first time. Better outcomes should be expected for patients treated by surgeons with greater experience., (© 2018 The Authors BJU International © 2018 BJU International Published by John Wiley & Sons Ltd.)

Erectile dysfunction (ED) is considered a sentinel marker for poor general men's health status. Severe ED has been associated with poor response to phosphodiesterase type 5 inhibitors (PDE5Is) therapy. We sought to assess the association of multiple PDE5Is prescription with the overall patients' health status. Socio-demographic and clinical variables from 939 consecutive white-European, heterosexual, sexually-active men seeking medical help for ED at same tertiary-referral academic outpatient clinic were analyzed. Health-significant comorbidities were scored with the Charlson Comorbidity Index (CCI). Patients have been stratified into naïve and non-naïve according to their history of previous prescriptions of any PDE5I. Every patient completed the International Index of Erectile Function (IIEF) questionnaire. Logistic regression models tested the association between patients' baseline characteristics (thus including previous PDE5Is prescriptions) and the overall health status. Overall, 328 (35%) patients were non-naïve for PDE5Is. Of them, 172 (52%), 99 (30%), and 57 (17%) had been prescribed with 1, 2 or 3 different PDE5Is, respectively. Naïve and non-naïve patients did not differ in terms of age, BMI, baseline ED severity; conversely, non-naïve patients had a higher CCI score. At logistic MVA, the number of PDE5Is prescriptions emerged as an independent predictor of a higher burden of comorbidities regardless of ED severity; the higher the number of PDE5Is prescriptions, the higher the CCI score (OR 1.69, 2.49, and 2.90 for 1, 2 or 3 previous PDE5Is, respectively), after accounting for age, BMI, baseline ED severity and cigarette smoking. More than a third of patients seeking medical help for ED at a single tertiary-referral center were non-naïve for PDE5Is. The increasing number of previous prescriptions of PDE5Is emerged as a worrisome marker of a poorer overall men's health status regardless of ED severity., Competing Interests: The authors have declared that no competing interests exist.

Introduction: The association between prediabetes (PreDM) and erectile dysfunction (ED) has been analyzed scantly., Aim: To assess the association between PreDM and erectile function (EF) in a cohort of white European men with ED., Methods: Demographic, clinical, and laboratory data from 372 consecutive men were analyzed. Health-significant comorbidities were scored with the Charlson Comorbidity Index (CCI). Patients were invited to complete the International Index of Erectile Function (IIEF)-EF domain questionnaire. The EF domain was categorized according to Cappelleri's criteria. Men were defined as having PreDM according to the criteria defined by the American Diabetes Association (2015). Descriptive statistics and logistic regression models tested the association between clinical variables and PreDM status and severe ED., Main Outcome Measures: We assessed the prevalence of PreDM in our cohort of men with ED and the potential association of PreDM and sexual health within the same cohort., Results: Of 372 men, +PreDM was found in 86 (23.1%) patients. Men with +PreDM had lower total testosterone (tT), higher triglycerides, and higher total cholesterol values (all P < .03) than those without PreDM. Likewise, +PreDM patients had a higher rate of CCI ≥1 (P = .03) and more frequently had severe ED (P = .013) compared with -PreDM. Age (OR 1.03; P = .01); lower tT (OR 0.81; P = .02); and severe ED (OR 3.37; P = .004) were associated with +PreDM status, after accounting for BMI, CCI, alcohol consumption, and cigarette smoking. Similarly, age (OR 1.02; P = .02) and +PreDM (OR 2.02; P = .02) were associated with severe ED, after accounting for other clinical variables., Clinical Implications: Identifying +PreDM status in ED men is clinically relevant in order to adopt preventive strategies to attempt and reduce risk of developing DM and subsequent cardiovascular diseases., Strengths & Limitations: To our knowledge, this is the first study evaluating the prevalence of unrecognized PreDM and the association of PreDM and ED severity in a real-life setting. Limitations are the retrospective nature of the cross-sectional study and the lack of haemodynamic parameters for every patient., Conclusions: 1 in 5 men seeking medical help for new-onset ED showed glucose values suggestive for unrecognized PreDM and +PreDM status was associated with worse hormonal and metabolic profiles, along with a higher risk of severe ED than -PreDM. Boeri L, Capogrosso P, Perderzoli F, et al. Unrecognized prediabetes is highly prevalent in men with erectile dysfunction-results from a cross-sectional study. J Sex Med 2018;15:1117-1124., (Copyright © 2018 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: The prevalence of sexual dysfunctions has increased over the last decades; despite a number of available treatments for erectile dysfunction (ED), premature ejaculation (PE), and Peyronie's disease (PD), still several unmet therapeutic needs deserve to be fulfilled. The aim of this review is to detail on phase I and II clinical trials investigating novel medical treatments for ED, PE, and PD., Areas Covered: We conducted a systematic review of the literature including both published and ongoing phase I and II registered trials focused on medical treatment of ED, PE, and PD during the last 5 years. A total of 35 trials have been identified. Most studies (63%) investigated ED treatments and 26% were still ongoing. Stem cells (SCs) therapy was assessed in 28% of trials., Expert Opinion: SCs therapy represent a promising treatment for ED although only few patients have been treated to date. Likewise, the oral selective oxytocin receptor antagonists for treating PE showed excellent safety profile and deserve further investigations in phase III trials. Preliminary results of novel topical treatments for PD with fibrinolytic and antiinflammatory drugs are encouraging, but urgently need to be confirmed in large placebo-controlled trials.

Background: Although erectile dysfunction (ED) has been associated with low circulating total testosterone (TT) levels, the utility of free testosterone (FT) over TT is debatable., Aim: To assess the relative impact of low TT and low calculated FT (cFT) on androgen-related sexual symptoms in men with ED., Methods: Data from 485 men were analyzed. Comorbidities were scored with the Charlson Comorbidity Index (CCI). Patients completed the International Index of Erectile Function (IIEF) and the Beck Inventory for Depression (BDI). Descriptive statistics tested differences between patients with normal TT levels (>3 ng/mL) and normal cFT levels (>65 pg/mL; group 1) and men with normal TT and low cFT (group 2), low TT and normal cFT (group 3), and low TT and low cFT (group 4). Linear regression models tested the association between clinical predictors and sexual function impairment., Outcomes: We assessed the impact of different hormonal categories on androgen-related symptoms and the clinical utility of measuring cFT in men with ED., Results: Groups 1, 2, 3, and 4 were composed of 338 (69.6%), 44 (9.1%), 34 (7.0%), and 69 (14.3%) patients, respectively. Compared with group 1, patients in group 2 were older (P < .001), had a higher body mass index (P < .01), and had a larger proportion with CCI scores of at least 1 (P = .006). Likewise, group 2 presented lower scores for the IIEF erectile function (P = .07), sexual desire (P = .04), and orgasmic function (P = .007) domains and lower BDI scores (P = .02) than group 1. Similar findings were found for group 4 vs 1. Conversely, patients in group 3 had similar scores on the questionnaires to those in group 1. Low cFT and normal or low TT achieved independent predictor status for pathologic IIEF domains and BDI scores after accounting for age, CCI, and body mass index. Conversely, low TT and normal cFT status was not associated with pathologic scores on the questionnaires., Clinical Implications: The inclusion of cFT in the first-line assessment of hypogonadal symptoms in men with ED has major clinical utility., Strengths and Limitations: This is the first study evaluating the concomitant impact of TT and cFT on men with ED using well-validated instruments to assess patients' sexuality and depressive symptoms. Limitations are the retrospective nature of the study and lack of physical function data and bone ultrasound measurements., Conclusions: Although normal cFT was not associated with signs and symptoms suggestive of testosterone deficiency, even when concomitant with low TT or low cFT irrespective of TT values, it was indicative of poorer clinical profiles and impaired sexual and depressive parameters compared with normal TT and normal cFT in a cohort of patients with ED. Boeri L, Capogrosso P, Ventimiglia E, et al. Does Calculated Free Testosterone Overcome Total Testosterone in Protecting From Sexual Symptom Impairment? Findings of a Cross-Sectional Study. J Sex Med 2017;14:1549-1557., (Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Erectile dysfunction (ED) is a worldwide commonly reported condition; epidemiological data showed a prevalence ranging from 2.3 to 53.4% within different population subsets. In this context, the advent of phosphodiesterase type 5 inhibitors (PDE5is) in the second mid of 1990s has deeply changed the treatment scenario of this bothersome condition. Being user-friendly compounds with an excellent overall safety profile, PDE5is emerged as the first-line treatment for ED, thus overcoming topical alprostadil and intracavernous injections (ICIs). However, available data on treatment-utilization patterns and medical prescriptions of PDE5is showed a range of as wide as 22-78% of patients reporting to purchase PDE5is even without a proper medical prescription. Moreover, an increase in the recreational use of PDE5is among young men has been observed in the last decades, with a worrisome diffusion of potential health-risky behaviours associated with this habit. Indeed, treatment of ED should carefully follow internationally based clinical guidelines to avoid inappropriate drug prescriptions, which may eventually expose treated patients to drug-related side effects. Thereof, a careful assessment of the so-called modifiable and reversible ED risk factors along with a patient-tailored screening for potential contraindications to the treatment itself should be performed in every case. Lastly, although conclusive data still lack, the potential association between life-risky PDE5is side effects (i.e. cardiovascular adverse events, melanoma skin cancer and worsening of prostate cancer outcomes) should be carefully taken into account when counselling patients for ED treatment.

Background: The surgical treatment of urinary incontinence and erectile dysfunction by prosthetic devices has become part of urologic practice, although sparse data exist at a national level on readmissions and hospital costs., Aim: To assess causes and costs of early (≤30 days) and late (31-90 days) readmissions after implantation of penile prostheses (PPs), artificial urinary sphincters (AUSs), or PP + AUS., Methods: Using the 2013 and 2014 US Nationwide Readmission Databases, sociodemographic characteristics, hospital costs, and causes of readmission were compared among PP, AUS and AUS + PP surgeries. Multivariable logistic regression models tested possible predictors of hospital readmission (early, late, and 90 days), increased hospital costs, and prolonged length of stay at initial hospitalization and readmission., Outcome: Outcomes were rates, causes, hospital costs, and predictive factors of early, late, and any 90-day readmissions., Results: Of 3,620 patients, 2,626 (73%) had PP implantation, 920 (25%) had AUS implantation, and 74 (2%) underwent PP + AUS placement. In patients undergoing PP, AUS, or PP + AUS placement, 30-day (6.3% vs 7.9% vs <15.0%, P = .5) and 90-day (11.6% vs 12.8% vs <15.0%, P = .8) readmission rates were comparable. Early readmissions were more frequently caused by wound complications compared with late readmissions (10.9% vs <4%, P = .03). Multivariable models identified longer length of stay, Charlson Comorbidity Index score higher than 0, complicated diabetes, and discharge not to home as predictors of 90-day readmissions. Notably, hospital volume was not a predictor of early, late, or any 90-day readmissions. However, within the subset of high-volume hospitals, each additional procedure was associated with increased risk of late (odds ratio = 1.06, 95% CI = 1.03-1.09, P < .001) and 90-day (odds ratio = 1.03 95% CI = 1.02-1.05, P < .001) readmissions. AUS and PP + AUS surgeries had higher initial hospitalization costs (P < .001). A high hospital prosthetic volume decreased costs at initial hospitalization. Mechanical complications led to readmission of all patients receiving PP + AUS., Clinical Implications: High-volume hospitals showed a weaker association with increased initial hospitalization costs. Charlson Comorbidity Index, diabetes, and length of stay were predictors of 90-day readmission, showing that comorbidity status is important for surgical candidacy., Strengths and Limitations: This is the first study focusing on readmissions and costs after PP, AUS, and PP + AUS surgeries using a national database, which allows ascertainment of readmissions to hospitals that did not perform the initial surgery. Limitations are related to the limited geographic coverage of the database and lack of surgery- and surgeon-specific variables., Conclusions: Analysis of readmissions can provide better care for urologic prosthetic surgeries through better preoperative optimization, counseling, and resource allocation. Pederzoli F, Chappidi MR, Collica S, et al. Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors. J Sex Med 2017;14:1059-1065., (Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Sexual dysfunction is common in patients after radical prostatectomy (RP) for prostate cancer., Aim: To provide the International Consultation for Sexual Medicine (ICSM) 2015 recommendations concerning management strategies for post-RP erectile function impairment and to analyze post-RP sexual dysfunction other than erectile dysfunction., Methods: A literature search was performed using Google and PubMed database for English-language original and review articles published up to August 2016., Main Outcome Measures: Levels of evidence (LEs) and grades of recommendations (GRs) are provided based on a thorough analysis of the literature and committee consensus., Results: Nine recommendations are provided by the ICSM 2015 committee on sexual rehabilitation after RP. Recommendation 6 states that the recovery of postoperative erectile function can take several years (LE = 2, GR = C). Recommendation 7 states there are conflicting data as to whether penile rehabilitation with phosphodiesterase type 5 inhibitors improves recovery of spontaneous erections (LE = 1, GR = A). Recommendation 8 states that the data are inadequate to support any specific regimen as optimal for penile rehabilitation (LE = 3, GR = C). Recommendation 9 states that men undergoing RP (any technique) are at risk of sexual changes other than erectile dysfunction, including decreased libido, changes in orgasm, anejaculation, Peyronie-like disease, and changes in penile size (LE = 2, GR = B)., Conclusion: This article discusses Recommendations 6 to 9 of the ICSM 2015 committee on sexual rehabilitation after RP. Salonia A, Adaikan G, Buvat J, et al. Sexual Rehabilitation After Treatment For Prostate Cancer-Part 2: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017;14:297-315., (Copyright © 2017. Published by Elsevier Inc.)

Introduction: Sexual dysfunction is common in patients after radical prostatectomy (RP) for prostate cancer., Aim: To provide the International Consultation for Sexual Medicine (ICSM) 2015 recommendations concerning prevention and management strategies for post-RP erectile function impairment in terms of preoperative patient characteristics and intraoperative factors that could influence erectile function recovery., Methods: A literature search was performed using Google and PubMed databases for English-language original and review articles published up to August 2016., Main Outcome Measures: Levels of evidence (LEs) and grades of recommendations (GRs) based on a thorough analysis of the literature and committee consensus., Results: Nine recommendations are provided by the ICSM 2015 committee on sexual rehabilitation after RP. Recommendation 1 states that clinicians should discuss the occurrence of postsurgical erectile dysfunction (temporary or permanent) with every candidate for RP (expert opinion, clinical principle). Recommendation 2 states that validated instruments for assessing erectile function recovery such as the International Index of Erectile Function and Expanded Prostate Cancer Index Composite questionnaires are available to monitor EF recovery after RP (LE = 1, GR = A). Recommendation 3 states there is insufficient evidence that a specific surgical technique (open vs laparoscopic vs robot-assisted radical prostatectomy) promotes better results in postoperative EF recovery (LE = 2, GR = C). Recommendation 4 states that recognized predictors of EF recovery include but are not limited to younger age, preoperative EF, and bilateral nerve-sparing surgery (LE = 2, GR = B). Recommendation 5 states that patients should be informed about key elements of the pathophysiology of postoperative erectile dysfunction, such as nerve injury and cavernous venous leak (expert opinion, clinical principle)., Conclusions: This article discusses Recommendations 1 to 5 of the ICSM 2015 committee on sexual rehabilitation after RP. Salonia A, Adaikan G, Buvat J, et al. Sexual Rehabilitation After Treatment for Prostate Cancer-Part 1: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017;14:285-296., (Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Background: A rapid onset of action for phosphodiesterase type 5 inhibitors (PDE5is) emerged to be of clinical importance in men treated for erectile dysfunction (ED). Data from randomized clinical trials (RCTs) showed a rapid onset of action for vardenafil 10 mg orodispersible tablet (ODT). However, the effectiveness of vardenafil ODT has never been tested in a real-life setting. We assessed the efficacy and time to onset of action of vardenafil ODT in men seeking medical help for ED in the everyday real-life clinical practice., Research Design and Methods: Patients completed a baseline and follow-up International Index of Erectile Function (IIEF), along with a 8-item self-administered questionnaire about onset of action and overall treatment outcomes. Descriptive statistics tested efficacy rates, patient timing of drug intake and time to post-dosing onset of action., Results: Overall, 118(59.9%) patients used vardenafil ODT. Satisfactory erections for vaginal penetration were reported in 39(34.5%) and 26(21.8%), patients in =15 and =30, minutes post-dosing, respectively. Minimal Clinically Important Differences (MCIDs) criteria and Yang's criteria for responders were obtained in 80(67.8%) and 72(60.8%) patients., Conclusions: This study showed that one in three patients had satisfactory erection for vaginal penetration in less than 15 min post-dosing in the real-life setting.

Introduction: Phosphodiesterase type 5 inhibitors (PDE5Is) represent the first-line treatment for erectile dysfunction (ED). Almost one in two patients, however, show some level of treatment dissatisfaction and up to 30% fail to respond to any of the currently available PDE5Is. Recently, the second-generation PDE5I avanafil was launched for the treatment of ED., Areas Covered: Pivotal studies of clinical development along with placebo-controlled randomized clinical trials (RCTs) of avanafil in patients with ED were reviewed. Studies concerning the pharmacokinetics and pharmacodynamic of the drug were also analysed. A systematic literature search for English-language studies published up to May 2016 using the Medline database was performed. The search included the terms avanafil and ED. Expert commentary: Avanafil is a potent, highly selective PDE5I whose efficacy is comparable to that of currently available PDE5Is in both naïve and previous PDE5I users. Avanafil is effective within approximately 15 minutes of dosing, thus representing the only PDE5I approved for as-needed use, 15 to 30 minutes before sexual activity. Avanafil has high selectivity for the PDE5 isoenzyme, thus resulting in a lower incidence of drug-related side effects compared to other PDE5Is.