Cause Of Erectile Dysfunction Research Articles

Traumatic cavernosal artery pseudoaneurysm: a rare cause of erectile dysfunction following pelvic trauma: a case report and comprehensive literature review

Traumatic cavernosal artery pseudoaneurysm: a rare cause of erectile dysfunction following pelvic trauma: a case report and comprehensive literature review

(O-03) DORSAL VENOUS LEAK LIGATION IN PATIENTS WITH ERECTILE DYSFUNCTION. REPORT OF 60 PATIENTS WITH 12-MONTH FOLLOW-UP

Abstract Objective Penile dorsal venocclusive dysfunction is recognized as a cause of erectile dysfunction in some young patients with no other risk factors. The objective of this study is to report the results of a surgical technique in patients who presented ED before the age of 40, with follow-up up to 12 months after treatment. Materials and Methods A descriptive study was carried out in a retrospective cohort of medical records with 60 patients who met the inclusion criteria, evaluated, and underwent standardized ligature surgery by the same surgeon between 01/2014 and 04/2022. The group underwent a symptom score (International Index of Erectile Function-5), before surgery, 3, 6 and 12 months after. The results of the IIFE-5 before and after surgery were related to the different degrees of erectile dysfunction (severe, moderate, and mild); additionally they were divided into three groups according to criteria defined by the IIFE-5 as successful, moderate, and poor. The diagnosis of venous leaks was made by penile Doppler ultrasound, recording venous leaks and degree of penile fibrosis. The study protocol was approved by the Research Committee of the Pablo Tobon Uribe Hospital in Medellín. Results The age of onset of erectile dysfunction was between 14-39 years, mean 23.9; the mean age of the patients who consulted was 31.5 years. The time of evolution of the disease before attempting surgery varied between 2 months and 21 years (average 9.5 years). The result of the preoperative IIFE-5 was: Severe ED: n=6 (10%) and moderate ED: n=54 (90%), there were no preoperative mild ones. Postoperative outcomes at 12 months were: moderate ED n=13 (21.6%); mild ED n=25 (41.6%) and without ED n=22 (36.6%), after the intervention. Additionally, according to the internal analysis of IIFE-5: n=39 (65%) was successful; n=9 (15%) moderate and n=12 (20%) poor. Conclusions Ligation of penile dorsal venous leaks has good medium and long-term results in terms of erection quality and patient satisfaction. Financing No conflicto.

BMP4 and GREM1 are targets of SHH signaling and downstream regulators of collagen in the penis.

Cavernous nerve (CN) injury, caused by prostatectomy and diabetes, initiates a remodeling process (smooth muscle apoptosis and increased collagen) in the corpora cavernosa of the penis of patients and animal models that is an underlying cause of erectile dysfunction (ED), and the Sonic hedgehog (SHH) pathway plays an essential role in the response of the penis to denervation, as collagen increases with SHH inhibition and decreases with SHH treatment. We examined if part of the mechanism of how SHH prevents penile remodeling and increased collagen with CN injury involves bone morphogenetic protein 4 (BMP4) and gremlin1 (GREM1) and examined the relationship between SHH, BMP4, GREM1, and collagen in penis of ED patients and rat models of CN injury, SHH inhibition, and SHH, BMP4, and GREM1 treatment. Corpora cavernosa of Peyronie's disease (control), prostatectomy, and diabetic ED patients were obtained (N= 30). Adult Sprague Dawley rats (n = 90) underwent (1) CN crush (1-7days) or sham surgery; (2) CN injury and BMP4, GREM1, or mouse serum albumin (control) treatment via Affi-Gel beads or peptide amphiphile (PA) for 14days; (3) 5E1 SHH inhibitor, IgG, or phosphate-buffered saline (control) treatment for 2 to 4days; or (4) CN crush with mouse serum albumin or SHH for 9days. Immunohistochemical and Western analysis for BMP4 and GREM1, and collagen analysis by hydroxyproline and trichrome stain were performed. BMP4 and GREM1 proteins were identified in corpora cavernosa smooth muscle of prostatectomy, diabetic, and Peyronie's patients, and in rat smooth muscle, sympathetic nerve fibers, perineurium, blood vessels, and urethra. Collagen decreased 25.4% in rats with CN injury and BMP4 treatment (P = .02) and increased 61.3% with CN injury and GREM1 treatment (P = .005). Trichrome stain showed increased collagen in rats treated with GREM1. Western analysis identified increased BMP4 and GREM1 in corpora cavernosa of prostatectomy and diabetic patients, and after CN injury (1-2days) in our rat model. Localization of BMP4 and GREM1 changed with SHH inhibition. SHH treatment increased the monomer form of BMP4 and GREM1, altering their range of signaling. A better understanding of penile remodeling and how fibrosis occurs with loss of innervation is essential for development of novel ED therapies. The relationship between SHH, BMP4, GREM1, and collagen is complex in the penis. BMP4 and GREM1 are downstream targets of SHH that impact collagen and may be useful in collaboration with SHH to prevent penile remodeling and ED.

(064) Argonaute 2 Restores Erectile Function by Enhancing Angiogenesis and Reducing Reactive Oxygen Species Production in Streptozotocin (STZ)-Induced Type-1 Diabetic Mice

Abstract Introduction Diabetes mellitus (DM), a primary cause of erectile dysfunction (ED), is a pancreatic β-cell dysfunction that leads to insulin deficiency and resistance, resulting in microvascular complications. Argonaute 2 (Ago2), a catalytic engine in mammalian RNA interference, is involved in neurovascular regeneration under inflammatory conditions. Objective In the present study, we aimed to determine whether an exogenous injection of Ago2 proteins can improve erectile function in STZ-induced type-1 diabetic mice and explore the specific mechanisms of Ago2 in the process. Methods Eight-week-old male C57BL/6 mice were used for in vivo study. The detailed mechanisms were evaluated in age-matched control or STZ-induced type-1 diabetic mice. Mouse cavernous endothelial cells and human umbilical vein endothelial cells were used for in vitro study. The function of Ago2 in high-glucose condition was evaluated by tube formation assay, migration assay, immunofluorescence stain and western blot experiments. Results We report that Ago2 administration can effectively improve penile erection by enhancing cavernous endothelial cell angiogenesis and survival under diabetic conditions. We found that although Ago2 is highly expressed around blood vessels and nerves, it is significantly reduced in the penis tissue of diabetic mice. Exogenous administration of the Ago2 protein restored erectile function in diabetic mice by reducing reactive oxygen species production-signaling pathways (inducing eNOS Ser1177/NF-κB Ser536 signaling) and improving cavernous endothelial angiogenesis, migration, and cell survival. Our study provides new evidence that Ago2 mediation may be a promising therapeutic strategy and a new approach for diabetic ED treatment. Conclusions Our study provides new insights into Ago2 function and may represent a new therapeutic approach for ED and other vascular and neurological diseases. Disclosure No.

(100) Cavernovenous Leakage: A New Surgical Treatment in 171 Consecutive Patients with Severe, Drug-Resistant Erectile Dysfunction

Abstract Introduction Cavernovenous leakage (CVL) is a frequent cause of erectile dysfunction (ED) in which blood entering corpora cavernosa escapes too early due to abnormal venous network, for erections to develop or maintain. When PDE5Is are ineffective to compensate for leakage, CVL is a devastating condition, affecting millions worldwide for whom no specific treatment is currently proposed. Objective Evaluate results of a new method of treatment combining open surgery and embolization simultaneously during the same procedure, in patients with CVL resistant to PDE5Is. Methods 171 consecutive patients with severe ED for more than six months, with CVL diagnosed by pharmacologically-challenge penile duplex sonography (PC-PDS) using intracavernous injection of Prostaglandin E1 and Papaverine, were operated-on. Leaks were imaged by caverno-computed tomography. Patient with other cause of ED were excluded, all had refused a penile implant, signed an informed consent, had a control PC-PDS three months after surgery, and were clinically evaluated during follow-up. A retrospective analysis was performed on prospectively collected data. Comparisons of variables before and after surgery used a paired t-test. Results Mean age was 43.8±13.6 years, range 18–76. ED had started at the beginning of sexual life (30) in 47.4%. Mean ED duration before surgery was 11.1±9.1 years (range 0.5–30). All patients had two clinical signs of organic ED: 1. no phase of erection improvement in the past six months, 2. erection alterations during masturbation (Erection Hardness Score (EHS)<3 and/or erection instability). Signs suggesting CVL were 1. variation of erection hardness according to position during masturbations or intercourses in 59.1%, 2. erections instability during masturbation or intercourse in all patients. At three-month evaluation, mean pharmacologic EHS had increased from 2.56±.66 before surgery, to 3.40±.56 (p<.0001). All CVL hemodynamic parameters at PC-PDS had decreased compared to pre-surgery: mean End Diastolic Velocity (from 16.6±9.5 to 9.3±7.7 cm/s, p<.0001), mean leakage speed on Deep Dorsal Vein (from 12.8±13.4 to .8±3.2 cm/s, p<.0001), mean speed on any superficial vein (from 11.2±10.1 to 3.9±6.3 cm/s, p<.0001). Patients unable to perform penetrations despite ICC injection of Prostaglandin E1 20 micg plus Papaverine 40 mg (EHS<3) decreased from 66.9 to 11.6% (p<.001). At the end of the 29.8±20.4-month follow-up, IIEF-5 score had increased from 9.7±5.1 to 15.5±6.0 (p<.0001), clinical EHS during sexual intercourse from 2.0±.7 to 3.3±.7 (p<.0001), penetration success rate from 22.3±31,7 to 70.1±37.2% (p<.0001), mean EHS during masturbation from 2.11±.67 to 3.04±.75 (p<.0001), EHS at morning erection from .95±1.24 to 2.1±1.37 (p<.0001), before and after surgery, respectively. 30.4% did not take any medication for erection. Success rate defined by post-operative EHS>3 and/or EHS increase >0.5 and erection stability was 80.7%. 78.9% recognized sexual support by a sexual medicine specialist is necessary for sexual recovery after surgery. Conclusions Simultaneous open surgery and embolization is a new procedure that offers unprecedented documented results in CVL resistant to PDE5Is. Clinical screening of CVL in ED patients is simple and should be evaluated in sexual medicine practice. Disclosure No.

(065) Characterization of Cardiovascular Function, Metabolic Status and Erectile Function in Preclinical Model of Cardiometabolic Syndrome

Abstract Introduction Cardiometabolic syndrome is a widespread health issue and common cause of erectile dysfunction (ED). Cardiometabolic syndrome encompasses a group of indications including abdominal obesity, insulin-resistant glucose metabolism, dyslipidemia, and hypertension. To date, studies have looked at high fructose or high fat diets to induce cardiometabolic syndrome and ED in rodents, but these models do not closely model the clinical phenotype. Furthermore, the molecular basis of ED in cardiometabolic syndrome needs to be elucidated. Objective Our objective is to characterize the cardiovascular and erectile function, and metabolic status in the ZSF-1 obese rat. This hybrid rat is a cross between a Zucker diabetic fatty female and a spontaneously hypertensive heart failure male rat. We hypothesize that with age the ZSF-1 obese rats will demonstrate similar disease phenotype as seen clinically and develop ED. Methods We used male lean and obese ZSF-1 rats (n=8/group). We measured body weight weekly, and performed apomorphine erectile testing, MRI to assess body composition and glucose tolerance tests at 10, 20, 30 weeks. At 30 weeks, we assessed erectile function using ICP/MAP and vascular stiffness was measured via laser doppler pulse wave velocity (PWV). Additionally, acetylcholine (Ach)-mediated vasodilation, vasodilation to sodium nitroprusside (SNP), and contraction to phenylephrine (PE) was measured in thoracic and abdominal aortas. Aorta and penile segments were collected for histological analyses. Results On average, obese rats were 60% larger (230g) than controls, had greater percent body fat and had significantly impaired glucose tolerance at all time points (p<0.05). Over time, ZSF-1 obese rats developed ED as there was a significant decrease in apomorphine-induced erections by 30 weeks (p<0.05). ED was confirmed by significantly reduced ICP/MAP in ZSF-1 obese compared to lean rats (p<0.05). Obese rats were significantly more hypertensive compared to lean rats (MAP: 140.2 mmHg vs 99.6mmHg, p<0.05). Lean and obese rats had no difference in vascular stiffness indicated by PWV. In our tissue bath experiments, ACh-mediated vasodilation was significantly decreased in the thoracic aorta of obese rats (p<0.05) while the abdominal aorta was unchanged. SNP-mediated vasodilation was similar between groups in both thoracic and abdominal aortas. At high concentrations, PE-mediated vasoconstriction was significantly increased in the thoracic and decreased in the abdominal aortas of obese rats (p<0.05). Conclusions To our knowledge, this is the first report on the erectile function in the ZSF-1 rat model of cardiometabolic syndrome. The ZSF-1 obese rats had marked adiposity, hypertension, hyperglycemia and presented with aortic endothelial dysfunction and ED. We are currently assessing testosterone levels and penile fibrosis. We believe that the ZSF-1 rat is useful for studying ED as they gradually develop metabolic disease and ED over time like the human disease. Disclosure No.

(061) Analysis of BMP4 and GREM1 as Targets of SHH Signaling and Downstream Regulators of the Collagen Axis in the Penis

Abstract Introduction Cavernous nerve (CN) injury caused by prostatectomy and diabetes, initiates a remodeling process (smooth muscle apoptosis and increased collagen) in the corpora cavernosa of the penis of patients and animal models that is an underlying cause of erectile dysfunction (ED). The Sonic hedgehog (SHH) pathway plays an essential role in the response of the penis to denervation, as collagen increases with SHH inhibition and decreases with SHH treatment. Part of the mechanism of how SHH impacts collagen may involve bone morphogenetic protein four (BMP4) and GREMLIN (GREM1). Microarray analysis identified increased GREM1 (BMP4 antagonist) in corpora cavernosa of ED patients and SHH is a regulator of GREM1 in the limb bud. Objective We will examine the relationship between SHH, BMP4, GREM1 and collagen in penis of ED patients and rat models of CN injury, SHH inhibition, and SHH, BMP4 and GREM1 treatment. Methods Corpora cavernosa of Peyronie’s (control), prostatectomy and diabetic ED patients was obtained (n=26). Adult Sprague Dawley rats (n=90) underwent either: 1. CN crush (1-7 days) or sham control, 2. CN injury and BMP4, GREM1 or MSA (control) protein treatment via Affi-Gel beads or peptide amphiphile (PA) for 14 days, 3. 5E1 SHH inhibitor, IgG and PBS (controls), or SHH protein treatment for 2-4 days. Immunohistochemical and western analysis for BMP-4 and GREM1, and collagen analysis by hydroxyproline and trichrome stain were performed. Results BMP4 and GREM1 proteins were identified in corpora cavernosal smooth muscle of prostatectomy, diabetic and Peyronie’s patients, and in rat penis, sympathetic nerve fibers, perineurium, blood vessels, and urethra. Collagen decreased 25.4% in rats with CN injury and BMP4 PA treatment (p=0.02) and increased 61.3% with CN injury and GREM1 treatment (p=0.005). Trichrome showed increased collagen in rats treated with GREM1. BMP4 increased smooth muscle. Western identified increased BMP4 and GREM1 in corpora cavernosa of prostatectomy and diabetic patients, and after CN injury (1-2 days) in our rat model. Localization of BMP4 and GREM1 changed with SHH inhibition. SHH treatment increased BMP4 and GREM1. Aging did not impact BMP4 and GREM1 localization. Conclusions BMP4 and GREM1 are downstream targets of SHH that impact collagen and may be useful in collaboration with SHH to prevent penile remodeling and ED. Better understanding of penile remodeling and how fibrosis occurs is essential for development of novel therapies for ED. Disclosure No.

(151) Safety and Feasibility of the COCKTAIL (Combining Shockwave Therapy and Platelet-Rich Plasma for Erectile Dysfunction) Trial: A Single Center, Randomized, Double-Blind, Sham-Controlled Study Update

Abstract Introduction Therapeutic approaches focusing on tissue neovascularization play a crucial role in the development of treatments for erectile dysfunction (ED). Autologous Platelet-Rich Plasma (PRP) and Low-Intensity Shockwave Therapy (SWT) are two restorative therapies that potentially target underlying causes of ED. Pre-clinical evidence suggests their angiogenic and regenerative properties, indicating a potential synergistic pathway to improve vasculogenic ED. Objective The primary objective aims to investigate and compare the treatment efficacy of PRP injection and SWT vs placebo injection/SHAM treatment in men with mild-moderate ED, as measured by IIEF. The secondary objective aims to study incidence of adverse events and safety of PRP injection and SWT treatment in men with mild-moderate ED, as measured by IIEF. Methods The COCKTAIL (Combining Shockwave Therapy and Platelet Rich Plasma) trial is a Phase II, single-center study assessing the safety and efficacy of PRP and SWT in combination for ED (NCT05048667). Thirty-five men with mild to moderate ED were enrolled based on International Index of Erectile Function-EF subdomain (IIEF-EF) questionnaire (12-25). Data from a cohort of men treated with PRP and SWT were analyzed, comparing it to men who received placebo saline injections and sham SWT. Patients received two PRP or placebo injections directly into the corpus cavernosum and penile SWT every week for 5 weeks. Assessment included pain scale evaluations, immediate post-procedure examination, and follow-up for complications. IIEF scores were recorded at baseline, 3-month, and 6-month follow-up visits. All statistics and analyses were conducted with IBM SPSS Statistics 27.0.1. Non-parametric tests were used for analysis. Mann-Whitney U test was used to compare independent groups (Group A vs. Group B) at different time points. Related Samples Wilcoxon -Signed Rank test was used for dependent repeated groups, the serial measurements of IIEF-EF scores at different time points for each patient within a specific group. Findings at p< 0.05 were considered statistically significant. Results The primary endpoint of this study was to investigate the incidence of Serious Adverse Events (SAEs). Encouragingly, no adverse events were reported, suggesting that the procedure appears to be safe for the participants. The median baseline IIEF scores for patients in Group A were 17 (±4), and at the three-month follow-up, the scores increased to 19 (±4), slightly dropping to 18 (±8) at six months. In Group B, the median baseline IIEF scores were 19.50 (±4), which improved to 20 (±7) at the three-month follow-up and further increased to 21 (±10) at six months. No statistical differences were found likely because this is an ongoing study, and we only have complete data for 12 men. We aim to accrue a total of 30 men in each arm and plan to complete the recruitment by January 2024 and complete the study by July 2024. Currently, both the investigators and the patients remain blinded. Conclusions The combination of PRP and SWT appears to be safe, as no adverse events were reported. Although preliminary data do not show differences between the treatment and sham groups currently, we intend to complete the trial to perform a comprehensive statistical calculation for efficacy. Disclosure No.

(318) Factors Influencing Compliance with Trimix, an Intracavernosal Injection for Erectile Dysfunction: A Retrospective Analysis

Abstract Introduction Trimix, an intracavernosal injection therapy, is an effective treatment for erectile dysfunction. However, patient compliance with Trimix use is crucial for treatment success, and factors influencing compliance are not well understood. Objective This retrospective analysis aimed to identify factors that influence compliance with Trimix therapy among patients with erectile dysfunction. Additionally, the study aimed to investigate the impact of comorbidities, specifically diabetes and prostate cancer, on the duration of Trimix treatment. Methods Patient data from pharmacy records between 2017 and 2022 was analyzed. Custom Python code was used to calculate the duration of Trimix use based on the first and last prescription refill events. A comprehensive chart review was conducted to collect additional patient-related data, including demographics and comorbidities. Cox Proportional Hazards Regression models were employed to assess the effects of predictor variables on the duration of Trimix use. Simple linear regression was used to compare the presence of diabetes, prostate cancer, or both on time spent on Trimix treatment. Results The analysis included a total of 4,072 patients. Age was identified as a significant predictor of Trimix therapy discontinuation, with every additional year of age associated with an increased hazard ratio of 1.007 (p < 0.001). Preferred language also emerged as a significant predictor, with patients preferring Spanish exhibiting a higher hazard ratio of 1.163 compared to patients preferring English (p = 0.004). In terms of comorbidities, the presence of prostate cancer significantly differed from other organic causes of erectile dysfunction on time spent on Trimix treatment (p = 0.002), resulting in 80 fewer days of Trimix treatment. Conclusions This retrospective analysis revealed that age and preferred language are important factors influencing compliance with Trimix therapy. Older patients and those preferring Spanish were more likely to discontinue Trimix treatment. Additionally, the presence of prostate cancer significantly impacted the duration of Trimix treatment. These findings emphasize the need for age-specific counseling, language-concordant interventions, and tailored approaches to address comorbidities such as prostate cancer. Understanding these factors is vital for optimizing treatment adherence and efficacy in patients with erectile dysfunction. Disclosure No.

(153) Hyperbaric Oxygen Therapy as a Treatment for Erectile Dysfunction: A Meta-analysis

Abstract Introduction Hyperbaric oxygen therapy (HBOT) is a medical treatment in which the patient is exposed to 100% oxygen at a higher than atmospheric pressure. Over the past few decades, HBOT has been used to treat a variety of medical conditions, including radiation cystitis, decompression sickness and carbon monoxide poisoning. In recent times, there has been a rising curiosity regarding the potential therapeutic benefits of hyperbaric oxygen therapy in the treatment of erectile dysfunction (ED), a prevalent condition that affects a vast number of men globally. Objective The aim of this study was to review and meta-analyze available data regarding the use of HBOT for erectile dysfunction, including its potential mechanisms of action and effectiveness. Methods Two investigators (GS and TN) screened 54 articles and included only those that evaluated the impact of HBOT on ED symptoms using the IIEF score. Prospective non-randomized studies or randomized controlled clinical trials were included, while non-original studies, conference abstracts, and case reports were excluded. Data extraction was performed in duplicate. Data analysis was conducted using Review Manager 5.41, and the presence of heterogeneity between studies was evaluated. The results were presented as the Mean Difference (MD) with 95% confidence intervals (CI). The significance level was set at P = 0.05. Results A total of five studies that reported outcomes using the IIEF scores were included in this analysis, which comprised a total of 175 patients who received HBOT and 178 control patients. The IIEF scores were analyzed by stratifying the studies according to the indication for HBOT or the cause of ED. In patients with post-robotic assisted laparoscopic prostatectomy (RALP)-induced ED, the analysis showed a significant Mean Difference (MD) of -4.13[-6.08, -2.18] p<0.0001 in favor of the control group. Conversely, patients who received HBOT for reasons other than ED exhibited a MD of 4.58[2.63,6.52] p<0.00001. In the group that received HBOT for pure vasculogenic ED, the MD was 10.50[9.92,11.08] in favor of HBOT. Patients with urethral strictures exhibited a MD of 4.25[2.29-6.21] favoring the HBOT intervention. Meta-analysis of these data revealed a nonsignificant difference in erectile function scores, with an MD of 3.86[-2.13, 9.86] p<0.00001. Conclusions The use of HBOT in the treatment of ED appears to be a promising approach. While further research is needed to establish the efficacy and long-term effects of this treatment, preliminary studies have shown encouraging results in terms of improving erectile function in men with vasculogenic ED. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for AbbVie, Marius, Tolmar, Endo, Petros, Boston Scientific, Coloplast Investor: Sprout.

Type 2 Diabetes Mellitus and Erectile Dysfunction: A study on risk factors and their correlation to serum testosterone level.

Background 
 Diabetes mellitus (DM) is one of the major cause of erectile dysfunction (ED). Testosterone regulates nearly every component of ED and this subnormal testosterone concentration con tribute to ED. 
 The objective of our work was to study the age of the patient, duration of diabetes mellitus, body mass index (BMI), glycosylated haemoglobin (hbA1c) and urinary albumin creatinine ratio (uACR) in type 2 diabetic male patients as etiology for ED and their relation to the serum testosterone level. 
 Methodology 
 We studied 100 male type two diabetic patients selected from the outpatient department of the Family Medicine department in Olive Healthcare. We divided our patients into two groups. Group A: 50 patients with type 2 diabetes mellitus with ED and Group B: 50 patients with type 2 diabetes mellitus without ED. We assessed their history with special focus on the age of the patient, disease duration and lab investigations. The patients answered the five item version of the International Index of Erectile Function (IIEF-5) questionnaire. 
 Results 
 Total serum testosterone was significantly lower in type 2 diabetic male patients with ED compared to those without ED. HbA1c, diabetes duration and uACR were independently negatively correlated with testosterone level. 
 Conclusion 
 The duration of diabetes, glycemic control and uACR contributed to ED in type 2 diabetics and they are independently and negatively correlated with total serum testosterone level.

Chronic Pain and Erectile Dysfunction: Mechanism, Treatment, and Future Perspective

Erectile dysfunction is a problem with multiple causes and is challenging to diagnose. Chronic pain has been associated with erectile dysfunction in some studies. Chronic pain can be a potential direct or indirect cause of sexual dysfunction. A decreased sexual desire due to restricted sexual activity in chronic pain can result in erectile dysfunction. Erectile dysfunction has been linked to migraines, chronic pain, and psychological factors. Multiple neurotransmitters may contribute to the pathophysiology of erectile dysfunction. Depression and anxiety, as well as painkillers like pregabalin and opioids, can be indirect causes of erectile dysfunction. Numerous factors affect the occurrence of erectile dysfunction; therefore, erectile dysfunction must be treated holistically.

Erectile function in men with COVID-19 six months after recovery

Background. Based on the results of epidemiological studies, it was found that coronavirus disease 2019 (COVID-19) affects men more often than women. Among COVID-19 complications, erectile dysfunction is considered a marker of endothelial dysfunction and one of the main factors for the development of cardiovascular diseases. Lower total and free testosterone levels are predictors of adverse prognosis in males with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Testosterone deficiency syndrome is considered an independent risk factor of cardiometabolic disorders. The purpose of the study is to investigate the state of erectile function in men who suffered from COVID-19 six months after recovery. Materials and methods. Seventy-two men suffering from COVID-19 and being treated in an infectious disease hospital were examined 6.90 ± 0.29 months after recovery. Their average age was 45.23 ± 3.01 years. The control group included 18 conditionally healthy men aged 43.18 ± 2.90 years. The state of erectile function was assessed using the International Index of Erectile Function (IIEF). The concentration of testosterone was determined by the enzyme-linked immunosorbent assay with DRG (Germany) and DiaMetra (Italy) kits. All measurements were performed on the Stat Fax 3200 analyzer. Statistical comparison of the obtained results between groups was performed according to the Student’s test. A value of p < 0.05 was considered to be signifi­cant. Results. In addition to erectile dysfunction, as evidenced by a reduced corresponding integrative indicator “erectile function” of IIEF-15 in men with COVID-19, a decrease in sexual desire was found, as well as a deterioration of sensations in the form of a decrease in ejaculation frequency and orgasmic sensations during sex contacts. The average serum level of total testosterone was 10.9 nmol/l and was significantly reduced compared to that in the control group. Analysis of individual indicators showed that testosterone level was decreased in 10 patients and was within the normal range in 13 men with COVID-19. The average serum concentration of total testosterone in the examined men after the disease was 10.73 ± 1.07 nmol/l and was significantly reduced compared to that of the control group. Conclusions. There was an erectile dysfunction in men who suffered COVID-19, it was confirmed by a probable decrease in IIEF-15 score and integrative indicators of erectile function. A significant decrease in the blood concentration of total testosterone was detected in the examined men, which may be one of the causes of erectile dysfunction. Large-scale prospective, randomized, controlled trials in patients infected with SARS-CoV-2 are needed to provide an understanding of the molecular mechanisms that cause erectile dysfunction.

Risk of unfavorable outcomes after penile prosthesis implantation - results from a national registry (INSIST-ED).

Like all surgeries, penile prosthesis implantation (PPI) has the potential for both postoperative complications and suboptimal patient satisfaction. In order to assess risk factors for poor satisfaction, we reviewed patients who had been prospectively recruited in a national multi-institutional registry of penile prostheses procedures (INSIST-ED) from 2014 to 20121. Patient baseline characteristics and postoperative complications were recorded. The primary endpoint of this study was unfavorable outcomes after inflatable PPI, defined as significant postoperative complications (Clavien-Dindo ≥2) and/or Sexuality with Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) scores below the 10th percentile. A total of 256 patients were included in the study. The median age was 60 years (IQR 56-67). The most common cause of erectile dysfunction (ED) was organic (42.2%), followed by pelvic surgery/radiotherapy (39.8%) and Peyronie's disease (18.0%). Postoperative complications were recorded in 9.6%. High-grade complications (Clavien ≥2) occurred in 4.7%. At 1-year follow-up, the median QoLSPP total score was 71 (IQR 65-76). In all, 14.8% of patients were classified as having experienced unfavorable outcomes because of significant postoperative complications and/or QoLSPP scores below the 10th percentile. Logistic regression analysis demonstrated patient age to be non-linearly associated with the risk of experiencing unfavorable outcomes. A U-shaped correlation showed a lower risk for younger and older patients and a higher risk for middle-aged men. ED etiology and surgical volume were not associated with PPI outcomes. Physicians should, therefore, be aware that middle-aged men may be at higher risk of being unsatisfied following PPI compared to both younger and older patients.

Investigating the risk factors of penile arterial insufficiency and veno-occlusive dysfunction in patients with erectile dysfunction.

To investigate the risk factors for penile arterial insufficiency (PAI), which is a known cause of erectile dysfunction (ED). Patients who attended our urology clinic complaining of ED for more than 6 months were prospectively enrolled in this study over 1-year period. Patient consent was taken and ethical committee approval. Complete medical history and thorough general and local examination including body mass index (BMI), Peyronie's disease (PD) and penile size measurements (length and girth) were done for all of them. Laboratory tests included testosterone, lipid profile and glycated haemoglobin (HA1c). A penile duplex ultrasound study (PDU) was done for all patients after intracavernosal injection (ICI) with alprostadil. Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were measured after 15 min. Statistical analysis was done using SPSS. A total of 440 patients were enrolled in this analysis. The mean age was 48(23-81), and the mean BMI was 30 (18-51). Older patients had lower PSV (r= -0.361, P= 0.000) and higher EDV (r= 0.174, P= 0.001), and both correlations were highly statistically significant. Diabetics had lower PSV (r= -0.318, P= 0.000) and higher EDV (r= 0.139, P= 0.008), which were also highly statistically significant. Smokers had lower PSV (r= -0.140, P= 0.008) and higher EDV (r= 0.178, P= 0.001), which were highly statistically significant. Men with larger penises measured skin to tip had lower EDV (r= -0.119, P= 0.024), which was less significant. Interestingly, there was neither a significant correlation between BMI and PSV (0.16, P= 0.745) nor a significant correlation between testosterone and PSV (0.029, P= 0.552). Also, there was no correlation between PSV and both dyslipidaemia and penile PD. Ageing, tobacco consumption, DM and hypertension seem to have a negative impact on penile haemodynamics, which was statistically significant. In our patients, there was no statistically significant effect on penile haemodynamics in patients with increased BMI, low testosterone or PD or according to the size of the penis.

Endovascular treatment of traumatic penile arteriospongious fistula in a patient with erectile dysfunction: a case report and literature review

BackgroundAn arteriovenous fistula is an abnormal communication between an artery and a vein. Traumatic penile arteriospongious fistula is a rare complication and has been described as a cause of erectile dysfunction. Clinical evaluation of patients with erectile dysfunction after penile trauma includes a thorough history, physical examination, vascular assessment, and other complementary exams. Treatment consists of endovascular embolization, surgical ligation, or a combination of both techniques.Case presentationA 40-year-old man presented with erectile dysfunction that had persisted since suffering blunt trauma a few months ago. He reported problems with short duration of erection and insufficient penile tumescence. Due to high suspicion of an arteriovenous fistula, he was referred to angiography, which confirmed the diagnosis of an abnormal connection between the pudendal vessels. The patient was treated with the coil embolization technique and the symptoms were successfully resolved after endovascular treatment.ConclusionsThe appearance of a post-traumatic arteriospongious fistula is a rare complication with almost non-existent literature reported. Rapid development in endovascular techniques, in which we use embolic agents to block anomalous blood flow, has allowed safe, effective and less invasive alternative to surgery. Our case demonstrates that endovascular approach is a successful treatment for post-traumatic arteriospongious fistula since the symptoms were resolved, and normal erectile function was regained after the intervention.

Effect of hypoandrogenism on expression of transient receptor potential vanilloid channels in rat penile corpus cavernosum and erectile function.

Hypoandrogenism is a cause of erectile dysfunction (ED). Vascular smooth muscle cell contraction and relaxation are regulated by TRPV1-4 channels. However, the influence of hypoandrogenism on TRPV1-4 and its relationship with erectile function remain unclear. To reveal whether hypoandrogenism affects erectile function by influencing TRPV1-4 expression in the corpus cavernosum of rats. Male Sprague-Dawley rats (N = 36) aged 8 weeks were assigned to 6 groups at random (n = 6): sham operation, castrated, castrated + testosterone replacement, sham operation + transfection, castrated + transfection, and castrated + empty transfection. Four weeks after castration, 20μL of lentiviral vector (1 × 108 TU/mL) carrying the TRPV4 gene was injected into the penile cavernous tissue of the transfection groups. One week after transfection, the maximum intracavernous pressure (ICPmax)/mean arterial pressure (MAP) and the content of TRPV1-4, phosphorylated eNOS (p-eNOS)/eNOS, and nitric oxide (NO) in penile cavernous tissue of each group were measured. Under low androgen conditions, TRPV4 expression in endothelial cells in the rat penile cavernosum was sharply reduced, resulting in a decrease in p-eNOS/eNOS and NO content, which could inhibit erectile function. In rat penile cavernous tissue, TRPV1-4 was expressed in the cell membranes of endothelial cells and smooth muscle cells. The ICPmax/MAP and the content of TRPV4, p-eNOS/eNOS, and NO end product nitrite level in rat penile cavernous tissue was markedly reduced in the castrated group as compared with the sham group (P < .05). The ICPmax/MAP and the content of TRPV4, p-eNOS/eNOS, and NO end product nitrite level in rat penile cavernous tissue were markedly improved in the castrated + transfection group vs the castrated group (P < .01). Upregulation of TRPV4 expression in penile cavernosum tissue might be a viable therapeutic for ED caused by hypoandrogenism. The specific mechanism of TRPV4 in ED needs to be further verified by androgen receptor or TRPV4 gene knockout experiments. Hypoandrogenism may cause ED by reducing the expression of TRPV4 in rat penile cavernous tissue. Upregulation of TRPV4 expression in penile cavernous tissue can increase the ratio of p-eNOS/eNOS and NO levels and ameliorate the erectile function of castrated rats.

Correlation between erectile dysfunction and serum B12 levels: a 136-case cross-sectional analysis.

Erectile dysfunction (ED) involves the inability to initiate or sustain penile erection with sufficient hardness to ensure satisfying sexual relations. Many causes are blamed in the etiology. In this study, the correlation between serum vitamin B12 (vit B12) levels with ED was researched in a homogeneous case group after exclusion of all other predisposing conditions causing ED. The study included male patients attending the urology clinic from 2015 to 2022. Patients were prospectively registered to the study. Cases were divided into two groups as low and normal according to vit B12 levels. In the study, vit B12 levels ≤200mg/dL were accepted as low. The Sexual Health Inventory for Men-5 (SHIM-5) was used to assess the erectile function. The SHIM-5 scores for the groups were compared. All patients with comorbid diseases, medication use, or previous surgical history predisposing toward ED and organic and/or psychogenic causes for ED were excluded from the study. The study included 136 patients abiding by the study criteria among 957 patients. The mean age of cases was 63.35±7.83 years. Mean vit B12 value was 320.74±184.74mg/dL and 32 cases (23.5%) had inadequate vit B12 (<200mg/dL). The mean SHIM-5 value in the group was 15.48±6.71. In the inadequate vit B12 and normal vit B12 groups, the mean SHIM-5 values were 15.30±6.85 and 16.06±6.28, respectively, with no significant difference between the two groups (t=0.562, p=0.575). Vit B12 deficiency was identified in 26.7% of patients with sexual desire disorder (SDD) (n=90) and 17.4% of those without SDD (X2=1.46, p=0.228). Contrary to the general trend in the literature, we found no significant correlation between vit B12 levels and ED. There is a need for prospective randomized controlled studies for detailed analysis of the correlation between erectile dysfunction and vit B12.

Male Sexual Dysfunction-Related Medical Comorbidities in a Tertiary Care Center, Western Region, Saudi Arabia.

Sexual functionality is considered a vital component of human life and quality of life. Issues with sexual functionality can be a source of distress, lower self-esteem, and lower quality of life. Early detection of medical comorbidities can significantly lower the effect on sexual function. In Saudi Arabia, studies investigating the association between medical comorbidities and male sexual dysfunction (MSD) are limited. Therefore, our goal was to fill this knowledge gap. This study aimed to analyze and elaborate on all cases of MSD at a tertiary hospital, in Jeddah, Saudi Arabia from 2016 to 2021. This is a cross-sectional retrospective study. The medical records of 321 patients diagnosed with MSD from 2016 to 2021 were reviewed retrospectively. The age, sex, type of sexual dysfunction, comorbidities, and lipids profile were some of the factors obtained from the patient's computerized medical records. The study population included 321 men with MSD and a mean age of approximately 53 years (SD=11.5). Among the sexual dysfunction pattern, only erectile dysfunction (ED) was found in 279 (86.9%) patients. ED duration lasted one to five years in 169 (52.8%) patients. Most of the patients (196, 61.1%) had mild ED severity. Medical causes were seen in 278 (80.4%) patients. The most frequent comorbidities were diabetes mellitus (DM) in 179 (55.8%) patients, hypertension (HTN) in 155 (48.2%) patients, and dyslipidemia in 113 (35.2%) patients. Smoking was not a risk factor for ED. The risk of having a severe form of ED was associated with idiopathic causes, HTN, DM, and ischemic heart disease (IHD). The risk of having a long duration of ED was related to idiopathic causes of ED and high serum creatinine levels. In conclusion, patients diagnosed with DM, HTN, and IHD are at greater risk to experience a severe form of ED. It is crucial to keep erection function in mind for patients with DM, HTN, and IHD as this is associated with severe ED.

Use of Phytotherapy in the Treatment of Patients with Erectile Dysfunction

Erectile dysfunction (ED) is one of the most common sexual disorders. In men with a mild stage of ED, it is possible to achieve a therapeutic effect from the use of phytotherapy. The objective: analysis of the effectiveness of the combination of natural compounds in patients with mild ED. Materials and methods. 28 patients (average age – 35±5.3 years) with mild ED participated in the study of the effectiveness of the dietary supplement. All patients were examined before and 1 month after the use of the combination of natural compounds, namely: collection of a detailed medical and sexual history, ultrasound dopplerography of the vessels of the penis, lipidogram, blood glucose level and total testosterone level were measured in the laboratory. The patients received the dietary supplement, which includes zinc citrate, L-arginine, an extract of the fruits of slanky anchovies, an extract of epimedium leaves, an extract of the root of Tongkat Ali, an extract of the root of Korean red ginseng, 1 capsule 2 times a day. Results. During the study, a psychogenic form of ED was found in 12 (42.9%) men, an organic cause of ED in 3 (10.7%), and a mixed form in 13 (46.4%) men. 1 month after the end of the use of the complex, it was established that all indicators of the «International Index of Erectile Function-15» (MIEF-15) questionnaire improved in ED patients. Conclusions. The results of the study showed that the use of the complex significantly improved sexual satisfaction, sexual desire, orgasmic function and quality of life in men with mild ED.