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Background: In the SPOTLIGHT trial (Spot Sign Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy), patients with a computed tomography (CT) angiography spot-sign positive acute intracerebral hemorrhage were randomized to rFVIIa (recombinant activated factor VIIa; 80 μg/kg) or placebo within 6 hours of onset, aiming to limit hematoma expansion. Administration of rFVIIa did not significantly reduce hematoma expansion. In this prespecified analysis, we aimed to investigate the impact of delays from baseline imaging to study drug administration on hematoma expansion. Methods: Hematoma volumes were measured on the baseline CT, early post-dose CT, and 24 hours CT scans. Total hematoma volume (intracerebral hemorrhage+intraventricular hemorrhage) change between the 3 scans was calculated as an estimate of how much hematoma expansion occurred before and after studying drug administration. Results: Of the 50 patients included in the trial, 44 had an early post-dose CT scan. Median time (interquartile range) from onset to baseline CT was 1.4 hours (1.2–2.6). Median time from baseline CT to study drug was 62.5 (55–80) minutes, and from study drug to early post-dose CT was 19 (14.5–30) minutes. Median (interquartile range) total hematoma volume increased from baseline CT to early post-dose CT by 10.0 mL (−0.7 to 18.5) in the rFVIIa arm and 5.4 mL (1.8–8.3) in the placebo arm ( P =0.96). Median volume change between the early post-dose CT and follow-up scan was 0.6 mL (−2.6 to 8.3) in the rFVIIa arm and 0.7 mL (−1.6 to 2.1) in the placebo arm ( P =0.98). Total hematoma volume decreased between the early post-dose CT and 24-hour scan in 44.2% of cases (rFVIIa 38.9% and placebo 48%). The adjusted hematoma growth in volume immediately post dose for FVIIa was 0.998 times that of placebo ([95% CI, 0.71–1.43]; P =0.99). The hourly growth in FFVIIa was 0.998 times that for placebo ([95% CI, 0.994–1.003]; P =0.50; Table 3). Conclusions: In the SPOTLIGHT trial, the adjusted hematoma volume growth was not associated with Factor VIIa treatment. Most hematoma expansion occurred between the baseline CT and the early post-dose CT, limiting any potential treatment effect of hemostatic therapy. Future hemostatic trials must treat intracerebral hemorrhage patients earlier from onset, with minimal delay between baseline CT and drug administration. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01359202.

International guidelines recommend carotid revascularization within 14 days for patients with a symptomatic transient ischemic attack (TIA) or stroke event. However, significant delays in care persist, with only 9% of outpatients and 36% of inpatients in Ontario meeting this target. The study objective was to explore the influence of health system factors on carotid revascularization timelines.We conducted a retrospective chart review of all symptomatic TIA/stroke patients undergoing carotid endarterectomy or stenting at The Ottawa Hospital (2015-2016). The primary outcome was time from TIA/stroke to carotid revascularization. Health system variables of interest included location and timing of patient presentation, timelines to vascular imaging, and same-day collaboration between key services such as emergency, neurology, and surgery. Descriptive statistics and univariate analysis were used to determine statistically significant differences between groups.A total of 228 records met the inclusion criteria. The median time from TIA/stroke to carotid revascularization was 10 days, with 58% of patients meeting the 14-day guideline. Prompt patient presentation to emergency demonstrated significantly shorter timelines to surgery (7 days; P .001). Early vascular imaging was strongly correlated with early revascularization (4-5 days; P .001). In addition, collaboration from two or more care services enhanced timelines to surgery ranging from 2.0 to 6.5 days (P .001-.008).Early/emergency response to stroke symptoms was pivotal in achieving best practice recommendations for rapid carotid revascularization, emphasizing the need for ongoing public awareness. Emergency and ambulatory strategies to facilitate urgent vascular imaging, as well as mechanisms for same-day communication between teams require optimization to promote early revascularization.

Background/aim We previously reported the feasibility of RecoverNow (a mobile tablet-based post-stroke communication therapy in acute care). RecoverNow has since expanded to include fine motor and cognitive therapies. Our objectives were to gain a better understanding of patient experiences and recovery goals using mobile tablets. Methods Speech-language pathologists or occupational therapists identified patients with stroke and communication, fine motor, or cognitive/perceptual deficits. Patients were provided with iPads individually programmed with applications based on assessment results, and instructed to use it at least 1 h/day. At discharge, patients completed a 19-question quantitative and open-ended engagement survey addressing intervention timing, mobile device/apps, recovery goals, and therapy duration. Results Over a six-month period, we enrolled 33 participants (three did not complete the survey). Median time from stroke to initiation of tablet-based therapy was six days. Patients engaged in therapy on average 59.6 min/day and preferred communication and hand function therapies. Most patients (63.3%) agreed that therapy was commenced at a reasonable time, although half expressed an interest in starting sooner, 66.7% reported that using the device 1 h/day was enough, 64.3% would use it after discharge, and 60.7% would use it for eight weeks. Sixty-seven percent of patients expressed a need for family/friend/caregiver to help them use it. Conclusion Our results suggest that stroke patients are interested in mobile tablet-based therapy in acute care. Patients in the acute setting prefer to focus on communication and hand therapies, are willing to begin within days of their stroke and may require assistance with the tablets.

Introduction Stroke survivors frequently experience a range of post-stroke deficits. Specialized stroke rehabilitation improves recovery, especially if it is started early post-stroke. However, resource limitations often preclude early rehabilitation. Mobile technologies may provide a platform for stroke survivors to begin recovery when they might not be able to otherwise. The study objective was to demonstrate the feasibility of RecoverNow, a tablet-based stroke recovery platform aimed at delivering speech and cognitive therapy. Methods We recruited a convenience sample of 30 acute stroke patients to use RecoverNow for up to 3 months. Allied health professionals assigned specific applications based on standard of care assessments. Participants were encouraged to take home the RecoverNow tablets upon discharge from acute care. The study team contacted participants to return for a follow-up interview 3 months after enrollment. The primary outcome of interest was feasibility, defined using 5 facets: recruitment rate, adherence rate, retention rate, the proportion of successful follow-up interventions, and protocol deviations. We tracked barriers to tablet-based care as a secondary outcome. Results We successfully recruited 30 of 62 eligible patients in 15 weeks (48% recruitment rate). Participants were non-adherent to tablet-based therapy inside and outside of acute care, using RecoverNow for a median of 12 minutes a day. Retention was high with 23 of 30 patients participating in follow-up interviews (77% retention rate) and all but 3 of the 23 interviews (87%) were successfully completed. Only 2 major protocol deviations occurred: one enrollment failure and one therapy protocol violation. Barriers to tablet-based care were frequently encountered by study participants with many expressing the assigned applications were either too easy or too difficult. Conclusions Acute stroke patients are interested in attempting tablet-based stroke rehabilitation and are easily recruited early post-stroke. However, tablet-based therapy may be challenging due to patient, device and system-related barriers. Reducing the frequency of common barriers will be essential to keeping patients engaged in tablet-based therapy.

Background: For optimal stroke prevention, best practices guidelines recommend carotid endarterectomy (CEA) for symptomatic patients within two weeks; however, 2013 Ontario data indicated that only 9% of eligible patients from outpatient Stroke Prevention Clinics (SPCs) achieved this target. The goal of our study was to identify modifiable system factors that could enhance the quality and timeliness of care among patients needing urgent CEA. Methods: We conducted a retrospective chart review of transient ischemic attack/stroke patients assessed in Champlain Local Health Integrated Network SPCs between 2011 and 2014 who subsequently underwent CEA. Descriptive statistics were used to define patient characteristics, timelines from symptom onset to CEA, and system factors that contributed to delays or improvements in care. Multivariate analysis was used to determine statistically significant variations between groups. Results: Seventy-five records were eligible for study inclusion. Median time from initial symptoms to CEA was 31 days, with 21.3% of patients undergoing surgery within 2 weeks. Significant delays were common in patient presentation and assessment following symptom onset, wait times for vascular imaging and neurological assessment, and time from surgical assessment to CEA completion. Rapid testing and triage, coupled with collaborative initiatives among SPC, surgical, and radiology teams were associated with significantly improved timelines. Conclusions: Success factors for rapid CEA are multifaceted, including system changes that address public awareness of stroke and 911 response, improvements in vascular imaging access, and redesign of clinical services to promote collaboration and fast-tracking of care. Implementation of performance measures to monitor and guide clinical innovations is recommended.

Supplemental material, Appendix 1 for RecoverNow: A patient perspective on the delivery of mobile tablet-based stroke rehabilitation in the acute care setting by Karen Mallet, Rany Shamloul, Michael Pugliese, Emma Power, Dale Corbett, Simon Hatcher, Michel Shamy, Grant Stotts, Lise Zakutney, Sean Dukelow and Dar Dowlatshahi in International Journal of Stroke

Mobile health (mHealth) technology represents a means through which more stroke survivors could access early stroke rehabilitation. Although rehabilitation is most effective when begun early post-stroke, limited resources (facilities, therapists) prevent survivors from initiating therapy. Furthermore, the coupling of an aging population with advances in acute therapy has led to an increase in the absolute number of individuals suffering from and surviving strokes which in turn has put further strain on already scarce rehabilitation resources. There is an urgency to conduct high-quality research exploring cost-effective and creative mHealth devices for early rehabilitation in the acute setting. Mobile technology allows therapists to prescribe apps based on standard cognitive/physical assessments in the acute setting, remotely monitor patient progress across individual carepaths, and update prescribed therapies based on patient feedback and recovery. Recognition of the growing problem of accessing early stroke rehabilitation, and the possibilities offered by mHealth technology led to the development of the RecoverNow platform for stroke rehabilitation in the acute setting. RecoverNow is a custom built, tablet-based stroke rehabilitation platform that houses a variety of previously existing apps with activities analogous or identical to exercises in speech language and/or occupational therapy. While RecoverNow represents how mobile technology can be utilized to address a growing public health issue, the feasibility, acceptability and efficacy of tablet-based stroke rehabilitation are unknown. Studies with the goal of establishing feasibility of early tablet-based stroke rehabilitation are needed and, if appropriate, a randomized controlled trial to establish efficacy.

Introduction There are several contraceptive methods to prevent pregnancy, reversible as well as nonreversible ones. The sexual satisfaction of couples is affected by many types of contraceptives used. Aim The aim of this study was to evaluate prospectively the effect of vasectomy on the sexual life and satisfaction of couples. Methods Seventy‐six couples took part in this evaluation and filled out respective questionnaires before and after vasectomy. All the questionnaires were evaluated statistically for differences in the respective sexual domain scores. Main Outcome Measures Standardized questionnaires were used. The International Index of Erectile Function (IIEF) as well as postoperative pain score were completed by men. Female Sexual Function Index (FSFI) was completed by the female partner. For statistical analysis, the T‐Square Test was used. Results The average age of couples, who chose the vasectomy procedure, was 37 years for women and 39 years for men. The contraception method most frequently used prior to the vasectomy was the birth control pill. For the male partner, the IIEF showed no significant change in the respective domains. Out of the 76 couples, 93% of the males and 96% of their female partners would recommend and do vasectomy again. The postoperative pain score was 3.5 on 0–10 scale, and there were no postoperative complications reported. The best improvement of the sexual function was noticed for the female partners. The FSFI showed a significant improvement in the domains desire ( P P P P P Conclusion This is the first report to our very best knowledge that showed the positive impact of vasectomy on sexual satisfaction of couples. Vasectomy is a safe operation with minimal complication rates. Mohamad Al‐Ali B, Shamloul R, Ramsauer J, Bella AJ, Scrinzi U, Treu T, and Jungwirth A. The effect of vasectomy on the sexual life of couples. J Sex Med 2014;11:2239–2242.

Introduction: There has been a long history of man's fascination with better and stronger sex drive and performance across different cultures. Several literature texts from the Hindu, Egyptian, Chinese and Roman civilizations document the human endless search for substances that can enhance sexual experiences and/or treat erectile dysfunction. Aim: This review will discuss the current research done on the most popular plant aphrodisiacs and provide evidence to support or discourage the use of any of them to enhance sexual desire and/or function in men. Methods: We review the current evidence on the use of natural substances as aphrodisiacs. Results: We found very little evidence to support the use of plant aphrodisiacs in the treatment of male sexual dysfunction. The vast majority of studies were conducted on animals with very few clinical studies. Available data suggest a beneficial effect of ginseng as a pro-sexual supplement and not an independent treatment for male sexual dysfunction. Conclusions: Trans-culturally, many herbal therapies show some potential benefits in improving men's sexual function; however, adequate studies on the specific benefits and health risks associated with their use are needed. We strongly recommend the design and execution of well-controlled clinical studies to determine the efficacy and safety of plant aphrodisiacs. Copyright © 2013 John Wiley & Sons, Ltd.

Our study included 280 patients complaining of small-sized penis. They were seen in the outpatient clinic of the Andrology Department, Kasr El Aini, Cairo University. Patients were collected from 2002 till 2008 and classified into 4 categories from an etiological point of view. Eleven patients (3.9%) were operated upon according to fine selection criteria; six patients were selected for lengthening procedures, while two patients were selected for increasing girth procedures and three patients for combined operation of lengthening and increasing girth techniques. Seven patients showed subjective satisfaction after lengthening procedures and four patients showed subjective satisfaction after increasing girth techniques. In conclusion, detailed analysis of short penis complaint with a proper diagnosis and patient education are required for accurate management of patients complaining of a short penis.

For optimal stroke prevention following transient ischemic attack or minor stroke, international best practice guidelines recommend carotid endarterectomy for appropriate candidates as soon possible, with a target of less than two weeks. Research has demonstrated however, that delays to surgery occur frequently, in part due to complex clinical care processes. The goal of our study was to identify modifiable factors which could improve timely access to urgent carotid endarterectomy. A retrospective chart review was competed, examining transient ischemic attack /stroke patients assessed in four regional Stroke Prevention Clinics between 2011 and 2014, who subsequently underwent carotid endarterectomy. Descriptive statistics were used to examine patient characteristics and time points to carotid surgery. A thematic analysis was performed to identify key factors which enhanced or delayed timelines to carotid endarterectomy. These themes were further analyzed to determine avoidable delays and key success factors. Seventy-five records were eligible for study inclusion. Completion of carotid endarterectomy within two weeks was achieved for 21% of patients. Six key themes were identified including patient response to stroke, first health care contact, surgical fitness, resource capacity and physician availability (neurology or surgery). Forty four percent of patients did not present to medical attention the day of symptom onset contributing substantially to avoidable delays in care. Furthermore, 79% of patients experienced delays in access to vascular imaging, neurologist assessment and surgical bookings. Success was influenced by distinct triage, rapid diagnostic testing, and physician accessibility strategies. This often required divergence from standard clinical practices and interdepartmental collaboration. Delayed patient presentation was the most common reason for delayed carotid endarterectomy which highlights the importance of ongoing public awareness strategies. Significant clinical delays were also noted at each step where patients required imaging or consultation. In order to reach carotid endarterectomy benchmarks, quality enhancement approaches will require coordinated, multifaceted care innovations.

Diabetes mellitus is a common chronic disease, affecting 0.5-2% worldwide. The Massachusetts Male Aging Study reported that up to 75% of men with diabetes have a lifetime risk of developing ED. Type 2 diabetes is associated with low total serum testosterone (TT) identified in several cross-sectional studies and systemic analyses. There is a lack of consensus regarding what constitutes the lowest level of testosterone within the boundaries of normality. In this retrospective study, we sought to evaluate the effect of associated co-morbidities on serum total testosterone (TT) level in men with type 2 diabetes DM, either with or without erectile dysfunction (ED). Three hundred and ninety-one patients were evaluated for erectile function using an abridged, five-item version of the International Index of Erectile Function-5. Measurements of TT, fasting lipid profile, blood sugar and glycated haemoglobin (HbA1c) were conducted. Penile hemodynamics was assessed using intracavernosal injection and penile duplex study. Hypogonadism was found in 126 cases (33.2%), and normal TT was observed in 254 (66.8%). ED was detected in 119 cases in the hypogonadal group (94.4%) as compared to 155/254 (61.0%) in eugonadal group, P = 0.0001. TT was lower in diabetic men with ED as compared to those with normal erectile function (EF), 392.4 ± 314.9 versus 524.3 ± 140.2 ng dl(-1) , respectively, P

Background Approximately 40% of patients diagnosed with stroke experience some degree of aphasia. With limited health care resources, patients’ access to speech and language therapies is often delayed. We propose using mobile-platform technology to initiate early speech-language therapy in the acute care setting. For this pilot, our objective was to assess the feasibility of a tablet-based speech-language therapy for patients with communication deficits following acute stroke. Methods We enrolled consecutive patients admitted with a stroke and communication deficits with NIHSS score ≥1 on the best language and/or dysarthria parameters. We excluded patients with severe comprehension deficits where communication was not possible. Following baseline assessment by a speech-language pathologist (SLP), patients were provided with a mobile tablet programmed with individualized therapy applications based on the assessment, and instructed to use it for at least one hour per day. Our objective was to establish feasibility by measuring recruitment rate, adherence rate, retention rate, protocol deviations and acceptability. Results Over 6 months, 143 patients were admitted with a new diagnosis of stroke: 73 had communication deficits, 44 met inclusion criteria, and 30 were enrolled into RecoverNow (median age 62, 26.6% female) for a recruitment rate of 68% of eligible participants. Participants received mobile tablets at a mean 6.8 days from admission [SEM 1.6], and used them for a mean 149.8 minutes/day [SEM 19.1]. In-hospital retention rate was 97%, and 96% of patients scored the mobile tablet-based communication therapy as at least moderately convenient 3/5 or better with 5/5 being most “convenient”. Conclusions Individualized speech-language therapy delivered by mobile tablet technology is feasible in acute care.

Late-onset hypogonadism (LOH) or age-associated testosterone deficiency syndrome is defined as a clinical and biochemical syndrome associated with advancing age and characterised by symptoms and a deficiency in serum testosterone levels. This condition may result in significant detriment in the quality of life and adversely affect the function of multiple organ systems. It has been suggested that sex steroid hormones may play a causal role in the development of insulin resistance and type II diabetes. This comparative study was aimed at determining the prevalence of LOH in diabetic men with erectile dysfunction and investigating the effect of testosterone replacement therapy on erectile function and on glycaemic control.

Premature ejaculation (PE) is by far the most common male sexual complaint, with millions of men affected all over the world. It is estimated that up to 20-30% of all men may be suffering from various forms of PE. A variety of filler materials are widely used nowadays for soft tissue augmentation. The appropriate filler can restore symmetry, volume and create a smooth skin surface The aim of this pilot study was to evaluate the therapeutic effect of hyaluronic acid gel injection in patients with PE. Sixty men with self-reported PE who were referred to our outpatient andrology clinic (between January 2007 and January 2008) were included in this study. Participants were randomly assigned using random sampling numbers into two distinct groups. Group A (n = 30) received a single injection of 2 ml of hyaluronic acid gel (Hyalift 3.5% micronised hyaluronic acid) using the previously described fan technique. Group B (n = 30) received a single injection of 2 ml of hyaluronic acid gel using the multiple puncture technique. Twenty-three patients (46.9%) received injection by the fan technique, while 26 patients (53.1%) received it through the multiple-point technique. The mean intravaginal ejaculation latency time (IELT) increased significantly from 2.12 ± 1.16 to 7.71 ± 7.86 min, after 1 month of injection and then dropped to 5.32 ± 3.52 min, but still remaining significantly higher than the baseline values. Results from our present pilot study demonstrated the usefulness of the application of hyaluronic acid dermal fillers in the treatment of PE; however, further investigations in large cohorts with longer follow-up are definitely needed to obtain more consistent results.

Summary The objective of the present retrospective study was to report our experience concerning the effects of cell phone usage on semen parameters. We examined 2110 men attending our infertility clinic from 1993 to October 2007. Semen analysis was performed in all patients. Serum free testosterone (T), follicle stimulating hormone (FSH), luteinising hormone (LH) and prolactin (PRL) were collected from all patients. The information on cell phone use of the patients was recorded and the subjects were divided into two groups according to their cell phone use: group A: cell phone use (n = 991); group B: no use (n = 1119). Significant difference was observed in sperm morphology between the two groups. In the patients of group A, 68.0% of the spermatozoa featured a pathological morphology compared to only 58.1% in the subjects of group B. Patients with cell phone usage showed significantly higher T and lower LH levels than those who did not use cell phone. No significant difference between the two groups was observed regarding FSH and PRL values. Our results showed that cell phone use negatively affects sperm quality in men. Further studies with a careful design are needed to determine the effect of cell phone use on male fertility.

Peyronie’s disease (PD) is an acquired inelastic scar of the tunica albuginea of the penis, resulting in penile pain, curvature and other deformities, and sexual dysfunction, as well as significant psychological morbidity and relationship/partner issues. Contemporary data suggest an incidence of one in 20 men, with peak occurrence between ages of 50–55 years. Initial diagnosis of PD is made by thorough medical history and examination of the external genitalia; early referal to an urologist experienced in PD management is recommended. Evidence for nonsurgical treatment options is limited; the most commonly used, vitamin E, has not been shown to have benefit over placebo. Recent double-blinded placebo-controlled evidence suggests a role for oral pentoxifylline as a first-line agent. Intralesional injection therapy with verapamil is a frequently utilized option, as first- or second-line treatment, or in combination with other modalities. IFN-β2b injections into the penile plaque have also shown benefit over placebo in decreasing penile curvature, plaque size, penile pain and plaque density. Penile traction is currently under investigation for a potential role in PD management. The gold standard treatment for clinically significant deformity after PD has stabilized remains surgery. Several surgical options are available, including minimally invasive plication procedures, incision of the plaque and grafting or a penile prosthesis (when concurrent treatment-resistant erectile dysfunction is present).

Introduction Genital morphology (especially male) among the animal kingdom is characterized by extensive differences that even members of closely related species with similar general morphology may have remarkably diverse genitalia. Aim To present the sexual medicine specialist with a basic understanding of the current hypotheses on genital evolution with an emphasis on the sexual selection theories. Methods A review of current literature on the theories of genital evolution. Main Outcome Measures Analysis of the supporting evidence for the sexual selection theories of genital evolution. Results Several theories have been proposed to explain genital evolution. Currently, the sexual selection theories are being considered to present valid and solid evidence explaining genital evolution. However, other theories, including sexual conflict, are still being investigated. All theories of genital evolution have their own weaknesses and strengths. Conclusions Given that many complex biological mechanisms, mostly unknown yet, are involved in the process of genital evolution, it is thus reasonable to conclude that not one theory can independently explain genital evolution. It is likely that these mechanisms may prove to have synergistic rather than exclusive effects. Shamloul R, El-Sakka A, and Bella AJ. Sexual selection and genital evolution: An overview.

Introduction: Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient preferences and values. Aim: This narrative review aims to assist the physicians to make informed decisions based on the best available evidence in the area of male infertility and the patients’ own preferences and values. Methods: In this review we present the current state of knowledge and uncertainties about the medical management of male infertility. We describe the best available evidence from systematic reviews, randomized controlled studies and observational studies where appropriate. Results: Data from the literature suggest that gonadotropin treatment of male infertility can lead to a significant increase in pregnancy rates, however larger studies are needed to confirm such findings. Studies including combinations of antiestrogens, antioxidants and androgens are promising but need confirmation with further research. Conclusions: Most current combination therapies consist of orphan medications without industry support. Andrology research centers and other dedicated departments and units need to conduct randomized controlled trials of sufficient duration, sample number and robust design for groups most likely to benefit from antiestrogens, L-carnitine, antioxidants, and combination therapy. The ease of administration, low cost and mild side effects of antiestrogens justify their utility despite insufficient evidence of effect as monotherapies. Randomized controlled trials assessing other forms of medical therapy and combination therapy are available but are still in the preliminary stages.

Introduction Despite the major breakthroughs basic research in erectile physiology experienced in the last, most of the methods used for quantitative assessment of erectile function in longitudinal studies suffer many drawbacks. Objective This review will focus on radiotelemetric assessment of intracavernosal (ICP) and intraspongiosal (ISP) regarding the technique, data collection, interpretation, and overall benefits. Results Telemetric recording of ICP and ISP allows for qualitative and quantitative assessment of erectile responses in experimental animals, a characteristic that is not possible using other techniques. This technique has many advantages that can collectively lead to production of high quality data regarding erection. The system suffers two drawbacks, its high cost and the need for surgical implantation of the transmitter. Conclusion The use of telemetric monitoring of ICP and ISP carries many advantages that will, hopefully, establish this technique as the gold standard method for assessment of erectile responses in the near future. Shamloul R. Telemetric intracavernosal and intraspongiosal pressure monitoring. J Sex Med 2008;5:2246–2252.

Introduction Currently there is no universally accepted gold standard diagnostic test to differentiate psychogenic from physical erectile dysfunction (ED). Instead, sexual health specialists rely on a detailed history, a focused physical examination, and specialized diagnostic tests, to decide if the etiology of the ED is mainly psychogenic or organically caused. Aim In this review we point out the status of evidence-based principles in the area of diagnosis in Sexual Medicine. Methods We review the concepts of evidence-based medicine (EBM) in the area of medical diagnostic tests. We highlight four of the well-known diagnostic tests (penile duplex, pharmacoarteriography, pharmacocavernosometry/cavernosography [PHCAS/PHCAG], and nocturnal penile tumescence [NPT monitoring]) for ED evaluation within an evidence-based perspective. Main Outcome Measures Assessment of diagnostic tests for ED using principles of EBM. Results Several good diagnostic tests are useful in the evaluation of men with ED. However, modern evidence-based concepts—mainly the likelihood ratio—have not yet been applied to these tests to obtain their maximum clinical benefits. Conclusions While penile duplex/color Doppler has good evidence of supporting its use in the diagnosis of arteriogenic ED, data supporting its diagnosis of a physical disorder associated with cavernous venous occlusion dysfunction are lacking. PHCAS/PHCAG's main drawback is an unknown positive predictive value and a possibility of frequent false-positive results. NPT has many advantages when differentiating psychogenic from organic ED, however, several questions related to its physiological mechanisms do exist. Ghanem H, and Shamloul R. An evidence-based perspective to commonly performed erectile dysfunction investigations. [Correction added after online publication 14-Dec-2007: In the above reference for this article, the order of the author names has been updated.]

Objectives Our report describes the construction and evaluation of the Arabic Index Premature Ejaculation (AIPE) as a diagnostic tool for premature ejaculation (PE) and presents data supporting its validity. Methods and Main Outcome Measures Seventy-one men complaining of PE and 73 healthy subjects were asked to complete the seven-question AIPE. Diagnosis of PE was based on the criteria set by the second consultation on sexual dysfunctions. The seven items selected were based on assessment of erectile function, sexual desire, ejaculation latency, ejaculation control, patient satisfaction, partner satisfaction, and psychological distress. The AIPE was examined for sensitivity, specificity, and construct validity. Results A receiver operating characteristic curve indicated that the AIPE is an excellent diagnostic test. A cutoff score of 30 (range of scores 7–35) discriminated best (sensitivity = 0.98, specificity = 0.88). Severity of PE ranged from none (31–35) to severe (7–13). A high kappa value (0.85) indicated existence of significant agreement existed between the predicted and “true” PE classes. Conclusions AIPE shows a potential to be a reliable aid to decrease the number of misdiagnosed cases of PE.Arafa M, and Shamloul R. Development and evaluation of the Arabic Index of Premature Ejaculation (AIPE).

Introduction Penile augmentation surgery has become increasingly common though there is no consensus about the management strategy for men with a complaint of small penis. Aim To introduce and evaluate the outcome of a structured management and counseling protocol for patients with a complaint of a small-sized penis. Methods A structured protocol for consultation and management of (physically normal) patients with a complaint of a small penis through a descriptive study comprised of a series of 250 patients. Main Outcome Measures Percentage of patients who elect to undergo penile augmentation surgery. Results Only nine patients (3.6%) chose to seek further surgical intervention. Two had a buried penis, two had true micropenis and five had normal penile size. Conclusions Using a structured management and counseling protocol, most men chose not to undergo penile augmentation surgery, even when offered for free. Ghanem H, Shamloul R, Khodeir F, ElShafie H, Kaddah A, and Ismail I. Structured management and counseling for patients with a complaint of a small penis.

Introduction Premature ejaculation (PE) is regarded as the most common male sexual disorder. Previous studies reported that prostatic inflammation was highly prevalent in PE. However, the effect of antibiotic treatment of cases with PE and chronic prostatitis has not been extensively investigated. Aim To examine the effect of antibiotic treatment in delaying ejaculation in patients with PE and chronic prostatitis. Methods A total of 145 consecutive men attending of secondary premature ejaculation (SPE) were included in this study. Sequential microbiologic specimens were obtained from urine and prostatic fluid. Antibiotics were given for 1 month according to the results of their culture and sensitivity test. All patients were instructed to follow up with our clinic monthly for at least 4 months. At the end of the 4-month follow-up, another prostatic secretion analysis was performed. Results Based on expressed prostatic secretion culture and white blood cell (WBC) count, 94 (64.8%) were having chronic bacterial prostatitis. The remaining 51 (35.2%) patients had negative WBC count. Of the 94 patients with SPE and chronic bacterial prostatitis, 20 patients were left untreated and considered as a control group. All 74 patients with PE and chronic prostatitis continued the 1-month treatment duration. Following 1-month antibiotic treatment, all 74 patients with initially positive cultures had sterile final cultures ( P Conclusions Successful eradication of causative organisms in patients with PE and chronic prostatitis may lead to marked improvement in intravaginal ejaculatory latency time and ejaculatory control. El-Nashaar A, and Shamloul R. Antibiotic treatment can delay ejaculation in patients with premature ejaculation and chronic bacterial prostatitis.

Introduction: The main advantages of semirigid penile prosthesis are simple implantation, ease of use, very low risk of mechanical failure and more financial suitability for patients in developing countries. Aim: To evaluate reliability and safety of Tube® (Promedon, Cordoba, Argentina) penile prosthesis in the surgical treatment of erectile dysfunction. Patients and Methods: This retrospective case series was conducted on 83 patients who underwent Tube penile implant surgeries between 2001 and 2006. The choice of Promedon penile implant was determined by the patient himself. Strict infection control measures were applied. Patients were followed up for stability of vital signs and discharged within 72 h. Results: Successful sexual intercourse was possible for 75 (90.4%) of cases. Common postoperative complaintswere: prosthesis too short in 27 cases (32.5%), not happy with the appearance of the penis in 8 cases (9.6%), non-specific pain which subsided spontaneously in 20 cases (24%), in which no further intervention was done apart from reassurance. 79 (95.2%) patients were on regular follow-up for the first year and the rest dropped out. None of the patients experienced prosthetic infection postoperatively. Crural cross-perforation (4%) was managed intraoperatively. Hematomas (1.6%) were managed conservatively. Retarded ejaculation (10%) and penile hypothesia (0.8%) resolved spontaneously within 6 months in all cases. Conclusion: The Promedon malleable penile prosthesis is reliable and safe in the surgical treatment of erectile dysfunction.

Treatment of established hypertension, especially for prolonged control of this pathogenic process, represents a great challenge. To upregulate the expression of heme oxygenase (HO) to lower blood pressure (BP) of spontaneously hypertensive rats (SHRs), we administered hemin to 12-week-old adult SHRs through subcutaneously implanted osmotic minipumps for 3 consecutive weeks (the hemin protocol). Systolic BP of SHRs was normalized 123±2 mm Hg (n=20; P

Introduction Erectile dysfunction (ED) and depression are highly prevalent medical disorders affecting men of diverse cultures throughout the world. Tianeptine is a new antidepressant drug with less adverse effects on sexual functions. Aim To evaluate the efficacy of tianeptine in the treatment of mild to moderate depression with ED. Methods and Main Outcome Measures A randomized, double‐blind, placebo‐controlled, crossover trial. Subjects were assigned either tianeptine or matching placebo, each for 8 weeks. All patients were followed up on monthly basis where they were asked to complete three assessment questionnaires, namely, Anxiety and Depression Scale, Brief Sexual Inventory, and Quality‐of‐life and erection questionnaire. All patients were asked a global assessment question. Treatment‐responsive subjects were defined as study participants who had scores 1–16 on the Anxiety and depression Scale, showed normal erectile function on the Brief Sexual Inventory, and answered “yes” to the global assessment question. Results Of the 237 consecutive men complaining of ED of >6 months and screened for this study, 110 patients met our inclusive criteria; 42 declined to participate. The remaining 68 patients were randomly assigned to treatment. Significant improvement ( P Conclusions Tianeptine could be considered an effective therapy for the treatment of depression and ED. Further large‐scale multicentered studies are warranted. El‐Shafey H, Atteya A, el‐Magd SA, Hassanein A, Fathy A, and Shamloul R. Tianeptine can be effective in men with depression and erectile dysfunction. J Sex Med 2006;3:910–917.

Objectives To evaluate the efficacy of regular prostatic massage in combination with culture-specific antibiotic therapy for men with chronic prostatitis. Methods This study included 81 consecutive patients who attended our outpatient clinic with a history or symptoms suggestive of chronic prostatitis (National Institutes of Health category II and IIIA). In addition to prostatic culture and sensitivity, all patients were asked to complete the National Institutes of Health Chronic Prostatitis Symptom Index. According to their chronic prostatitis category, all patients were divided into four groups: group 1, chronic bacterial prostatitis treated with antibiotics and prostatic massage, n = 17; group 2, chronic bacterial prostatitis treated with antibiotics alone, n = 20; group 3, chronic nonbacterial prostatitis treated with antibiotics and prostatic massage, n = 25; and group 4, chronic nonbacterial prostatitis treated with antibiotics alone, n = 19. Results Of the 37 patients with initially positive cultures, 30 (81.1%) had sterile final cultures. Overall, 30 patients (37%) of 81 had complete resolution of symptoms, 18 (22.2%) had initial resolution but had recurrence after therapy, 22 (27.1%) had partial improvement, and 11 (13.5%) had no improvement. No significant difference was found in the response between patients treated with antibiotics alone and those treated with antibiotics and prostatic massage in all four groups. Only 29% of class IIIa patients had complete improvement in contrast to 52% complete improvement in the class II patients. Conclusions Prostatic massage did not significantly improve the response of patients with chronic pelvic pain syndrome to antibiotics. Patients with National Institutes of Health class II prostatitis should be primarily treated with culture-sensitive antibiotics. Treatment of nonbacterial prostatitis is challenging and requires additional extensive research.

Selective serotonin reuptake inhibitors (SSRIs) are increasingly used to treat premature ejaculation. We report a large prospective placebo-controlled crossover study of sertraline in premature ejaculation (PE) using Arabic Index of Premature Ejaculation (AIPE). One hundred and forty-seven men suffering from PE were enrolled in a randomized single-blinded crossover study of sertraline hydrochloride and placebo. Patients were randomized into group 1 (n=77) and group 2 (n=70). Both groups received sertraline and placebo interchangeably for 4 weeks. Overall, 127 (81%) of 157 subjects experienced a significant increase in their AIPE total score after sertraline treatment. Sixty-six (66%) of 100 patients available for follow-up experienced relapse of PE within 6 months after sertraline withdrawal. The active drug was generally well tolerated. Our relatively large study, using a validated questionnaire (AIPE), confirmed the useful effect of sertraline on PE.

Introduction Honeymoon impotence can be defined as the failure to be successfully involved in sexual intercourse at the beginning of marriage, particularly in the first few nights. While its exact causes are not yet elucidated, many studies recognize this problem as related to performance anxiety. Aim The aim of this study was to report the outcome of management of patients with honeymoon impotence. Methods and Main Outcome Measures This study included 100 consecutive patients presenting to our department complaining of failed sexual intercourse since the beginning of their marriage. History taking, completion of the abridged form of the International Index of Erectile Function (IIEF‐5) questionnaire, and combined intracavernous injection and stimulation and nocturnal penile tumescence monitoring were performed. Penile duplex was performed to elucidate vascular insufficiency. All psychogenic patients with erectile dysfunction (ED) were treated with sildenafil and sex therapy. All organic ED patients were treated either with sildenafil alone or combined therapy with either intracavernous prostaglandin E1 or vacuum constriction device. Results Seventy‐four patients had psychogenic ED and 26 patients had vasculogenic ED. All psychogenic ED patients were treated successfully with sildenafil and sex therapy. Twenty‐two patients with vasculogenic ED were treated successfully with sildenafil or combined therapy, while four patients needed venous surgery. Minimal side effects of all treatment modalities occurred throughout the study. Conclusions Management of honeymoon impotence requires profound diagnosis of its causative factors. Treating physicians in areas with high prevalence of this condition should be ready to manage this problem with vigilant systematic overture. A combined approach of sildenafil and sex therapy proved highly effective in treatment of honeymoon impotence of psychogenic origin; however, controlled studies are needed. Other patients showing functional erectile abnormalities should be treated accordingly. Shamloul R. Management of honeymoon impotence. J Sex Med 2006;3:361–366.

Introduction Premature ejaculation is a common male sexual dysfunction, affecting 30–40% of sexually active men in an age‐dependent manner. Chronic prostatitis has been suggested as an important organic cause of premature ejaculation. Aim The aim of this study was to confirm previous data reported on the incidence of chronic prostatitis in a large cohort of patients with primary and secondary premature ejaculation. Methods A total of 153 consecutive heterosexual men aged 29–51 years with premature ejaculation and another 100 male healthy subjects were included in this study. Sequential microbiologic specimens were obtained according to the standardized Meares and Stamey protocol. Nonbacterial prostatitis was defined by the evidence of prostatic inflammation but negative cultures of urine and prostatic fluids in men with various genitourinary symptoms. Results There was no significant difference between patients and control subjects regarding age, education, or intercourse frequency. Prostatic inflammation was found in 64% and chronic bacterial prostatitis in 52% of the patients with premature ejaculation, respectively, showing statistical significance compared with control subjects ( P Conclusions Results in our study showed a high prevalence of chronic prostatitis in patients with premature ejaculation. Examination of the prostate, physically and microbiologically, should be considered during assessment of patients with premature ejaculation. Shamloul R, and Nashaar A. Chronic prostatitis in premature ejaculation: A cohort study in 153 men. J Sex Med 2006;3:150–154.

Penile reconstructive surgeries are performed mainly as radical treatment for conditions associated with congenital abnormalities of the urethra or penis, after penile trauma, penile cancer, short penis, corporal fibrosis and in cases of gender reassignment. In this article, we review the controversial penile augmentation topic, clarifying how most workers disagree with its scientific basis. We also highlight recent advances in surgical techniques in treatment of penile injuries and those employed for female-to-male sex reassignment procedures. We also propose a practical approach for evaluating and counseling patients complaining of a small sized penis.

Introduction Introduction of duplex ultrasonography with color flow Doppler analysis after intracavernous injection of vasoactive drugs has been reported to be a minimally invasive and accurate method, and considered the gold‐standard technique for evaluating penile hemodynamics. However, several studies have demonstrated that in some cases Color Doppler Ultrasound (CDU) testing may result in wrong diagnosis because of anxiety and increased sympathetic stimulation. Aim This study was carried out to evaluate the impact of age on the decision to repeat CDU in patients with initial low peak systolic velocities (PSVs). Methods This is a prospective study involving 71 patients with erectile dysfunction (ED) who presented to the Department of Andrology, Sexology and Sexually Transmitted Diseases at Cairo University between December 2000 and April 2002. An intracavernous pharmacotest and CDU with prostaglandin E1, papaverine, and phentolamine was performed. All patients in the study had poor response to intracavernous pharmacotesting and achieved a low PSV ( Results The group A patients experienced a statistically significant increase ( P P > 0.05) in their PSV measurements in the second CDU, which remained below normal values. Also, there was a statistically significant difference between the PSV measurements of group A and the other three groups. Conclusions Low PSV measurements in young men (less than 30 years old) with ED should be interpreted with caution. The effect of sympathetic overtone because of the environment in the office and anxiety related to penile injection, together with any underlying psychological disturbance, should be taken into consideration during the evaluation of the results of the CDU. Repetition of the CDU is recommended before considering any additional invasive diagnostic or therapeutic modalities. Shamloul R. Peak systolic velocities may be falsely low in young patients with erectile dysfunction. J Sex Med 2006;3:138–143.

INTRODUCTION: The objective of this pilot study was to report our experience concerning the effects of cell phone usage on erectile function (EF) in men. MATERIAL AND METHODS: We recruited 20 consecutive men complaining of erectile dysfunction (ED) for at least six months (Group A), and another group of 10 healthy men with no complaints of ED (Group B). Anamnesis, basic laboratory investigations, and clinical examinations were performed. All men completed the German version of the Sexual Health Inventory for Men (SHIM) for evaluation of the International Index of Erectile Function (IIEF), as well as another questionnaire designed by our clinicians that assessed cell phone usage habits. RESULTS: There was no significant difference between both groups regarding age, weight, height, and total testosterone (Table 1). The SHIM scores of Group A were significantly lower than that of Group B, 11.2 ±5 and 24.2 ±2.3, respectively. Total time spent talking on the cell phone per week was not significantly higher in Group A over B, 17.6 ±11.1 vs. 12.5 ±7 hours. Men with ED were found to carry their 'switched on' cell phones for a significantly longer time than those without ED, 4.4 ±3.6 vs. 1.8 ±1 hours per day. CONCLUSIONS: We found a potential correlation with cell phone usage and a negative impact on EF. Further large-scale studies confirming our initial data and exploring the mechanisms involved in this phenomenon are recommended.

Objectives To compare and assess objectively the postoperative outcome parameters of both microsurgical subinguinal artery sparing and retroperitoneal high ligation techniques for varicocele in infertile men. Methods We performed a prospective study that included 413 consecutive patients who presented with varicocele. Of the 413 patients, 304 underwent subinguinal varicocelectomy (group 1) and 109 patients underwent high ligation varicocelectomy (group 2). Subinguinal varicocelectomies were performed under local anesthesia, with intravenous propofol sedation administered as needed. The operating microscope (×10 to ×16) was used to spare the arteries and lymphatics. High ligation was performed through a retroperitoneal approach. Results All patients went home on the evening after surgery with minimal discomfort. No intraoperative complications occurred. The internal spermatic artery was identified in all microvaricocelectomy cases. No testicular atrophy occurred in either group. Five (1.6%) and seven (6.4%) hydroceles were identified at the 3-month postoperative visit in groups 1 and 2, respectively. Conclusions Microvaricocelectomy is safe and effective and associated with a rapid recovery and minimal morbidity. However, it requires microsurgical training.

There has been a long history of man’s fascination with better and stronger sex drive and performance across different cultures. Several literature texts from the Hindu, Egyptian, Chinese and Roman civilizations document the human endless search for substances that can enhance sexual experiences and/or treat erectile dysfunction.This review will discuss the current research done on the most popular plant aphrodisiacs and provide evidence to support or discourage the use of any of them to enhance sexual desire and/or function in men.We review the current evidence on the use of natural substances as aphrodisiacs.We found very little evidence to support the use of plant aphrodisiacs in the treatment of male sexual dysfunction. The vast majority of studies were conducted on animals with very few clinical studies. Available data suggest a beneficial effect of ginseng as a pro-sexual supplement and not an independent treatment for male sexual dysfunction.Trans-culturally, many herbal therapies show some potential benefits in improving men’s sexual function; however, adequate studies on the specific benefits and health risks associated with their use are needed. We strongly recommend the design and execution of well-controlled clinical studies to determine the efficacy and safety of plant aphrodisiacs.

We report a new technique of preserving the lymphatics during varicocelectomy using saline infusion that we have termed "lymphatic hydrodissection."

Introduction Some of the more common complications of intracavernous injection (ICI) therapy include pain and prolonged erections. Rare reported complications include intracorporeal needle breakage and postinjection cavernositis. Aim We report a case of early management of postinjection cavernositis resulting in preservation of erectile function with no angulation. Methods A 53‐year‐old male with no history of diabetes mellitus presented to our department with a small painful penile swelling 36 hours after ICI of 15 µg prostaglandin E1. Clinical, laboratory, and ultrasound assessments suggested the occurrence of cavernositis. Surgical debridement, abscess drainage, and antibiotics resulted in marked improvement. Follow‐up showed normal erectile function with minimal scarring. Conclusions Timely management of cavernositis can help prevent loss of erectile function. Stringent supervision of patients, after adequate ICI training, together with drug prescription, is essential. Shamloul R, and Kamel I. Early treatment of cavernositis resulted in erectile function preservation. J Sex Med 2006;3:320–322.

Introduction Chronic priapism represents a challenging therapeutic dilemma. Inadequate or deferred treatment can result in impaired quality of life and permanent erectile dysfunction. The etiology of stuttering priapism is speculated to be initially an ischemic injury that damages the neurologic and/or endothelial‐mediated mechanisms that normally regulate detumescence and maintain penile flaccidity. Aim We report a case of stuttering priapism successfully treated with low‐dose ethinyl estradiol. Methods A 51‐year‐old man presented with idiopathic stuttering priapism. Treatment was given in the form of low‐dose ethinyl estradiol for six consecutive weeks. Results Moderate lowering of testosterone level and effective prevention of priapism for at least 6 months with retaining of erectile function. Conclusion The use of low‐dose estrogen shows a potential to be an effective and relatively rapid treatment option for some cases of idiopathic stuttering priapism. Shamloul R, and Nashaar A. Idiopathic stuttering priapism treated successfully with low‐dose ethinyl estradiol: A single case report. J Sex Med 2005;2:732–734.