Vasculogenic ED Research Articles

(202) Comparative Study of the Efficacy of Avanafil and Atorvastatin Daily Dose in Management of Vasculogenic Erectile Dysfunction

Abstract Introduction Erectile dysfunction (ED) is defined as the “consistent inability to attain or maintain a penile erection, or both, sufficient for adequate sexual relations”. ED is not only a medical problem but affects the marital relations and patient's self-esteem and causes the quality of life to decrease. which in turn causes the patient to go into depression or develop anxiety. In the past, erectile dysfunction was considered, in most cases, to be a purely psychogenic disorder, but current evidence suggests that more than 80% of cases have an organic aetiology. Causes of organic erectile dysfunction can now be broadly divided into nonendocrine and endocrine. Of the nonendocrine aetiologies, vasculogenic (affecting blood supply) is the most common and can involve arterial inflow disorders and abnormalities of venous outflow (corporeal veno-occlusion). Avanafil is a second-generation phosphodiesterase type 5 inhibitor approved for erectile dysfunction by the FDA on 2012 and by EMA in 2013. With a high selectivity for phosphodiesterase type 5 isoform AND faster onset of action compared with other PDE5 inhibitors, it offers more tolerability and less adverse events. Atorvastatin is 3-hydroxy-methylglutaryl (HMG)-CoA reductase inhibitor act on the rate-limiting step in cholesterol biosynthesis (the conversion of HMG-CoA to mevalonate) and are effective in treating dyslipidemia. statins reverse endothelial dysfunction by decreasing the action of oxidized low-density lipoprotein (LDL) on endothelial cells, resulting in an increase of NO activity. Objective is to evaluate and compare the efficacy of avanafil and atorvastatin daily dose in management of patients with vasculogenic erectile dysfunction. Methods A 60 adult heterosexual males complaining of vasculogenic erectile dysfunction proven by penile duplex were collected from outpatient andrology clinics of Al-Azhar University Hospitals. The patients were divided into two treatment groups: (Group A): 30 patients received daily dose of 100 mg avanafil. (Group B): 30 patients received daily dose of 40 mg atorvastatin, The main outcome measures and the difference in penile duplex ultrasound results and IIEF-EF scores between the two groups are evaluated and compared at the end of the study, Age of patients between 20 and 50 years, established diagnoses of Vasculogenic erectile dysfunction, Normal lipid profile, Normal Total and Free testosterone levels and No contraindications to the study medications were included criteria. However patients who failed to fulfill any of the inclusion criteria, psychogenic or neurogenic erectile dysfunction, dyslipidemia Patients with Renal or Hepatic insufficiency and Patients with advanced cardiovascular diseases such as heart failure and coronary artery disease on antianginal drugs especially nitrates were excluded. Results Our study revealed statistically significant improvement in Penile Doppler ultrasonography parameters (PSV, EDV& RI) and IIEF-EF scores in avanafil group compared to atorvastatin group. Conclusions avanafil 100 mg daily dose leads to significant improvement in men with vasculogenic erectile, while atorvastatin 40 mg caused no significant differences, neither positively nor adversely. In summary, avanafil at dose of 100 mg can be a therapeutic appropriate choice in cases of vasculogenic ED. Disclosure No.

(055) LRRC8A-VRAC Controls Superoxide Anion Flux in Diabetic Vasculogenic Erectile Dysfunction

Abstract Introduction Erectile dysfunction (ED) may be an early marker for cardiovascular diseases, and it is often associated with an hypercontractility of the corpus cavernosum (CC) as a consequence of increased reactive oxygen species (ROS), which favors the flaccid state of the penis. Leucine Rich Repeat Containing 8 (LRRC8A) Volume Regulated Anion Channels (VRACs) regulates Nox1 and modulates the extracellular production of superoxide anion (O2•-). Downregulation of LRRC8A is associated with decreased production of O2•- and we have demonstrated improved relaxation and reduced contraction of the pudendal artery in LRRC8A knockout mice. Objective We hypothesized that the role of LRRC8A in contractile responses to phenylephrine (PE) and electrical field stimulation (EFS) in the CC of diabetic mice would be exaggerated compared to that in normal mice. Methods To test this hypothesis, the CC of diabetic (dbdb-/-) mice was mounted in a myograph, and contraction elicited by PE or EFS was performed in the presence of apocynin (non-selective NOX inhibitor), GKT137831 (NOX1/4 inhibitor) and montelukast (LRRC8A inhibitor). In LRRC8A KO dbdb-/- mice, contractions to PE and EFS were obtained in the absence or in the presence of GKT137831. Results In the CC, the maximal contraction to PE was increased in diabetic animals, and in the presence of 3 mM of apocynin, the contractile response was markedly diminished in both control and diabetic mice. The LRRC8A inhibitor, montelukast, significantly reduced PE-induced contraction of the CC reaching maximal contraction of 69 + 7% and 65 + 10% in the control and diabetic group, respectively, compared to the contraction in the absence of the inhibitor. In the presence of the Nox1/Nox4 inhibitor, GKT137831, the contraction elicited by PE was reduced only in the diabetic group (68 + 9% of the maximal contraction), whereas in the control group this reduction was not significant (82 + 14% of the PE-maximal contraction). In the LRRC8A KO dbdb-/- mice, the contraction to EFS was similar to dbdb-/-, however, GKT137831 reduced the contraction to EFS with lesser magnitude of inhibition in the LRRC8A KO dbdb-/- mice (35% of inhibition) compared to dbdb-/- mice (50% of inhibition), suggesting that the participation of O2•- in the contractile response was reduced by the lack of functional LRRC8A. Conclusions LRRC8A modulates the contractile response of the CC induced by α-adrenergic stimulation and in diabetes, this may be associated with O2•- production, which plays a role in the development of ED. Inhibition of LRRC8A may be a therapeutic target to prevent hypercontractility of arteries and CC in vasculogenic ED. Disclosure No.

(420) Assessing the Quality and Readability of Online Content on Shockwave Therapy for Erectile Dysfunction

Abstract Introduction In our current technology-driven society, patients and healthcare professionals alike are becoming increasingly reliant on online platforms for disseminating and obtaining health information. Previous research has shown that the quality of information available on the internet about novel medical therapies is generally poor and frequently misleading. Therefore, we hypothesized that online sources regarding novel erectile dysfunction treatment options, such as shockwave therapy, would be fraught with misleading claims and unreliable health information. Objective To evaluate the quality and readability of online health information on shockwave therapy as a treatment for erectile dysfunction. Methods Websites were generated using a Google search of “shockwave therapy for erectile dysfunction” with location filters disabled. Advertisements, scientific research articles, clinical trials, and websites that required subscriptions to access information were excluded from analysis. The websites included were from universities, private clinics, and news media outlets. Readability was analyzed using the Readable software (Readable.com, Horsham, UK). The content quality was graded using the DISCERN tool, a questionnaire that assesses the quality of written information on treatment choices for a health problem. Screening was done independently by 3 reviewers. Statistical analysis was conducted using the Student’s t-test. Results Nine articles that resulted from the Google search had mean readability scores as follows: Flesch-Kincaid grade level (10.8), Gunning-Fog Index (13.67), Coleman-Liau Index (12.74), Simple Measure of Gobbledygook (SMOG) Index (13.33), FORCAST Grade Level (11.33), and Automated Readability Index (11.08). The mean Flesch-Kincaid reading ease index was 46.4, which is difficult. No single article was at the 6th or 8th grade reading level, as recommended by the American Medical Association (AMA) and National Institutes of Health (NIH), respectively. There was no significant difference between the overall website ratings based on the DISCERN instrument (p= 0.565). The articles had a mean DISCERN score of 3.1, which refers to moderate quality (potentially important but not serious shortcomings). Four articles were from websites of private medical practices that each offered shockwave therapy for ED with a mean DISCERN score of 2.1. Five of the nine articles were from universities (n=2) or news sources (n=3) with a significantly higher mean DISCERN score of 4.0 (p<0.001). While the quality of content was significantly poorer, the mean automated readability grade level remained similar (p=0.607). A separate questionnaire was implemented to evaluate website content. Only two websites mentioned radial wave therapy, and both accurately dismissed its efficacy. Five websites mentioned that men with vasculogenic ED are the only candidates that should consider shockwave therapy. Two websites either mentioned the SMSNA statement or recommended that shockwave therapy "should only be used under strict research protocol." Five websites mentioned pricing (mean: $400 per session). Conclusions Overall, the quality of online information on shockwave therapy for ED is adequate. However, while articles from private clinics are just as readable as those from universities or news media, they are significantly more biased and misleading. The current online material may not support patients in making medical decisions and garnering knowledge, necessitating closer collaboration between the sources disseminating information and urologists. Disclosure Yes, this is sponsored by industry/sponsor: National Institutes of Health Grant R01 DK130991, American Cancer Society Clinician Scientist Development Grant. Clarification Industry funding only - investigator initiated and executed study.

(359) Validation of Peripheral Endothelial Assessment and Central Arterial Tonometry as Tools in Arteriogenic Erectile Dysfunction and Can These Tools Aid in Better Selection of Patients for LI-ESWT Treatment Improving Success Rates?

Abstract Introduction An important mechanism of ED is vascular endothelial function injury or disorder and low-intensity extracorporeal shock wave therapy (LI-ESWT) can stimulate and promote vascular regeneration, especially in failed PDE5i. The present selection criteria used for EDSWT are subjective in the form of IIEF, EHS or SEP with no objective definition of the extent of vascular involvement. There is a need to comprehensively evaluate ED including the extent of local and systemic involvement. Objective To develop objective parameters of validated assessment of endothelium in men with organic erectile dysfunction and to evaluate if they could be used to plan accurate PDE5i, non-invasive modalities of treatment. Methods In a prospective study, patients who were earlier evaluated and had vasculogenic ED and failed PDE5i treatment were clinically re-evaluated with questionnaires and CDDU. Additionally endothelial function and large arterial stiffness was assessed with the Vendys (reactive hyperaemia) & Sphygmocor (central arterial pressure waveform analysis). Categories identified were, endothelial dysfunction by Vendys, Aortic augmentation index abnormality by Sphygmocor (age corrected), combined abnormality with poor scores with or without metabolic comorbidity. All three groups underwent LI-ESWT with low dose PDE5 inhibitors with a revised protocol. Results Validation of diagnostic tools was done in thirty five patients aged 48.24 ± 4.6 years (mean ± SD) with a mean IIEF score of 8.4 were evaluated by the three techniques. Positive predictive value (PPV) of the three techniques was similar, in the range 89-91% and a negative predictive value (NPV) around 41-45%. CDDU had highest sensitivity at 85%, but low specificity of 55%, followed by Sphygmocor® at 77% and Vendys at 75% and the latter techniques had better specificity of 70%. Parameter Penile Doppler SphygmoCor® Vendys® Value 95% CI Value 95% CI Value 95% CI Sensitivity 85 % 70.1-94.3 77.5 % 61.5-89.1 75 % 58.8-87.3 Specificity 55.6 % 21.2-86.3 70.0 % 34.7-93.3 70 % 34.7-93.3 Positive likelihood Ratio 1.91 0.91-4.02 2.58 0.99-6.76 2.50 0.95-6.55 Negative likelihood Ratio 0.27 0.11-0.69 0.32 0.16-0.65 0.36 0.18-0.70 PSV (N) IIEF Class (N) % < 25 (22) Severe (18) 81.82 44.00 Mod (3) 13.64 Mild (1) 4.55 25-30 (17) Severe (0) 0.00 34.00 Mod (14) 82.35 Mild (3) 17.65 CDDU Vs IIEF score The patients were grouped into three arms Vendys abnormality, Sphygmocor and combined; for Li-ESWT treatment (15 each). Pre and Post questionnaire based assessment was done and maximum improvement of IIEF was in the Alx abnormality arm with poor results in combined abnormality. Conclusions The aortic strain index and distensibility index were impaired in patients with ED. Vendys® SphygmoCor® are new tools in diagnosis of ED and superior to penile Doppler or questionnaire assessment. Li-ESWT is most beneficial in patients with Aortic elastic abnormality probably due shock wave effect on sheer stress of vessels by altering vessel wall pulsatality and resistivity index. Disclosure No

Effect of diabetes on shock wave therapy for the treatment of erectile dysfunction

Objectives To evaluate the effect of diabetes in patients with erectile dysfunction treated with focal shock wave therapy in a specialized center in Spain. Methods The clinical data of men with erectile dysfunction treated during 2018-2019 in a specialized institution in Spain, who received 1 cycle of shock waves, were extracted. Patients with other sexual dysfunctions or incomplete data were excluded for analysis. The change in the score of the IIEF-15 questionnaire in diabetics versus non-diabetics was compared, adjusting for confounding variables using linear regression models. Results 409 patients met selection criteria and were included in this study. 53.5% were treated in Barcelona and 18% in Madrid, the average age was 55.5 years (+/- 12.5), 16.9% were diabetic and 80.4% had some other cardiovascular risk factor. The time with erectile dysfunction ranged between 1 and 36 months, and the baseline IIEF-5 score was 12.5 (+/- 6.2). At the end of therapy, the mean change in this score was lower in diabetics compared to non-diabetics (4.6 vs 1.9, p-value 0.006), which was independent of other confounding variables (p-value 0.029). Conclusions Diabetes decreases the effectiveness of focal shock wave therapy in Spanish men with vasculogenic ED, this condition should be treated to obtain better results. Conflicts of Interest The authors are employees of Boston Medical Group. This is a private institution to treat men's sexual dysfunctions. To evaluate the effect of diabetes in patients with erectile dysfunction treated with focal shock wave therapy in a specialized center in Spain. The clinical data of men with erectile dysfunction treated during 2018-2019 in a specialized institution in Spain, who received 1 cycle of shock waves, were extracted. Patients with other sexual dysfunctions or incomplete data were excluded for analysis. The change in the score of the IIEF-15 questionnaire in diabetics versus non-diabetics was compared, adjusting for confounding variables using linear regression models. 409 patients met selection criteria and were included in this study. 53.5% were treated in Barcelona and 18% in Madrid, the average age was 55.5 years (+/- 12.5), 16.9% were diabetic and 80.4% had some other cardiovascular risk factor. The time with erectile dysfunction ranged between 1 and 36 months, and the baseline IIEF-5 score was 12.5 (+/- 6.2). At the end of therapy, the mean change in this score was lower in diabetics compared to non-diabetics (4.6 vs 1.9, p-value 0.006), which was independent of other confounding variables (p-value 0.029). Diabetes decreases the effectiveness of focal shock wave therapy in Spanish men with vasculogenic ED, this condition should be treated to obtain better results.

Erectile dysfunction, generalized vascular disease and the long term effects of smoking exposure on arterial properties: time is of the essence

Abstract Introduction Erectile dysfunction (ED) is considered an early manifestation of generalized vascular disease and may precede clinically overt cardiovascular disease (CVD) by 2 to 5 years. We examined macrovascular changes according to time of ED onset and the impact of smoking on the severity of penile vascular damage and large artery wall changes. Methods We measured carotid-femoral pulse wave velocity (PWV), carotid intima media thickness (cIMT), augmentation index (AIx) and brachial flow-mediated dilation (FMD) in 378 males with ED (age: 54±7 years). All participants had no clinical manifestations or a history of atherosclerotic disease. They were assessed using the Sexual Health in Men (SHIM)-5 score for ED severity and the penile colour Doppler ultrasonography after intracavernous injection of prostaglandin E1 for measurement of peak systolic velocity (PSV). Low PSV values indicate impaired penile blood inflow and severe vasculogenic ED. ED duration was defined as the time interval between age at diagnosis and study entry. Results The study population was divided into three groups according to duration of ED. Group 1: <2 years, Group 2: 2–5 years and Group 3: >5 years. Comparison of various parameters among the three groups using one-way ANOVA or the Kruskal–Wallis test did not demonstrate statistically significant differences in age, prevalence of hypertension, diabetes, smoking, peripheral blood pressure (BP) and metabolic parameters (fasting blood glucose, lipid profile, testosterone levels). Total tobacco cigarette exposure was greater in males with ED duration >5 years (Group 3), compared to Group 2 and 1 patients (23.8 vs 22.5 vs 20.7 pack-years, P<0.01). PWV, AIx and cIMT increased and FMD decreased across the three groups (Figure 1). The three groups had comparable PSV value. We then divided the study population into four subgroups according to tobacco exposure (never smokers; light smokers<20 pack-years, moderate smokers 20–40 pack-years and heavy smokers >40 pack-years). The subgroups have similar age and BP. The three smoking subgroups had significantly higher PWV (P<0.001), AIx (P<0.01), cIMT (P<0.01) and lower FMD (P<0.05) and PSV (P<0.05) compared to never smokers. Post hoc analysis revealed higher PWV, AIx and cIMT and lower FMD in heavy smokers compared to moderate and light smokers (all p<0.05). PSV was similar across the three smoking subgroups. Conclusions The study shows that longer ED duration is associated with a more pronounced vascular dysfunction and subclinical vascular wall changes and that heavy tobacco cigarette exposure significantly deteriorates macrovascular parameters. Furthermore there was a significant impairment of penile vasculature even in light smokers. These findings may partly explain why the same process that contribute to CVD may cause earlier ED symptoms and imply that smoking cessation should be a premising non pharmacological intervention in men with ED. Funding Acknowledgement Type of funding sources: None.

Expedited algorithm for IPP following Radical Prostatectomy

ABSTRACT Introduction Erectile dysfunction (ED) following radical prostatectomy (RP) is a postoperative result that negatively impacts patient quality of life. The recovery of potency following radical prostatectomy varies depending on a multitude of factors including but not limited to surgical technique, surgeon experience and patient comorbidities. There are several factors that contribute to this decline in erectile function as a result of oncologic control after RP which may be classified as vasculogenic, neurogenic, and psychological. Current guidelines recommend patients wait up to 24 months before IPP surgery. However, no definitive algorithm or guideline has been established for the expedited management of ED in the postoperative setting following radical prostatectomy. Objective We are proposing an expedited algorithm for patients who fail PDE-5 inhibitors at the three-month follow-up following RP. Methods Patients who underwent inflatable penile prosthesis (IPP) surgery for the treatment of ED over a 36-month period following RP were identified from our IRB approved database. All patients completed an IIEF-5 questionnaire and had a penile doppler ultrasound (PDUS) performed preoperatively. Validated scoring for erectile function was performed with the International Index of Erectile Function (IIEF-5), and the Sexual Health Inventory for Men (SHIM) was defined. The relationships, according to Doppler diagnosis, IIEF-5 score, SHIM scale, and erection score were evaluated as well as surgical outcomes and patient comorbidities. Logistic regression and Wilcoxon rank sum tests were performed. Results 1,158 patients were evaluated in this series, of whom 121 met inclusion criteria. PDUS determined that 88 (72.8%) suffered from veno-occlusive disease, while 19 (15.7%) had arterial insufficiency. 101 (83.4%) had a RALP vs 20 (16.6%) who received an open RP. The mean time between RP and IPP was 20 months, with the mean ages of RP and IPP being 58 and 64 years respectively. Ages of patients ranged from 40 to 82 years old. Increased time between RP and subsequent IPP was correlated with lower SHIM scores. Additionally, each month that passed caused a decrease of 1.8% in SHIM scores (p< 0.05), as well as a greater likelihood of developing worsening vasculogenic ED (p= 0.042). Increased patient age during RP and subsequent IPP was also correlated with lower SHIM scores (p= 0.049), while RALP was found to be a predictor of higher patient satisfaction (p= 0.02). Conclusions As a result of the overwhelming diminishing SHIM scores over the 20 month postoperative course following RP as well as the significant prevalence of veno-ccclusive disease in this common patient population, we are strongly recommending a baseline PDUS at the 3 month followup. Furthermore, if veno-occlusive disease is identified upon the 3 month baseline PDUS, we encourage frank discussion of IPP placement with the patient. Equally important is it to consider discussing the degree of veno-occlusive disease and resultant ED will worsen as the postoperative period lengthens. Those patients found to have veno-occlusive etiology should have early surgical intervention mitigating further severity of the subsequent veno-occlusive disease. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast and Boston Scientific

Long-term high-dose l-arginine supplementation in patients with vasculogenic erectile dysfunction: a multicentre, double-blind, randomized, placebo-controlled clinical trial

PurposeThe current randomized, double-blind, placebo-controlled clinical trial addressed the effects on penile erectile function of relatively high daily oral doses (6 g/day) of l-ARG for 3 months (N = 51) compared to placebo (N = 47), in patients with vasculogenic ED, with comparison between mild–moderate and severe vasculogenic ED.MethodsThe outcome measures included IIEF-6 score and cavernous arteries peak systolic flow velocity (PSV) at dynamic penile duplex ultrasonography (PDU).Resultsl-ARG supplementation for 3 months significantly increased IIEF-6 score in the overall cohort (p < 0.0001) and in subgroups of patients with mild–moderate (p < 0.0001) and severe (p = 0.007) vasculogenic ED; PSV was significantly increased in the overall cohort (p < 0.0001) and in patients with mild–moderate (p < 0.0001), but not severe vasculogenic ED. At study completion, 74% of patients improved ED degree category, although only 24% of patients, mainly belonging to the baseline category of mild ED, reached IIEF-6 scores compatible with absence of ED; moreover, 20% of patients, exclusively belonging to the baseline category of mild–moderate vasculogenic ED, reached PSV values compatible with absence of ED.ConclusionThe results of the current study demonstrated that supplementation with relatively high doses of l-ARG as a single compound for 3 months significantly improved penile erectile function, assessed by both IIEF-6 score and PSV at dynamic PDU in patients with mild–moderate, and improved IIEF-6 score, but not PSV, in patients with severe vasculogenic ED, therefore suggesting that l-ARG might be an alternative treatment in mild–moderate vasculogenic ED patients experiencing adverse effects or with contraindications for chronic treatment with PDE5i compounds.

Li-Eswt improves hemodynamic parameters thus suggesting neoangiogenesis in patients with vascular erectile dysfunction.

Extracorporeal treatment with low intensity shock-wave therapy (LI-ESWT) is a recently introduced non-invasive method which purposes the restoration of the pathophysiological alterations at the base of vasculogenic ED in male patients. The evidence in favour of the neoangiogenic potential of this treatment derived from in vitro studies and on animal models. The purpose of this study, in which the Power Doppler method was applied, is to demonstrate 'objectively' the real efficacy of LI-ESWT at the level of the microcirculation of the corpora cavernosa (neoangiogenesis) in patients affected by vasculogenic ED. Data from this study show, for the first time, that LI-ESWT treatment promotes neovascularisation of the functional arteries in patients affected by vasculogenic ED.

A Systematic Review on Rho-Kinase as a Potential Therapeutic Target for the Treatment of Erectile Dysfunction.

BackgroundErectile dysfunction (ED) is a common clinical condition with limited treatment options. The main aim of the present systematic review was to synthesize information on Rho-kinase as a novel therapeutic approach for the treatment of ED.MethodsWe performed a systematic literature study in PubMed, Google Scholar and Scopus. Included studies were original articles studied the role of Rho-kinase in the pathogenesis and/or new treatment approach for ED in animal models and clinical studies, published between 2014 and 2019. Data derived from each study were study design used, interventions applied and main treatment outcomes. The quality of the selected articles was assessed by CAMARADES criteria and data were analyzed using descriptive statistics.ResultsA total of 1067 original articles were retrieved in the given period and eighteen papers met our inclusion criteria. Five articles explain the role of Rho-kinase in ED pathogenesis using different models such as cavernous nerve crush injury, heart failure-induced ED, vasculogenic and post-radical prostatectomy ED, diabetes-induced ED and age-related ED. Other ten papers explain the role of novel drugs evaluated for ED treatment by targeting Rho-kinase as a new approach for ED therapy. The rest three papers discuss the role of plant extracts used by traditional society for the treatment of ED and assess their potential function in targeting Rho-kinase in animal models. The penile erectile functional index has shown that the ratio of intracavernosal pressure to mean arterial pressure (ICP/MAP) was decreased due to age and various chronic diseases. Whilst, ROCK I and ROCK II expression were increased. Western blot findings have also shown that ROCK II and MYPT-1 phosphorylation rates increased in cavernous tissue after ED induction. Besides, compounds which can inhibit the action of Rho-kinase activity showed relaxation of the corpus cavernosum, decrease in corporal fibrosis, and alleviate increased apoptosis and caspase-3 activity in an NO-independent manner. Moreover, histological and molecular dysregulation have been improved by inhibition of Rho-kinase.ConclusionTargeting Rho-kinase may be a possible target for the treatment of ED secondary to specific causes, and Rho-kinase inhibitors may be a new drug family for the treatment of ED. However, this requires further studies for in-depth understanding.

P-02-84 New Approaches to Improve Treatment Outcomes of Vasculogenic ED by LIESWT

P-02-84 New Approaches to Improve Treatment Outcomes of Vasculogenic ED by LIESWT

The correlation between atherogenic indexes and erectile dysfunction

Aside from the ordinary plasma lipid level measurements, the ratios based on individual plasma lipid levels such as atherogenic index of plasma (AIP), Castelli’s risk index 1/2 (CRI-1/2), and atherogenic coefficient (AC) are the novel parameters to evaluate the patients with a high risk of CVD. In this study, we aim to evaluate the relationship between AIP, AC, and CRI-1/2 with increased risk of ED. Between April 2018 and February 2019, 253 patients, who were diagnosed as a vasculogenic ED in our clinic, were enrolled in the study. While the first group (n = 134) consisted of patients with moderate and mild ED (IIEF-EF: 17–30), the second group (n = 119) consisted of patients with severe ED. In addition to the mean values of lipid parameters; CRI-1 (total cholesterol/HDL), CRI-2 (LDL/HDL) AIP (log10(triglycerides/HDL), and AC (non-HDL/HDL) were calculated. The mean age was 44.02 ± 10.41 (24–70), and the mean BMI was 27.80 ± 4.12 (18.52 ± 41.97). However, CRI-1 and AIP values were found to be higher in the severe ED group compared to the mild ED group (CRI-1: 4.50 ± 1.47, 4.88 ± 1.30; p = .039; AIP: 0.489 ± 0.315, 0.617 ± 0.283; p = .007). Our results demonstrated that CR-1 and AIP have a positive correlation with the severity of ED. Moreover, we can suggest that patients with higher CR-1 and AIP values are likely to have more severe ED in the future.

PD20-07 A DESCRIPTIVE ANALYSIS OF POST-OPERATIVE URINARY RETENTION (POUR) IN PATIENTS UNDERGOING IMPLANTATION OF INFLATABLE PENILE PROSTHESIS: A SINGLE CENTER EXPERIENCE

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy I (PD20)1 Apr 2020PD20-07 A DESCRIPTIVE ANALYSIS OF POST-OPERATIVE URINARY RETENTION (POUR) IN PATIENTS UNDERGOING IMPLANTATION OF INFLATABLE PENILE PROSTHESIS: A SINGLE CENTER EXPERIENCE Johnathan Drevik*, Jacob Lucas, Jay Simhan, and Joshua Cohn Johnathan Drevik*Johnathan Drevik* More articles by this author , Jacob LucasJacob Lucas More articles by this author , Jay SimhanJay Simhan More articles by this author , and Joshua CohnJoshua Cohn More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000870.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The rates of Post-operative urinary retention (POUR) following inflatable penile prosthesis (IPP) are not well defined but are of interest given the potential implications for length of stay and feasibility of outpatient surgery. Herein we attempt to characterize and identify potential risk factors for POUR after IPP. METHODS: We reviewed all patients who underwent IPP implantation by a single surgeon (JS) from January 2014 to December 2018 with data regarding POUR. A Foley catheter was placed at the start of each case and the bladder emptied prior to removal at the end of the procedure. Post-void residuals (PVR) were checked after the first void post-operatively, and indwelling catheterization or intermittent catheterization performed for PVR >350 mL or symptomatic retention at lesser volumes. We compared patients who experienced post-operative urinary retention (POUR), defined as need for urinary catheterization at any time postoperatively, to patients who did not experience post-operative urinary retention (N-POUR). Patients were excluded if they underwent a concomitant procedure or had a diagnosis of neurogenic bladder. RESULTS: A total of 200 patients comprised the study population, of whom 53 (26.5%) experienced POUR and 147 (73.5%) did not. There were no differences between groups with regards to age, race, BMI, ASA, or other comorbidities (Table 1). Patients who experienced POUR had a median retained volume of 546 cc (25-75 IQR 378.0-693.5 cc). Among men with POUR, 33 (62.3%) had resolution of their urinary retention prior to discharge, while the remainder 20 (37.7%) were discharged with a Foley catheter. The rate of POUR was significantly lower in patients with a prior history of radical prostatectomy (10.7% vs 32.6%, p<0.001). On multivariable analysis, absent history of prostatectomy (OR 2.9, 95%CI 1.1-8.0, p=0.03) was found to be an independent risk factor for POUR. CONCLUSIONS: In our series, ∼25% of patients undergoing implantation of IPP developed POUR requiring catheterization. It is likely that bladder outlet obstruction and/or detrusor underactivity—which share similar risk factors as vasculogenic ED—result in POUR following IPP placement. Clinicians should carefully counsel patients regarding their risk. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e449-e450 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Johnathan Drevik* More articles by this author Jacob Lucas More articles by this author Jay Simhan More articles by this author Joshua Cohn More articles by this author Expand All Advertisement PDF downloadLoading ...

EVALUATION OF PLASMA LEVEL OF HOMOCYSTEINE IN THE PERIPHERAL AND PENILE BLOOD BEFORE AND AFTER FOLIC ACID SUPPLENTATION IN VASCULOGENIC ERECTILE DYSFUNCTION PATIENTS

Background: Erectile function may be secondary to much systemic illness, both physical and psychological, and is a well-documented side effect of prostatic cancer treatment. Objective: To asses effect of folic acid supplementation on homocysteine plasma level in either peripheral and penile blood before among vasculogenic erectile dysfunction patients. Patients and methods: This study included 22 Egyptian patients ranged from 30-60 years old with vasculogenic ED proved by penile duplex ultrasound. All patients subjected to penile Duplex ultrasound, peripheral and penile blood samples were for plasma homocysteine concentration evaluation before and after oral folic acid 500 mcg per day for 3 months. Results: There was statistically significant difference between either peripheral or penile homocystiene before and after. There was a significant increase in peak systolic value (PSV) after the treatment than its value before the treatment. Also, the end-diastolic velocity (EDV) before therapy was significantly higher than its value after therapy. There was a significant increase in international index of erectile Function-5 questionnaire after the treatment (15.5±3.3) than its value before the treatment. Conclusion: There was a significant relation between Hcys and either ED or penile arterial flow. From these results, Elevated plasma Hcys level was considered as independent risk factor for ED.

The Role of the Low-Intensity Extracorporeal Shockwave Therapy on Penile Rehabilitation After Radical Prostatectomy: A Randomized Clinical Trial

BackgroundErectile dysfunction (ED) after radical prostatectomy (RP) still represents a major issue. Considering the benefits recently described regarding the application of low-intensity extracorporeal shockwave therapy (LiESWT) in vasculogenic ED, questions arise about its role in the scenario of penile rehabilitation. AimTo compare the early introduction of phosphodiesterase-5 inhibitor (PDE5i) with a combination therapy enrolling both early PDE5i use and LiESWT in patients submitted to RP. MethodsThis study is a randomized clinical trial, open-label, with 2 parallel arms and an allocation ratio of 1:1. The study was registered in ReBEC (ensaiosclinicos.gov.br) Trial: RBR-85HGCG. Both arms started tadalafil at a dose of 5 mg/day right after the removal of the transurethral catheter, and the experimental group received 2,400 shocks/session-week distributed on 4 different penile regions. The full treatment consisted of 19,200 impulses across 8 weeks. OutcomesThe primary clincal end point was ≥4-point difference favoring the experimental group considering the mean International Index of Erectile Function short form (IIEF-5) at last follow-up. Any statistical difference in the IIEF-5 score between the arms was stated as the primary statistical end point. ResultsBetween September 25, 2017, and December 3, 2018, 92 men were enrolled in the study. At last follow-up, we assessed 77 patients, 41 in the control group and 36 in the intervention group. A difference between groups was detected when accessing the final median IIEF-5 score (12.0 vs 10.0; P = .006). However, the primary clinical endpoint considering a difference ≥4-point between the arms has not been reached. When performing an exploratory analysis comparing the proportion of those individuals with an IIEF-5 score ≥17, no difference between groups was noted (17.1% vs 22.2%; P = .57). Clinical ImplicationsSo far, the benefits arising from LiESWT for penile rehabilitation after RP have been uncertain. Strengths & LimitationsThis is the first trial assessing the role of LiESWT on erectile function after RP. Our study protocol included only one session per week for the experimental group, raising a query if a more intensive application could achieve better results once a statistically significant difference was found between groups. We discontinue the PDE5i use at the last session, which may have interfered in the penile vascular rehabilitation, maybe compromising the results too. ConclusionAfter therapy with 19,200 impulses therapy across 8 weeks, we found an improvement of the IIEF-5 score, but it was not enough to be considered clinically significant. More studies are warranted before any recommendation on this topic.Baccaglini W, Pazeto CL, Corrêa Barros EA, et al. The Role of the Low-Intensity Extracorporeal Shockwave Therapy on Penile Rehabilitation After Radical Prostatectomy: A Randomized Clinical Trial. J Sex Med 2020;17:688–694.

COMBINATION OF PLATELET RICH PLASMA, LOWINTENSITY PULSED ULTRASOUND AND SILDENAFIL ORAL SPRAY IN TREATMENT OF ERECTILE DYSFUNCTION

Relevance. Some non-pharmacological methods, such as low-intensity pulsed ultrasound (LIPUS) proved to be effective in ED treatment due to stimulation of penile tissue regeneration and penile hemodynamics increase. The biological methods that utilize cellular growth factors such as platelet-rich plasma (PRP) therapy proved to be effective in stimulation of neovascularization processes and correction of endothelial dysfunction while ED treatment.Local negative pressure (LNP) therapy shall be considered as an auxiliary method to PRP and LIPUS due to its ability to slow down PRP outflow from injection zones. Sildenafil («Strondex») is perspective pharmacological addition to ED treatment protocol. Aim. Evaluation of the efficacy and safety of therapeutic model of combined application of PRP intracavernous injections, LNP, LIPUS and Sildenafil («Strondex») for vasculogenic (arterial and corporal veno-occlusive) ED treatment.Materials and methods. Prospective study was conducted in a group of 64 outpatients with diagnosis of erectile dysfunction of vascular genesis (ICD-10: N48.4) in Men’s Health Clinic (Kyiv, Ukraine). “International Index of Erectile Function-5” (IIEF-5), “Erectile Hardness Score” (EHS) were used as the tools for clinical assessment. Ultrasonic cavernous bodies scanning and pharmacodopplersonography were used for the data validation.Study results. Main group patients underwent treatment consisting of 6 sessions of PRP intracavernous injections and 12 sessions of local penile LIPUS combined with LNP and Sildenafil («Strondex») pharmacotherapy. Control group underwent 12 sessions of local penile LIPUS combined with LNP and the same pharmacotherapy. According to the IIEF-5 data obtained 12 weeks after the study the erectile function improvement was found in 27 patients of the main group and 20 patients of the control group. EHS improved by 1 point or more in 29 and 20 patients correspondingly.Conclusions. Treatment protocol specifying combination of PRP, LIPUS, LNP and Sildenafil («Strondex») is promising due to PRP-therapy augmentation by intracavernous ultrasonic activation of platelet growth factors, but the data obtained require further physiological validation and clinical placebo-controlled studies with involvement of larger groups of population.

PO-01-096 Low Intensity Electromagnetic Shock Wave Treatment in erectile dysfunction: Our experience on 442 patients

In this paper we want to check the feasibility and efficacy of LISWT in ED patients in the frametime between April 2015 and September 2018 we treated for ED 442 pts of which 381 for vasculogeni ED and 61 fo ED following radical prostatectomy . 40 nerve sparing radica prostatectomy(NSRP) and 21 non nerve sparing radical prostatectomy(NNSRP) for prostatic cancer ,in this group 10 pts received adjuvant radiotherpy for positive surgical margins. The LISWT protocol we used was 4 sessions (once a week) in one month in vasculogenic ED pts and 6 sessions (once a week)in in ED post radical prostatectomy patients with a linear probe at an energy level of 0.09 mj/cm2. Everytime we started a treatment the psa was <0.03 and there remained afterward. The efficacy of the treatment was validated by admininstration of IIEF test and GEQ test in 442 pts treated with LISWT 276 improved their performances(62%) with or without the help of medications(Pde5 inhibitors or alprostadil) The IIEF was improved by 50% with an average increase from 12 to 18. Of the 381 vasculogenic ED 254 had an improvement of their performance (65%). of these patients ,177 were responder to PDE5 and they got rid of medications. 77 were non responders to PDE5 or alprostadil and became responders to these drugs. Of the 40 pts undergone to NSRP 17 improved their status (42%), of the other 21 NNSRP 5 (25%)improved , in this group 10 pts had adjuvant radiotreatment and none improved we had 5 patients with transitory side effects 3 testis pain 2 penile paresthesias and 1 UTI

031 Low intensity-shockwave therapy (Li-ESWT) delivered by Aries® improves erectile function and decreases cavernosal fibrosis of spontaneously hypertensive rats (SHR)

Li-ESWT has been reported to improve erectile function in patients with vasculogenic ED, and convert PDE5i non-responders into responders. Erectile function of SHR, a validated rat model of hypertension associated ED, is partially improved by PDE5is. Here, we investigated whether Li-ESWT could affect erectile function with and without acute sildenafil in SHR. A pronounced accumulation of collagen in erectile tissue of SHR has been described, thus we also investigated the histological features of SHR erectile tissue after ESWT. 2 groups of male SHR (CTRL and ESWT; n=14/group) were treated twice/week for 6 weeks. Only in the ESWT group, shockwaves were delivered to the penis at the mid-shaft and base (Aries®, Dornier MedTech, Germany). Each session comprised 1000 shocks per site (total: 2000 shocks, EFD: 0.06 mJ/mm2). 4 weeks after the final session, erectile function was assessed by recording intracavernosal pressure (ICP) and mean arterial pressure (MAP) under electrical stimulation of the cavernous nerve (ES CN), first in absence then in presence of sildenafil (0.3mg/kg iv). Then rats were sacrificed, the corpora cavernosa were harvested and prepared for histological analysis. Cavernosal smooth muscle (SM)/collagen ratio was assessed by trichrome staining. Cavernosal microvasculature and nitrergic nerves were assessed by immunohistology against CD31 and nNOS.

The Predictive Value of Arteriogenic Erectile Dysfunction for Coronary Artery Disease in Men

BackgroundErectile dysfunction (ED) is assumed to be connected with vascular disease caused by endothelial dysfunction, and characterized by the incapability of the smooth muscle cells lining the arterioles to relax, therefore, inhibit vasodilatation. AimTo assess the predictive value of arteriogenic ED for coronary artery disease in men above the age of 40 years. Methods75 Patients reporting arteriogenic ED and 25 men with normal erectile function were enrolled in the study. Both patients and controls were subjected to the following investigations: lipid profile, fasting blood sugar, body mass index (BMI), waist circumference, penile duplex study, stress electrocardiography (ECG) test, International Index of Erectile Function (IIEF) Type 5 (Arabic version), and cardiovascular (CV) 10-year risk assessment using Framingham and Prospective Cardiovascular Münster (PROCAM) scoring systems. OutcomesWe compare between the study groups regarding the interpretation of exercise testing. ResultsWe observed significant increase in the mean value of age, systolic blood pressure, BMI, weight, height, and waist circumference in the cases; significant prevalence of obesity and overweight in the cases (P < .001); significant increase in the mean value of total cholesterol, triglycerides (TG), and low-density lipoprotein; and decrease in mean value of high-density lipoprotein in the cases (P < .001). Additionally, there was high incidence of positive stress ECG in the cases (25.3%) vs that in controls (12%), and significant difference between patients with positive stress ECG test and those with negative stress ECG test regarding their lipid profile, age, BMI, and waist circumference with higher values in positive stress ECG for total cholesterol, TG, and low-density lipoprotein, and lower value for high-density lipoprotein (P < .001). According to PROCAM and Framingham scoring systems 10-year risk assessment, there was a high significant difference between the cases and control groups with a higher score in cases than the control group with 30.7% of cases having ≥ 30% risk of developing coronary heart disease, and significant positive correlations between CV risk and BMI, and negative correlations with IIEF-5 cases (P < .001). Clinical TranslationIschemic heart disease events were higher in men with documented arteriogenic ED than those without ED. ConclusionsAll items of metabolic syndrome were investigated and analyzed and we evaluated our groups using both PROCAM and Framingham scoring system. An exercise ECG is suggested before starting treatment of vasculogenic ED at least in patients with CV risk factors.Azab SS, Hosni HED, El Far TA, et al. The Predictive Value of Arteriogenic Erectile Dysfunction for Coronary Artery Disease in Men. J Sex Med 2018;15:880–887.

02 Studying the Erectile Function Impact of Vitamin D Therapy in Patients with ED: Interim Analysis From A Randomized Controlled Study

Vitamin D deficiency (VD) has been associated with increased cardiovascular disease risk. Several studies have reported a link between ED and VD. We aimed to investigate if correcting vitamin D levels improved erectile function in ED patients with concomitant VD. We prospectively sequentially assigned 200 consecutive vitamin D deficient patients diagnosed with vasculogenic ED, based on duplex Doppler ultrasound, into two groups. Group A received tadalafil 5 mg daily alone; Group B received vitamin D 5000 iu orally daily in combination with tadalafil 5 mg daily; the intervention was for 6 weeks. Data collected pre and post therapy included the IIEF erectile function domain (IIEF-6), erection hardness score (EHS) and a sexual encounter profile (SEP). A total of 174 patients completed the study, 81 in group A and 93 in group B. Median age was 50 overall, 56 (42, 65) in group A and 47 (35, 55) in group B (p<0.01). Prevalence of comorbidities were (group A vs group B): diabetes 63% v 32% (p<0.01); hypertension 56% vs 27%; cigarette smoking 38% vs 27% (p=0.14); vitamin D level 22 vs 15 (p,0.01). Baseline median IIEF-6 and EHS scores were: 13 vs 16 (p<0.01) and 2 vs 3 (p<0.01). End of treatment data are presented in Table 1. The median changes for IIEF-6 were 3 vs 5 (p<0.01); for vitamin D level 0 vs 17 (p<0.01).