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Introduction: There is a rising concern about developing innovative, efficacious PDE5I molecules that provide better safety, efficacy, and tolerability with less adverse effects. Innovative PDE5I with dual targets have also been defined in the literature. Additionally, some of PDE5I are able to selectively inhibit other enzymes such as histone deacetylase, acetylcholine esterase, and cyclooxygenase or act as nitric oxide donors. This review presents knowledge concerning the advanced trends and perspectives in using PDE5I in treatment of ED and other conditions., Areas Covered: Pre-clinical and early clinical trials that investigated the safety, efficacy, and tolerability of novel PDE5I such as Udenafil, Mirodenafil, Lodenafil, Youkenafil, Celecoxib, and TPN729 in treatment of ED and other conditions., Expert Opinion: Preclinical and limited early clinical studies of the new molecules of PDE5I have demonstrated encouraging results; however, safety, efficacy, and tolerability are still issues that necessitate further long-term multicenter clinical studies to ensure justification of their uses in treatment of ED and other conditions. Progress in molecular delivery techniques and tailored patient-specific management and additional therapeutic technology will dramatically improve care for ED and other conditions. The dream of ED and many other conditions becoming more effectively managed may be feasible in the near future.

Background: Injection of adipose-derived stem cells (ADSCs) into the injured tunica albuginea (TA) may prevent fibrosis, restore the balance between pro- and antifibrotic pathways, and potentially mitigate erectile dysfunction caused by abnormal TA healing., Aim: To assess the potential role of ADSC injection on structural, ultrastructural, functional, and molecular changes in surgically induced trauma of the rat's TA., Methods: Forty adult male albino Wistar rats were divided into 5 groups of 8 rats each: group 1, sham; group 2, injury to TA without treatment; group 3, injury to TA and suture repair; group 4, injury to TA and injection of ADSCs without suture repair; group 5, injury to TA followed by injection of ADSCs and suture repair., Outcomes: After 6 weeks, all groups were subjected to functional, histologic, and ultrastructural examination and molecular expression of healing growth factors., Results: The intracavernous pressure (ICP; mean ± SD) was 114 ± 2, 32 ± 2, 65 ± 2, 68 ± 2, and 111 ± 2 mm Hg in groups 1 to 5, respectively. There were significant differences in ICP between each of groups 3 to 5 and group 2 ( P  < .05), and groups 3 and 4 each had significant differences with group 1 ( P  < .05). No significant difference in ICP occurred between groups 3 and 4 ( P  > .05). There were significant histologic and ultrastructural alterations in tunical tissues from group 2; however, these changes were markedly less in group 5 in terms of lower levels of fibrotic changes, elastosis, and superior overall neuroendothelial expression. Groups 3 and 4 showed improved structural and ultrastructural parameters when compared with group 2. Group 5 demonstrated lower levels of transforming growth factor β1 and basic fibroblast growth factor expression., Clinical Implications: This experimental model may encourage administration of ADSCs to prevent the deleterious effects of trauma to the TA., Strengths and Limitations: Injecting ADSCs can improve the healing process and erectile dysfunction in a rat model following TA injury, and combining ADSC injection with surgical suturing resulted in superior outcomes. The main limitation was the absence of long-term ICP measurements and a longer follow-up period that may provide further insight into the chronic phase of the healing process., Conclusion: ADSC injection may prevent structural, ultrastructural, functional, and molecular alterations in surgically induced trauma of the rat's TA and enhance the effect of tunical suturing after trauma., Competing Interests: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine.)

Objective: To study whether varicocele repair would improve sperm capacitation and probability of generating a pregnancy., Methods: Data were collected prospectively from 40 consecutive adult men who presented with infertility confirmed by semen analysis (SA) and found to have a varicocele on exam or ultrasound who underwent unilateral or bilateral subinguinal microscopic varicocelectomy. We recorded pre and postoperative SA, Cap-Score, and probability of generating a pregnancy (PGP) with a 3-month follow-up. Values were compared using paired t test and Wilcox rank-sum test., Results: Results showed a 17.4% relative increase in Cap-Score (23%-27% capacitation), 25% relative increase in PGP (24%-30%), as well as statistically significant improvements in sperm concentration, motility, and total sperm count postoperatively., Conclusion: This study confirms that microsurgical varicocelectomy significantly improves sperm capacitation ability and improves the expected probability of generating a pregnancy within 3 rounds of intrauterine insemination. The improvement in sperm capacitation ability may help explain how varicocele repair may improve the chance of pregnancy, regardless of standard semen parameter improvements., Competing Interests: Declaration of Competing Interest All authors have no conflict., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition., Materials and Methods: An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method., Results: A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4-6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated., Conclusions: This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians., Competing Interests: The authors have nothing to disclose., (Copyright © 2023 Korean Society for Sexual Medicine and Andrology.)

Purpose: Sperm DNA fragmentation (SDF) testing was recently added to the sixth edition of the World Health Organization laboratory manual for the examination and processing of human semen. Many conditions and risk factors have been associated with elevated SDF; therefore, it is important to identify the population of infertile men who might benefit from this test. The purpose of this study was to investigate global practices related to indications for SDF testing, compare the relevant professional society guideline recommendations, and provide expert recommendations., Materials and Methods: Clinicians managing male infertility were invited to take part in a global online survey on SDF clinical practices. This was conducted following the CHERRIES checklist criteria. The responses were compared to professional society guideline recommendations related to SDF and the appropriate available evidence. Expert recommendations on indications for SDF testing were then formulated, and the Delphi method was used to reach consensus., Results: The survey was completed by 436 experts from 55 countries. Almost 75% of respondents test for SDF in all or some men with unexplained or idiopathic infertility, 39% order it routinely in the work-up of recurrent pregnancy loss (RPL), and 62.2% investigate SDF in smokers. While 47% of reproductive urologists test SDF to support the decision for varicocele repair surgery when conventional semen parameters are normal, significantly fewer general urologists (23%; p=0.008) do the same. Nearly 70% would assess SDF before assisted reproductive technologies (ART), either always or for certain conditions. Recurrent ART failure is a common indication for SDF testing. Very few society recommendations were found regarding SDF testing., Conclusions: This article presents the largest global survey on the indications for SDF testing in infertile men, and demonstrates diverse practices. Furthermore, it highlights the paucity of professional society guideline recommendations. Expert recommendations are proposed to help guide clinicians., Competing Interests: The authors have nothing to disclose., (Copyright © 2023 Korean Society for Sexual Medicine and Andrology.)

Background: Bladder cancer (BC) has a particular importance in Egyptian patients due to aggressive behavior and absence of prognostic markers., Objective: To evaluate the expression of gene and protein expression of HER2 and epidermal growth factor (EGFR) in Egyptian patients with BC and ultimately to investigate their clinical implication and prognostic significance., Material and Methods: The study was carried out on 46 patients with urothelial bladder BC. Tissue were obtained from transurethral resection ( N  = 22) and radical cystectomy ( N  = 24) specimens. The original hematoxylin and eosin slides were re-evaluated and the formalin fixed, paraffin-embedded (FFPE) tissues which had sufficient tumor tissue (>75%) and minimal or absent tumor necrosis were selected for immunohistochemistry ( IHC) and RNA extraction. Furthermore, five control biopsies were obtained from patients with cystitis. Follow-up data were retrieved from the medical records which included the treatment regimen, disease recurrence and/or progression, and survival., Results: EGFR and HER2 protein were overexpressed in 35% and 46% of patients respectively. EGFR was correlated with the tumor size, grade and pathological stage, with a similar trend for HER2. The recurrence rate was higher in patients with expression of any of the markers. Gene expression was significantly higher (10.6-folds) for EGFR and (21-folds) for HER2 in patients with BC in comparison to control patients. Survival analysis showed lower median disease-free survival in association with HER2 protein overexpression., Conclusions: Our data highlighted the prognostic significance of EGFR and HER in BC and proposed their possible use as predictive markers and potential therapeutic targets.

Introduction: Multiparametric magnetic resonance imaging (mpMRI) of the prostate gland is now the recommended initial investigation of choice for the detection of Prostate cancer (PCa). It effectively identifies patients who require prostate biopsies due to the risk of clinically significant PCa. It helps patients with clinically insignificant PCa avoid the invasive biopsies and possible accompanying complications. Large clinical trials have investigated the accuracy of mpMRI in detecting PCa. We performed a local review to examine the reliability of omitting tissue sampling in men with a negative (PIRADS 2 (P2) or less) mpMRI in the primary diagnostic setting., Methods: This was a retrospective study of patients with clinical suspicion of PCa within a 2-year period. Patients had a mpMRI prior to having trans-perineal prostate gland biopsies. Clinically significant disease was defined as Gleason 7 and above. The descriptive data was analysed using contingency table methods. A p-value less than 0.05 was statistically significant., Results: Out of 700 patients 90 had an mpMRI score of PIRADS 2. Seventy-seven (85.5%) of these patients had a negative biopsy, 9(10%) showed Gleason 6, 4 patients showed Gleason 7 or above. 78 patients with PIRADS 2 had a PSA density of < 0.15, none of which had a clinically significant biopsy result. The negative predictive value of mpMRI from this study is 95%., Conclusion: Our results are in line with negative predictive values demonstrated in the current literature. This local study, likely applicable to other district general hospitals, shows that mpMRI is a safe and reliable initial investigation to aid decisions on which patients require biopsies., (© 2023. Crown.)

Purpose: Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility., Materials and Methods: Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field., Results: The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available., Conclusions: This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men., Competing Interests: The authors have nothing to disclose., (Copyright © 2023 Korean Society for Sexual Medicine and Andrology.)

Androgen deprivation therapy for prostate cancer can lead to osteoporosis and increased fracture risk. The Fracture Risk Assessment Tool (FRAX®) questionnaire can be used for risk stratification, and our study has demonstrated that the majority of men (91%) in our cohort commencing ADT for prostate cancer were considered low risk for future osteoporotic fracture., Purpose/introduction: Long-term use of androgen deprivation therapy (ADT) in prostate cancer patients results in increased bone turnover and decreased bone mineral density (BMD). Proper assessment of any existing osteoporotic fracture risk is crucial prior to starting treatment. However, this risk assessment is poorly performed in these patients in spite of available validated tools including the Fracture Risk Assessment Tool (FRAX®). The objective of this study was to assess the distribution of osteoporotic fracture risk in a cohort of men commencing ADT for prostate cancer using the FRAX® algorithm., Methods: Between July 2020 and May 2022, 200 men filled in the FRAX® questionnaire just before ADT. They were stratified into the high-risk (> 20% probability of a MOF over the next 10 years), intermediate-, and low-risk categories for fragility fractures. We also measured their serum vitamin D and calcium levels., Results: The average age was 73.5 years (54-89). It took less than 10 min to complete the assessment. Only six patients were at high-risk, were started on bisphosphonates immediately, and referred for a dual energy X-ray absorptiometry (DEXA) scan. Twelve patients in the intermediate-risk category were referred for DEXA scans for bone mineral density measurements. A total of 182 patients (91%), were in the low-risk category and given lifestyle advice only. All had normal calcium levels but 134 (67%) patients, mostly in the low-risk category, had reduced vitamin D levels (< 50 nmol/L)., Conclusion: The FRAX® questionnaire is simple and immediately identifies patients who are at risk of fragility fractures. Our study has demonstrated that the majority of men (91%) in our cohort commencing ADT for prostate cancer were considered low risk for future osteoporotic fracture. We were surprised that more than half of our patients had low vitamin D levels., (© 2022. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Objective: To assess safety and efficacy of hyaluronic acid (HA) gel injection in glans penis for treatment of premature ejaculation (PE) using our new five puncture technique., Patients and Methods: This is a prospective, non-randomized clinical trial on HA gel injection in glans penis for all patients with lifelong PE; all patients were circumcised having heterosexual normal marital life and sexually active. Patients with history of ejaculatory medication use within the previous 3 months, psychiatric disorders, erectile dysfunction, lower urinary tract symptoms (LUTS) due to prostatitis and acquired PE were excluded from the study. A local anesthetic was applied to the skin of glans penis for 30 minutes before the injection of 2 ml HA in glans penis via 30-gauge needle using our new Five-puncture technique. Intra-vaginal ejaculatory latency time (IELT) was measured at 1, 3, 6 and 12 months after injection., Results: Thirty patients completed our study follow up schedule. Mean age of the patients was 41.72 ± 8.50, while mean age of female partner was 37.23 ± 8.54 years. IELT was highly significantly increased ( P -value < 0.001) after HA gel injection from baseline, which was in maximum 37.83 ± 11.01 sec at baseline to 323.03 ± 42.06, 281.07 ± 41.05, 241.03 ± 43.09 and 235.6 ± 41.87 sec after 1, 3, 6 and 12 months, respectively, after injection. Three patients complained from discomfort at the site of injection, two from bullae formation at the site of injection and one from ecchymosis, and all resolved spontaneously after 1 week to 10 days after injection., Conclusion: HA gel injection in glans penis using our new five-puncture technique is a safe and effective method that ensures a modest long-term significant increase in IELT and improves ejaculatory control., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Introduction: Sexual dysfunction (SD) and depression have a bidirectional relationship. The rising prescription of antidepressants, especially those with a serotonergic effect, is associated with increased SD. Sexual dysfunction reduces compliance and increases risk of recurrence of depressive episodes. Various strategies have been studied to manage antidepressant-induced SD., Areas Covered: This review covers the identification of symptoms of antidepressant-induced SD, prevalence of symptoms in association with commonly used antidepressants, and the main lines of management, with a focus on pharmacological strategies., Expert Opinion: The management of antidepressant-induced SD aims to reduce the unwanted sexual adverse effects while maintaining an acceptable control of depressive symptoms. It should implicate a multidisciplinary approach and determination of baseline sexual function and SD risk factors. In spite of several methodological issues, antidepressants can be divided into low- and high-risk categories with regard to the possibility of developing SD. In patients interested in sexual activity, it is recommended to start with low-risk antidepressants. Otherwise, encourage the patient to wait for tolerance and then switch to low-risk. In selected cases, dose reduction or a drug holiday may be applied. The adjunctive use of a PDE5i can help in a significant number of patients. Randomized controlled trials are needed to set high-level evidence-based recommendations.

COVID-19 pandemic is associated with devastating effects on social, psychological, and economical aspects of survivors. We assume that erectile function (EF) is affected as well. We performed a systematic review of the published articles about the change in EF among patients and health care providers during the COVID-19 pandemic. We searched PubMed and Cochrane databases for English literature using a combination of medical subject headings (MeSH) terms and keywords. We extracted data of erectile dysfunction (ED) rate, international index of erectile function (IIEF), changes related to exposure to the pandemic (Primary objectives), and factors affecting these differences (Secondary objectives). Twenty articles were included in the screening phase. Only 3 articles were eligible for primary objectives, and 2 articles were included for the secondary objective. Three articles revealed an increase in ED cases and a reduction in IIEF-5 scores during the pandemic. Rates of ED have ranged from 32% to 87% of the study populations. Anxiety, depression, and post-traumatic stress disorder (PTSD) were associated with increased ED rates. We conclude that the COVID-19 pandemic is associated with increased rates of ED. Anxiety and depression augment this increase. Health care providers are at higher risk for PTSD, which increases the risk of ED., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Peyronie's disease (PD) is associated with penile pain, deviation, and sexual dysfunction. Up till now, there is no conservative standard treatment for PD. However, the role of Extracorporeal Shock Wave Therapy (ESWT) is gaining increasing interest., Aim: To evaluate the effect of ESWT on penile deviation, plaque size, erectile function, pain scale, and the rate of complications in PD patients., Methods: PubMed database was searched for articles published from January 2000 to November 2020, using related keywords and including randomized controlled trials (RCTs) only. Meta-analysis and forest plots were carried out using RevMan, and outcomes were reviewed by 2 authors independently. PRISMA guidelines were used in this article to achieve the quantitative and qualitative synthesis of data., Outcomes: Changes in penile deviation, plaque size, erectile function, pain scale, and the rate of ESWT related complications., Results: The search yielded 73 articles. Three RCTs, including 117 patients in the ESWT group and 121 patients in the placebo group, were reviewed. ESWT is associated with reduction in plaque size (OR = 2.59, 95% CI (1.15-5.85), P= .02). No significant difference in reduction of penile deviation angle or rate of bruises were detected in post ESWT group when compared to placebo. No evidence was found to show an effect of ESWT on erectile function or pain scale., Clinical Implications: Based on the available RCTs, ESWT fails to improve penile curvature or pain in men with PD.  Although ESWT may reduce plaque size, this remains of questionable clinical significance., Strengths & Limitations: RCTs used different metrics to report the same outcome. Missed data were imputed to match the requirements of meta-analysis. However, there is still much data that cannot be estimated., Conclusion: The current data suggest that ESWT fails to improve penile curvature or pain in men with PD.  Although ESWT may reduce plaque size, this remains of questionable clinical significance, and further studies are required to confirm findings. Bakr AM, El-Sakka A. Extracorporeal Shockwave Therapy in Peyronie's Disease: Systematic Review and Meta-Analysis. J Sex Med 2021;18:1705-1714., (Copyright © 2021 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

We assessed the effect of smoking and/or obesity on semen parameters and testosterone/oestradiol (T/E) ratio among sub-fertile men treated with sub-inguinal varicocelectomy. In this prospective, controlled, clinical study, 80 sub-fertile men with clinical varicocele who were subjected to sub-inguinal varicocelectomy were assigned into four equal groups (n = 20/each), group A: obese and smokers, group B: obese and nonsmokers, group C: smokers and nonobese and group D: nonsmokers and nonobese. Semen parameters, serum testosterone, oestradiol, follicle-stimulating hormone, luteinising hormone, prolactin and calculation of T/E ratio were assessed at baseline and 6 months post-varicocelectomy. The mean age ± SD of the study population was 26.1 ± 4.55. No statistical difference was detected among the study groups regarding age, residence, education, marital status and occupation (p > 0.05 for each). Post-operatively, significant improvements in semen parameters were detected in all groups. There was a significant difference between groups A and B versus C and D (obese versus nonobese groups) and between groups A and C versus B and D (smokers versus nonsmokers; p < 0.05 for each) regarding semen parameters, testosterone level and T/E ratio. Smoking and/or obesity negatively affect(s) the favourable outcome of varicocelectomy, specifically improvement of semen parameters and hormonal pattern in sub-fertile men with varicocele., (© 2021 Wiley-VCH GmbH.)

Introduction : The effectiveness of phosphodiesterase type 5 inhibitors (PDE5i) in treating erectile dysfunction (ED) creates a new field of both medical practice and pharmaceutical manufacturing. Both paved the way for emerging minimally invasive therapies to restore male sexual function. However, what is the best drug to achieve the optimum outcome is still a challenging question to be answered. Areas covered : The general viewpoint of matching the pharmacotherapeutic characteristics with the patient's medical, social, and psychological variables, in order to balance between efficacy and safety. Several studies had investigated considerations for preference and long-term adherence for PDE5i. However, a thorough investigation of considerations for prescribing ED pharmacotherapy is still lacking in the literature. This is the aim of this manuscript. Expert opinion : Several issues should be considered in the planning of ED management such as the patient's and partner's expectations, etiologic considerations, performance status, safety, adverse effects, ease of administration, compliance, bad experiences with previous treatment, availability, cost, social factors, satisfaction, and finally, regimen considerations. Addressing the patient's and partner's individual needs help to tailoring treatment in order to minimize compromises and optimize gains.

Background: The treatment of Peyronie's disease (PD) remains a dilemma as the true pathogenesis of PD remains an enigma. Consequently, new molecules and therapies continue to evolve. The safety and efficacy of conservative treatment for PD have not yet established., Objectives: To provide the available information of the status of conservative therapy for PD., Methods: A systematic literature search was conducted using PubMed, EMBASE, and the Cochrane Library for English-language journal articles between January 2000 and July 2019, using the terms "Conservative treatment for PD", "medical treatment for PD", "non-invasive therapies for PD" and "minimally invasive therapies for PD". This systematic review was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) system. We also manually reviewed references from selected articles. The risk of bias in the included RCTs was assessed using the Cochrane Risk of Bias Assessment tool (RoB 2)., Results: Conservative treatment is accepted as the initial treatment step in most of the cases. This kind of therapy includes various methods of treatment such as medical, non-invasive, and minimally invasive therapies. Ideal management of PD is not yet available. It is not possible to assess the value of treatment without well-designed, randomized, placebo-controlled, large-scale clinical studies., Conclusion: Optimistically, in the near future, we may witness emergence of efficacious new agents and modalities to revolutionize medical, non-invasive, and minimally invasive treatment of this devastating condition., (© 2020 American Society of Andrology and European Academy of Andrology.)

Objective: To assess if the effect of intracavernosal injection of prostaglandin E1 (PGE1) on duration and rigidity of erection is dose dependent in patients with different types of vasculogenic erectile dysfunction (ED)?, Methods: A hundred patients with ED were assigned into 4 groups (n = 25/each); group (A) patients with arteriogenic ED, group (B) patients with veno-occlusive ED, group (C) patients with mixed (arteriogenic and veno-occlusive) ED, and group (D) patients who have only psychogenic ED (control). After intracavernosal injection of PGE1, patients were assessed using penile Doppler ultrasonography and erection hardness score together with calculation of erection duration. The starting dose of PGE1 was 5 μg which was increased to 10 µg and 20 µg as a maximal dose when needed., Results: The mean PSV of patients in groups A, B, C, and D were 24.38 ± 3.3, 37.74 ± 8.28, 22.24 ± 3.85, and 47.76 ± 6.27, respectively. In group D, 88% have achieved the best response at dose of 5 µg while 5.3%, 21.7%, and 0% have achieved the best response at dose of 5 µg in groups A, B, and C, respectively (P < .05 for each). The rest of patients have required either 10 or 20µg to achieve the best response. Patients in group C have required the highest dose of PGE1 to achieve the best response (P < .05)., Conclusion: Intracavernosal injection of PGE1 in escalating doses have improved the rigidity and duration of erection in patients with different types of vasculogenic ED. Patients with mixed arteriogenic and veno-occlusive ED have required the highest dose of PGE1 to achieve the best response., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate the correlation between maternal age and anogenital distance (AGD) in patients with hypospadias., Patients Subjects and Methods: A total of 82 participants were divided into two groups, Group 1 included 52 male children with different types of primary hypospadias and Group 2 included 30 normal controls. In both groups, child age and weight, maternal age, and AGD were recorded. In Group 1, the Glans-Urethral Meatus-Shaft score was used to categorise the patients into mild (score 3-6), moderate (score 7-9) and severe (score 10-12) hypospadias., Results: Both groups were similar for maternal age, child age and child weight ( P = 0.308, P = 0.283 and P = 0.664, respectively). The mean (SD) AGD was 4.64 (1.23) and 5.33 (1.01) cm for groups 1 and 2, respectively ( P = 0.011). Patients in Group 1 were subdivided regarding severity of hypospadias into mild (40.4%), moderate (38.5%) and severe (21.1%). There was a significant relationship between older maternal age and short AGD in both groups ( P < 0.001 for Group 1 and P = 0.001 for Group 2). In Group 1, there was a significant correlation between both short AGD and older maternal age, and severe hypospadias (both P < 0.001). Maternal age of ≥34 years significantly predicted a severe hypospadias score (10-12) (sensitivity 100% and specificity 68.3%)., Conclusion: Older maternal age is associated with a shorter AGD in patients with hypospadias and controls. Maternal age of ≥34 years is significantly correlated with patients with severe hypospadias., Competing Interests: The authors declare no conflict of interest, including specific financial interests, relations and affiliations relevant to the subject matter or materials discussed in the manuscript., (© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: The angiographically documented association between severity of coronary artery disease (CAD) and aorto-ilio-pudendal (A-I-P) artery disease and vascular erectile dysfunction (ED) was not yet settled., Aim: To assess the relation between angiographically proved CAD and A-I-P artery disease in patients with ischemic heart disease (IHD)-associated vascular ED., Methods: 60 men were assigned to 3 study groups: Group 1 (n = 25), patients who had IHD and ED; group 2 (n = 25), patients who had IHD and had no ED; group 3 (n = 10), patients who had ED and had no suspected IHD. All patients were subjected to detailed medical, cardiac, and sexual history. International Index of Erectile Function and penile color Doppler ultrasound were used to assess ED. Quantitative coronary angiography and invasive angiography were used to assess the vascular tree for the right and left (A-I-P) arteries. Endothelial markers, that is, endothelial microparticles and endothelial progenitor cells were also assessed., Outcomes: The main outcome measures are assessment of ED and angiographically proved CAD and A-I-P artery disease., Results: The mean age ± SD of the 3 study groups were 50.4 ± 6.6, 51.4 ± 3.9, and 49.9 ± 6.1 years, respectively, with no statistically significant difference among groups (P = .380). There were significant higher rates of left main (LM) lesions (≥50%), CAD (≥70%), right and left internal pudendal artery lesions, and right and left internal iliac artery lesions in G1 in comparison with G2 and G3. Patients with ED alone had a higher rate of peripheral lesions compared with patients with CAD alone. 10 percent of patients with ED alone had CAD. Patients in G1 had notably higher rates of peripheral lesions than the other groups combined Patients with left internal pudendal artery lesions had a chance by 1.25 and 2.11 times to have LM lesions and significant CAD, respectively. There was a significant increase of endothelial microparticles in G1 in comparison with other groups (P < .05)., Clinical Implications: The clinical implications are uses of peripheral angiograghy as a diagnostic tool in patients with CAD-associated vascular ED may have a clinical merit., Strengths & Limitations: The strengths in the present study are the use of angiography, color Doppler ultrasound, and standardized instruments. The main limitations are the small sample size and lack of intervention and longitudinal data., Conclusion: ED correlates more with A-I-P vascular lesions compared with CAD alone. There was a statistically significant association between severity of CAD including LM significant lesions and A-I-P arteries disease in patients with CAD-associated vascular ED. Sanad AM, Younis SE, Oraby, MA, et al. Relation Between Severity of Coronary Artery Disease and Aorto-Ilio-Pudendal Artery Disease in Patients With Ischemic Heart Disease-Associated Vascular Erectile Dysfunction. J Sex Med 2020;17:1086-1093., (Copyright © 2020 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: The impact of prostate zonal volume on erectile function and penile Doppler parameters is not yet settled., Aim: To assess the association between prostate zonal volume and erectile dysfunction in patients with benign prostatic hyperplasia., Methods: This cross-sectional analytical study included 70 men (aged ≥ 40 years). Of them, 60 patients were assigned to 3 study groups (n = 20/each): group (A) patients who had lower urinary tract symptoms (LUTSs) and erectile dysfunction (ED), group (B) patients who had LUTSs with no ED, group (C) patients who had ED with no LUTS, and other 10 age-matched patients who had no LUTS or ED acted as a control group (D). All patients were subjected to detailed medical and sexual history. International prostate symptom score (IPSS) was used to assess LUTSs, and international index of erectile function (IIEF) was used to assess ED., Main Outcome Measure: Transrectal ultrasound and penile Doppler ultrasound were used to assess zonal anatomy of the prostate and the vascular pattern of erection., Results: There was a significant difference in IPSS between group A (26) and B (19) (P < .05). Each of groups A and C had significant lower peak systolic velocity (PSV) than each of groups B and D (P < .001/each). There was a significant positive correlation between transitional zone index (TZI) and IPSS (r = 0.71, P < .01), and significant negative correlation between TZI and both of IIEF (r = -0.48, P < .05) and PSV (r = -0.606, P < .05)., Conclusion: This study clearly demonstrated that there were significant correlations between increased transitional zone volume, TZI, and decreased both of IIEF score and PSV. Qalawena MM, Al-Shatouri MA, Motawaa MA, et al. Association Between Prostate Zonal Volume and Erectile Dysfunction in Patients With Benign Prostatic Hyperplasia. Sex Med 2020;8:205-213., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The possible role of phosphodiesterase 5 inhibitors (PDE5Is) in prevention of negative effect of diabetes mellitus (DM) on erectile function is not well settled., Objectives: To investigate the effect of early administration of vardenafil on erectile function, cavernosal structure, and genes expression in a rat model of DM., Materials and Methods: This experimental study was carried out at Suez Canal University's research laboratory. This study was conducted on a total of 60 adult male Albino Wistar rats, aged 60-80 days and weighing an average of 200 g. Rats were equally divided into six groups of 10 rats each: Group I (sham); Group II (DM with no treatment); Groups III, IV, V, and VI received vardenafil started at day 1, week 4, week 8, and week 12 after induction of DM, respectively. Functional study assessment of all groups was performed before euthanization, and then tissues were harvested for histopathological, ultrastructural, and molecular examinations., Results: There was a significant difference of intracavernosal pressure between early (94 ± 2.18) and late (40.5 ± 1.94) treatment groups (p = 0.011). Histopathological and ultrastructural changes of DM with no treatment and late treatment groups showed distorted cavernous architecture and extensive fibrosis. There was significant difference of smooth muscle to collagen ratio between early and late treatment groups (p = 0.035). There was significant upregulation of nNOS(p = 0.021) and iNOS (p = 0.047) in early vs. late treatment group. The difference was insignificant in eNOS (p = 0.386) or TGF-β1(p = 0.149)., Discussion and Conclusion: Early treated rats with vardenafil had preserved erection and normal cavernosal structure, ultrastructure and gene expression of iNOS, nNOS, eNOS, and TGF-β1. Quantification of gene expression would improve our knowledge regarding cytokines expression and molecular background of DM-associated ED. Clinical application of this result may encourage early administration of PDE5I to prevent deleterious effects of DM on erectile function in newly diagnosed DM patients with probable uncontrolled blood glucose., (© 2019 American Society of Andrology and European Academy of Andrology.)

Aim: In this study we aimed to find out the heart rate variability measuring using electrical cardiometry is not reliable as a predictor for hypotension following spinal anesthesia in preeclamptic parturients undergoing elective cesarean section., Methods: Electrical Cardiometry system was used to measure Heart rate variability (HRV) at five different time points before fluid loading (T0, baseline), after fluid loading (T1), 5 min after spinal anaesthesia (T2), 15 min after spinal anaesthesia (T3) and 30 min after spinal anaesthesia (T4). Traditional HRV measurement was determined using time-domain analysis. This Observational descriptive cohort study was conducted in Kasr Al-Ainy Hospital, Faculty of Medicine, Cairo University from February 2018 till June 2019, after approval of the Ethical Committee and written patients consent., Results: The main finding of the current study is that heart rate variability measuring using electrical cardiometry is not reliable as a predictor for hypotension following spinal anaesthesia in preeclamptic parturients undergoing elective cesarean section., Conclusion: Heart rate variability cannot be used as a predictor for hypotension following spinal anaesthesia in preeclamptic patients undergoing elective caesarean section using electrical cardiometry., (Copyright: © 2019 Jehan Helmy Shehata, Ahmed Ibrahim El Sakka, Amina Omran, Mahmoud Abdeltawab Mahmoud Atia Gbre, Ahmed Abdalla Mohamed, Ahmed Mohamed Fetouh, Abdelrahman Ahmed Aly Hassan Abourhama, Mohamed Ibrahim Belita.)

Background and Aims: The use of dexamethasone as an adjuvant to local anesthetic rarely has been described. Some studies have demonstrated the analgesic effect of local spinal and systemic corticosteroids in combination with bupivacaine. It works by decreasing inflammation and blocking transmission of nociceptive C-fibers and by stopping the ectopic discharge of the nerve. The aim of this randomized controlled trial was to compare the efficacy of epidural levobupivacaine alone versus a combination of levobupivacaine with dexamethasone for labor analgesia., Material and Methods: This prospective double-blind trial included the 60 primigravidas during vaginal delivery with a cervical dilatation ≥4 cm and 50% effacement randomly assigned to one of two groups - Group A ( n =30): epidural levobupivacaine 0.125% in normal saline in a total volume of 15 mL and Group B ( n =30): epidural levobupivacaine 0.125% in normal saline combined with dexamethasone 4 mg in a total volume of 15 mL. At first request of analgesia, 10 mL of 0.125% levobupivacaine was administrated through epidural catheter. Further analgesia was provided with 8 mL of 0.125% levobupivacaine hourly. Primary outcome measure was the duration of epidural analgesia. Secondary outcome measures include pain score by Visual Analog Scale score before the block and 15 min following it, the total amount of levobupivacaine used, Apgar score and umbilical vein blood gas analysis, maternal satisfaction, and side effects recorded., Results and Conclusion: The duration of epidural analgesia was significantly longer ( P < 0.05) upon adding dexamethasone to levobupivacaine. Total epidural levobupivacaine consumption was significantly lower ( P = 0.05) in Group B. There were no statistical differences between the two groups regarding hemodynamics, pain score, neonatal outcome, and complications. Epidural dexamethasone plus levobupivacaine prolongs the duration of epidural analgesia during management of labor pain with hemodynamic stability and limited maternal and neonatal adverse effects., Competing Interests: There are no conflicts of interest.

We assessed the change of homocysteine (Hcy), insulin-like growth factor one (IGF-Ι) and oestrogen (E2) levels in patients with erectile dysfunction (ED) associated with chronic hepatitis C virus (HCV) infection. Eighty-five male patients with chronic HCV and/or ED were enrolled in this study. Seventy-five men were assigned to three equal groups (n = 25/each); Group A: patients who had chronic HCV and ED. Group B: patients who had chronic HCV and had no ED complaint. Group C: patients who had ED with no chronic HCV. In addition to 10 control patients with no ED or chronic HCV (Group D). All patients were subjected to: detailed medical and sexual history, complete physical examination, laboratory assessment including measurement of serum Hcy, IGF-1 and E2. The means of international index of erectile function scores were 8 and 16 in groups A and C respectively. There were significant differences in Hcy, IGF-I and E2 among study groups (p < 0.05 for each). There were significant differences in Hcy between patients with Child B and Child C. A strong association between severity of ED and chronic HCV was demonstrated. There was statistically significant increase of Hcy and E2 levels and reduction in IGF-I level in patients with ED associated with chronic HCV infection., (© 2018 Blackwell Verlag GmbH.)

To review the contemporary knowledge regarding the dehydroepiandrosterone and erectile function. Medline was reviewed for English-language journal articles spanning the time between January 1990 and December 2017, using the terms 'erectile function', 'dehydroepiandrosterone'. We used Journal Articles and review articles that found to be relevant to the purpose of this review. Criteria included all pertinent review articles, randomized controlled trials with tight methodological design, cohort studies and retrospective analyses. We also manually revised references from selected articles. Several interesting studies have addressed the age-related decline in dehydroepiandrosterone levels with many age-related phenomena or deterioration in various physiological functions. Particularly, aging; neurological functions including decreased well-being, cognition, and memory; increased depression, decreased bone mineral density, obesity, diabetes, increased cardiovascular morbidity, erectile dysfunction (ED), and decreased libido. Supporting this result, some trials of dehydroepiandrosterone supplementation in healthy, middle-aged, and elderly subjects have reported improvements in different aspects of well-being. Several studies had demonstrated that dehydroepiandrosterone level is declined as a part of aging. Large-scale well-designed prospective studies are warranted to better define indications and therapeutic implications of dehydroepiandrosterone in men with ED., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2018 Korean Society for Sexual Medicine and Andrology.)

Seminal cytokines were previously reported to adversely affect process of spermatogenesis and ultimately induce poor semen quality. However, association between both IL-6 and TNF-α and leukocytospermia was not yet settled. The aim of this study was to evaluate the association between leukocytospermia and levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) in semen of infertile men. This cross-sectional study included 100 age-matched (≥18-45 years.) men. Participants were divided into four groups with 25 patients in each group: Group (A) - infertile patients with leukocytospermia and normal other semen parameters; Group (B) - infertile patients with leukocytospermia and abnormal semen parameters; Group (C) - infertile patients with oligospermia and/or asthenospermia and/or teratospermia but with no leukocytospermia; Group (D) - fertile patients with normal semen parameters and without leukocytospermia. All patients were assessed by detailed medical, sexual, fertility history, and complete physical examination. Laboratory assessment included hormonal and semen analysis and assessment of IL-6 and TNF-α in semen plasma. There were significant differences among the study groups regarding total sperm count, sperm concentration, and progressive motility (p < 0.05 for each). There was significant increase in semen WBC counts in groups A and B vs. groups C and D (p = 0.003). There were significant associations between increase levels of WBCs ≥ 5/HPF and decrease levels of total sperm count (p = 0.023), sperm concentration (p = 0.001), and sperm progressive motility (p = 0.02). There were significant upregulations in mean level of IL-6 (p = 0.001) and mean level of TNF-α (p = 0.003) in groups A and B vs. groups C and D. Overall, leukocytospermia is associated with reduction in sperm count, progressive motility and further upregulation of seminal IL-6 and TNF-α. The effect of treatment of leukocytospermia on the level of seminal cytokines is important point of future research., (© 2018 American Society of Andrology and European Academy of Andrology.)

Introduction: Numerous studies have highlighted the intimate association between erectile dysfunction (ED) and diabetes mellitus (DM). However, the true pathogenesis of ED among diabetic men has not yet been fully discovered. The treatment of ED in diabetic patients remains an interesting area of research. The last two decades have witnessed phenomenal advances in the management of ED with the efficacy of pharmacotherapy for ED in diabetic patients encouraging, especially with introduction of innovative conservative tools for treatment., Areas Covered: The aim of this review is to discuss the currently available information on ED pharmacotherapy in diabetic males and provide an expert perspective on the current treatment strategies., Expert Opinion: Conservative treatment remains the initial step for the treatment of ED in diabetic patients. This kind of therapy consists of different modalities including: oral treatments, intracavernosal pharmacotherapy, and evolving modalities such as soluble guanylate cyclase activators, stem cells (SCs), and alternative treatments such as herbal treatment and transdermal/topical pharmacotherapy. However, it should be noted that the currently available pharmacotherapy is still far from ideal. One hopes to witness new drugs and technologies that may revolutionize ED treatment in the future, especially in such complex cases as DM.

Objective: To assess the effect of varicocele and subsequent varicocelectomy on testosterone-estradiol ratio in patients presented with infertility or testicular pain., Materials and Methods: In this prospective, controlled, clinical study, 135 men were assigned to 3 equal groups (n = 45 per group). The varicocele-treated "varicocelectomy" group included patients with varicocele who underwent loupe-assisted subinguinal varicocelectomy for infertility or testicular pain; the varicocele-not-treated "positive control" group included patients with varicocele who refused or who wished to postpone varicocelectomy; and the no-varicocele "negative control" group included fertile men without varicocele. The varicocele-treated patients underwent loupe-assisted subinguinal varicocelectomy for infertility or testicular pain. Semen analysis, serum testosterone, estradiol, follicle stimulating hormone, luteinizing hormone, prolactin, calculation of testosterone to estradiol ratio (T:E ratio), and scrotal Doppler ultrasound were assessed at baseline and 6 months later., Results: Total testosterone levels and T:E ratio were in the normal range in all groups. Men with varicocele had significantly lower levels of total testosterone and T:E ratio than men without varicocele (P <.001 for each). Testosterone levels were 4.9, 4.6, and 7.3 ng/mL, and T:E ratios were 19, 17.4, and 28.1 in the treated, positive, and negative control groups, respectively. Testosterone level and T:E ratio were significantly higher in the negative control group than the other 2 groups at baseline assessment (P <.001 for each). These parameters improved significantly 6 months after varicocelectomy in the treated group; whereas, they remained unchanged in the 2 control groups., Conclusion: Varicocele is associated with the diminishing of total testosterone and T:E ratio, which were significantly improved after subsequent subinguinal varicocelectomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of Interest: The author has no conflicts of interest to declare.

Background and Aims: Regional analgesia is commonly used for the relief of labour pain, Prolongation of analgesia can be achieved by adjuvant medications. The aim of this randomised controlled trial was to evaluate the efficacy of intrathecal levobupivacaine with dexamethasone for labour analgesia., Methods: A total of 80 females were included in this study, all were primigravidas undergoing vaginal delivery with cervical dilatation ≥4 cm and 50% or more effacement. Forty females were included randomly in either Group L (received intrathecal levobupivacaine 0.25% in 2 mL) or Group LD (received intrathecal levobupivacaine 0.25% combined with dexamethasone 4 mg in 2 mL). The primary outcome was the duration of spinal analgesia. Secondary outcomes included the total dose of epidural local anaesthetic given, time to delivery, neonatal outcome and adverse effects., Results: The duration of spinal analgesia was significantly longer in the LD group compared with L group (80.5 ± 12.4 min vs. 57.1 ± 11.5 min, respectively; P < 0.001). In Group LD compared with Group L, time from spinal analgesia to delivery was significantly lower (317.4 ± 98.9 min vs. 372.4 ± 118.8 min, respectively; P = 0.027), and total epidural levobupivacaine consumption was significantly lower (102.4 ± 34.8 mg vs. 120.1 ± 41.9 mg, respectively; P = 0.027). The two groups were comparable with respect to characteristics of sensory and motor block, haemodynamic parameters, pain scores, neonatal outcome and frequency of adverse effects., Conclusion: Intrathecal dexamethasone plus levobupivacaine prolongs the duration of spinal analgesia during combined spinal-epidural CSE for labour analgesia., Competing Interests: There are no conflicts of interest

The association between endothelial dysfunction and late onset hypogonadism (LOH) in patients with vasculogenic erectile dysfunction (ED) is not yet well settled. Our objective was to assess the association between LOH and endothelial dysfunction in patients with vasculogenic ED. Throughout 2014-2015 a total of 90 men were enrolled in this cross-sectional observational study. Of them 60 patients with a clinical diagnosis of ED were further subdivided into two equal groups: patients with vasculogenic ED and LOH (A); patients with vasculogenic ED and euogonadal (B). Thirty age-matched men with no ED or hypogonadism were enrolled as control group (C). All patients were subjected to detailed medical and sexual history, total testosterone (TT), calculated free (FT) and bioavailable testosterone (BT), flow cytometric evaluation for endothelial progenitor cells (EPCs) (CD45negative/CD34positive/CD144positive) and endothelial microparticles (EMPs) (CD45negative/CD144positive/annexin V positive). The mean age ± SD of the three groups A, B and C were 51.3 ± 11.1, 53.6 ± 10.6 and 48.3 ± 5 years, respectively, with insignificant age differences (p = 0.089). The diagnostic criteria of LOH were adapted according to European male aging study, 2010. The means of TT(ng/mL) were 2.32 ± 0.21, 6.43 ± 0.36 and 5.37 ± 0.30 in groups A, B and C, respectively. There were highly significant differences between group A and groups B and C (p < 0.001 for each). The means of EPCs were 0.43 ± 0.070, 0.22 ± 0.05 and 0.032 ± 0.013 in groups A, B and C, respectively. The means of EMPs were 0.15 ± 0.029, 0.056 ±  .013 and 0.014 ± 0.002 in groups A, B and C, respectively. There were significant differences between group C and groups A and B (p < 0.05 for each). This study clearly demonstrated that there is a significant association between LOH and the higher expression of EPCs and EMPs in patients with vasculogenic ED., (© 2017 American Society of Andrology and European Academy of Andrology.)

Objective: To review contemporary knowledge concerning the innovative trends and perspectives in the treatment of erectile dysfunction (ED)., Methods: Medline was reviewed for English-language journal articles between January 2000 and March 2016, using the terms 'erectile dysfunction treatments', 'new trends' and 'perspectives'. In all, 114 original articles and 16 review articles were found to be relevant. Of the 76 cited papers that met the inclusion criteria, 51 papers had level of evidence of 1a-2b, whilst 25 had level of evidence of 3-4. Criteria included all pertinent review articles, randomised controlled trials with tight methodological design, cohort studies, and retrospective analyses. We also manually reviewed references from selected articles., Results: Several interesting studies have addressed novel phosphodiesterase type 5 inhibitors (PDE5Is), orodispersible tablets, their recent chronic use, and combination with other agents. A few controlled studies have addressed herbal medicine as a sole or additional treatment for ED. Experimental studies and exciting review papers have addressed stem cells as novel players in the field of ED treatment. Other recent articles have revised the current status of low-intensity extracorporeal shockwave therapy in the field of ED. A few articles without long-term data have addressed new technologies that included: external penile support devices, penile vibrators, tissue engineering, nanotechnology, and endovascular tools for ED treatment., Conclusions: The current treatment of ED is still far from ideal. We expect to see new drugs and technologies that may revolutionise ED treatment, especially in complex cases.

The emerging of intracavernosal injection (ICI) of vasoactive materials was a major breakthrough in the treatment of erectile dysfunction (ED). However, the current state and future direction of ICI role in the armamentarium of diagnosis, prevention and treatment of ED are not well defined. The aim of this study was to address the current place of ICI in the armamentarium of ED diagnosis and treatment. An English-language MEDLINE review for the utilization of 'intracavernosal injection & erectile dysfunction' was performed from 1990 to present time. Four hundred forty-eight articles were analyzed and classified according to the current utilization of ICI in the following conditions; diagnosis of ED, phosphodiesterase-5 inhibitor (PDE5I) non-responders, diabetes, post radical prostatectomy (RP), stem cells and gene therapy, new intracavernosal drugs, adverse effects and couple satisfaction. This paper is not a standard systematic review; it is eventually a literature review of original peer-reviewed manuscripts and clinical trials reported in Medline. The comprehensive analyses of all the reviewed data were not possible as the level of evidence for utility of ICI in each topic was not available. Current date have established the role of ICI of vasoactive materials as a very common alternative domain in treatment of severe ED particularly in diabetic patients, post-RP, PDE5I non-responders. Further, new studies have denoted the potential future role of intracavernosal treatment for ED in the era of stem cells and gene therapy. ICI of vasoactive material continues to be a highly effective and safe treatment tool for men with wide varieties of ED etiologies. Several experimental and clinical studies are currently investigating new ICI materials. Hopefully in the near future, we might witness evolved molecules and innovative strategies that could help to treat ED patients with different etiologies.

Objective: To review the contemporary knowledge of the pathophysiology of Peyronie's disease (PD)., Methods: Medline was searched for papers published in English from 2000 to March 2013, using the keywords 'Peyronie's disease' and 'pathophysiology'., Results: More than 300 relevant articles were identified for the purpose of this review. Unfortunately only a few studies had a high level of evidence, and the remaining studies were not controlled in their design. Many theories have been proposed to explain the cause of PD, but the true pathogenesis of PD remains an enigma. Identifying particular growth factors and the specific genes responsible for the induction of PD have been the ultimate goal of research over the past several decades. This would provide the means to devise a possible gene therapy for this devastating condition. We discuss present controversies and new discoveries related to the pathophysiology of this condition., Conclusion: PD is one of the most puzzling diseases in urology. The pathogenesis remains uncertain and there is still controversy about the best management. The pathogenesis of PD has been explored in animal models, cell cultures and clinical trials, but the results have led to further questions. New research on the aetiology and pathogenesis of PD is needed, and which will hopefully improve the understanding and management for patients with this frustrating disease.

Our aim was to assess the impact of the association between elevated oestradiol (E2) and low testosterone (T) levels on erectile dysfunction (ED) severity. A total of 614 male patients with ED and a normal or low T level in association with normal or elevated E2 levels were enrolled. Patients underwent routine laboratory investigations in addition to measurements of total T, total E2, follicle-stimulating hormone (FSH), luteinizing hormone (LH) and prolactin. We compared the responses to the erectile function domain, Q3 (achieving erection) and Q4 (maintaining erection) of the International Index for Erectile Function (IIEF) score in patients with the following: normal T and E2 levels; low T level; low T level and elevated E2 level; and elevated E2 level. Of the patients included, 449 (73.1%) had normal T and E2 levels, 110 (17.9%) had a low T level, 36 (5.9%) had a low T level and an elevated E2 level, and 19 (3.1%) had an elevated E2 level. Increased ED severity was significantly associated with low T levels, elevated E2 levels, and both a low T level and an elevated E2 level. Additionally, the mean values of the EF-domain, Q3 and Q4 were significantly lower in patients with both a low T level and an elevated E2 level compared to patients with any condition alone. In conclusion, a low T level had the primary effect on erectile function; however, a concomitantly elevated E2 level had an additive impairment effect.

Objective: To review local published data on the diagnosis and treatment of erectile dysfunction (ED) in Arab countries., Methods: MEDLINE was searched for English-language articles published from 2000 to 2011, using the search terms 'Arab countries', 'sexual dysfunction', 'diagnosis' and 'treatment'., Results: In all, 86 articles were found to be relevant to this review; only a few had a high level of evidence and the remaining studies used an uncontrolled design. Several local studies were consistent with previous reports showing that a customised diagnostic pathway, with full consideration of the patient's goals, is adopted by most clinicians to treat ED. For an effective treatment, the evaluation methods should answer important questions about the aetiology and severity of ED, as well as the patient's and partner's goals and expectations. As ED is known to be associated with many common medical comorbidities and medications, careful questioning can yield information about peripheral vascular disease, coronary artery disease, diabetes, hypertension, dyslipidaemia, and tobacco and alcohol use. The presence of psychological, neurological or chronic debilitating diseases can direct further evaluation., Conclusion: The methods used for the diagnosis and treatment of ED need more investigation, especially in Arab countries. Only a few studies addressed the results of different methods of investigating and treating ED among Arab men.

Objective: To review the contemporary knowledge of local investigations in the Arab countries that were conducted to identify the magnitude of erectile dysfunction (ED) and its correlates among men in this region., Methods: MEDLINE was reviewed for English-language reports from 2000 to 2011 for Arab countries, using the terms 'erectile dysfunction' and 'prevalence'., Results: In all, 102 articles were found to be relevant to the review. Unfortunately only a few had a high level of evidence and the remaining studies were not controlled in their design. Several local studies showed that the prevalence of ED was >40% among Arab men. Risk factors and medical comorbidities that negatively affect the cardiovascular system, endothelial function and ultimately erectile function were common in men in Arab countries. For instance, at least five Arab countries are included in the top 10 countries worldwide with a high prevalence of diabetes mellitus. The global statistics showed that other risk factors such as obesity, smoking, hypertension and dyslipidaemia are also very prevalent in Arab countries. This fact can explain the high incidence of both cardiovascular disease and ED among Arab men., Conclusion: ED is very prevalent among Arab men. Arab countries are among those with the highest prevalence of endothelial dysfunction risk factors, which could explain this high prevalence of ED.

Introduction: It has been repeatedly demonstrated that presence of erectile dysfunction (ED) may predate the occurrence of overt event of coronary artery disease. However, the association between severity of ED and left ventricular diastolic dysfunction (LVDD) was rarely reported., Aim: The aim of this study was to assess the association between severity of ED and LVDD in patients without overt cardiac complaint., Main Outcome Measures: The International Index of Erectile Function (IIEF) was used to assess erectile function. Diastolic Doppler parameters measurements and tissue Doppler imaging were used to assess left ventricular diastolic function., Methods: A total of 230 male ED patients without overt cardiac complaint were enrolled in this study. Erectile function was assessed using the IIEF. Patients were also screened for socio demographic data and medical comorbidities that included age, smoking, diabetes, hypertension, and dyslipidemia. All patients were referred to cardiologist for cardiac assessment. Left ventricular diastolic function that included diastolic Doppler parameters measurements and tissue Doppler imaging were also assessed., Results: Mean age±standard deviation was 57.5±5.6 (range of 42-81). There were significant associations between the following risk factors: age, obesity, smoking, hypertension, dyslipidemia, and increased severity of ED (P<0.05 for each). Of the patients, 77.4%, 74.8%, 80%, and 66.1% had abnormal transmitral E/A (E/A) ratio, deceleration time (DT), isovolumic relaxation time (IVRT), mitral E velocity/tissue Doppler imaging E velocity (E/Em) ratio, respectively. Only the means of IVRT and (E/Em) ratio had significant associations with increased severity of ED (P<0.001 for each). There were significant associations between increased severity of ED and the following categorical echo parameters: grades 1 and 2 of E/A ratio, DT, IVRT, and grades 1, 2, and 3 of (E/Em) ratio (P<0.05 for each)., Conclusions: The current study clearly demonstrated that LVDD is prevalent among patients with ED-associated medical comorbidities without overt cardiac complaint. There were significant associations between increased severity of ED and presence of LVDD in those patients., (© 2011 International Society for Sexual Medicine.)

Introduction: Erectile dysfunction (ED) depression and ischemic heart disease (IHD) had long been classified as independent medical conditions managed by unrelated medical services. Recent studies have revealed the intimate associations among the three conditions. However, when a patient presents with one component of this triad, whether the physicians should also screen for the other two components is still an important question to be answered., Aim: The purpose of this Continuing Medical Education article is to review contemporary knowledge regarding the reinforcing associations between the three conditions and to highlight the importance of screening for the other two components when a patient presents with one component of this triad, thus enabling best-practice management., Methods: An English-language MEDLINE review was performed from 1990 to present-day for the association between ED, depression and IHD., Main Outcome Measure: Current state of information regarding associations among the three conditions., Results: Recent studies have established a new paradigm for the intimate associations among the three conditions. Furthermore, various risk factors and medical co-morbidities such as age, obesity, sedentary lifestyle, smoking, heart disease, hypertension, dyslipidemia, diabetes, and related medications have been demonstrated to be highly associated with psychological disorders, cardiovascular diseases, and sexual dysfunctions., Conclusions: The integrative view and holistic approach with full consideration of the property of each condition is the appropriate way for the diagnosis and management of patients with these conditions., (© 2011 International Society for Sexual Medicine.)

Ageing has a detrimental effect on cavernous tissue and the tunica albuginea of the penis. Furthermore, atherosclerosis of the penile vessels that occurs with ageing causes a decrease in penile oxygen tension. A reduction in smooth muscle cells (SMCs) was shown in relation to diminution of oxygen tension. Chronic ischaemia is therefore not only associated with fibrosis but also with nitric oxide-cyclic guanosine monophosphate reduction. The sensitivity of the α-adrenoceptors on the SMCs increases with ageing. The decrease in penile elasticity and compliance are explained by the changes in the ratio of penile collagen that occur with ageing. Contradictory to the view that testosterone is only necessary for sexual desire, numerous recent studies showed that androgen deprivation produces penile tissue atrophy, alterations in dorsal nerve structure, alterations in endothelial morphology, reduction in trabecular SM content, increase in deposition of extracellular matrix and accumulation of fat-containing cells (adipocytes) in the subtunical region of corpus cavernosum. The aim of the current review is to shed some light on the underlying aetiology of corporal fibrosis especially ageing, cavernous nerve damage, androgen deprivation and tunical fibrosis. Ultimately I will address the proposed prevention of erectile dysfunction associated with penile fibrosis.

Traditionally, clinical conditions synonymous with the ageing male included cardiovascular disease (CVD), type 2 diabetes mellitus (DM) and sexual dysfunction, and were widely regarded as independent clinical entities. Over the last decade, interrelationship of clinical conditions has been convincingly demonstrated. Declining testosterone levels in the elderly, once regarded as an academic endocrinological question, appear to be central to the listed pathologies. It is now clear that erectile dysfunction is an expression of endothelial dysfunction. Testosterone deficiency is associated with an increased incidence of CVD and DM. The latter is often the sequel of the metabolic syndrome. Visceral obesity, a pivotal characteristic of the metabolic syndrome, suppresses the hypothalamic-pituitary-testicular axis leading to diminished testosterone production. Conversely, substantial androgen deficiency leads to signs and symptoms of metabolic syndrome. It is erroneous not to include testosterone measurements in the progress of the CVD, DM and erectile dysfunction. These conditions correlate strongly with testosterone deficiency., (© 2010 Blackwell Verlag GmbH.)

Several changes have been reported to occur in the cavernosal tissue and tunica albuginea with aging. The atherosclerosis of the penis that occurs with aging causes a decrease in penile oxygen tension. A reduction in the number of smooth muscle cells (SMCs) has been demonstrated in relation to this change in oxygen tension. Changes in the ratio of penile collagen have also been observed and could explain the decrease in penile elasticity and compliance with aging. Chronic ischemia is therefore associated with fibrosis but also with nitric oxide-cGMP reduction. The sensitivity of the α-adrenoceptors on the SMCs increases with aging. Furthermore, androgen deprivation produces penile tissue atrophy, alterations in dorsal nerve structure, alterations in endothelial morphology, reductions in trabecular SM content, increases in deposition of extracellular matrix, and increases in accumulation of adipocytes in the subtunical region of the corpus cavernosum. All of these modifications can explain the prevalence of erectile dysfunction with aging. The aim of this review is to address the underlying etiology of corporal fibrosis, especially aging, cavernosal nerve damage, androgen deprivation, and tunical fibrosis. Finally, we will address the proposed amelioration and reversal of fibrosis in terms of correcting, at least partially, the relative SMC loss that occurs with aging, diabetes, or cavernosal nerve damage and its impact on prevention of erectile dysfunction-associated cavernosal fibrosis.

Objectives: To assess the impact of diabetes mellitus (DM) control on androgen pattern in men with type 2 DM-associated erectile dysfunction (ED)., Methods: This is a prospective office-based study. A total of 159 ED male patients with DM were enrolled in this study. Erectile function was assessed using the international index of erectile function (IIEF). Diabetes control was instituted using lifestyle modification in addition to hypoglycemic agents and/or insulin therapy. Regular follow-up visits were scheduled every 4 weeks to adjust the anti-DM treatment according to patients' response and tolerance. At baseline, 3- and 6-month visits, patients were assessed for control of DM, ED severity, and total testosterone (T), dehydroepiandrosterone sulfate (DHEA-S), and insulin assessment., Results: Of all patients, 25.8%, 6.3%, and 30.2% had low total T, low DHEA-S, and hyperinsulinemia, respectively, at baseline visit. There were significant increases in the mean total T levels (4.2 +/- 1.9 vs 4.7 +/- 2.1 and 5.3 +/- 2.2) and significant decreases in insulin level (23.7 +/- 17.4 vs 22.8 +/- 15.3 and 17.8 +/- 13.9) at 3- and 6-month visits, respectively. There were significant associations between good control of DM or decreased fasting blood sugar and normal levels of total T at 3- and 6-month visits. The prevalence of patients with normal testosterone and severe ED was significantly increased at 3- and 6-month visits., Conclusions: The present study clearly demonstrated that there were significant associations between control of DM and normal total T levels at 3- and 6-month follow-up visits.