Have you read? Best of the Best. Clinical Research.

Bruno Jorge Pereira
Urology Department of Portuguese Institute of Oncology of Coimbra (IPOC), Coimbra, Portugal and Health Sciences Faculty of the University of Beira Interior (FCS-UBI), Covilhã, Portugal

Covid-19 and Sexual Medicine

Cocci A, Presicce F, Russo G et al. How Sexual Medicine is Facing the Outbreak of COVID-19: Experience of Italian Urological Community and Future Perspectives. IJIR 2020 [published online, April 14]

This paper points out the pitfalls that COVID-19 created in the Italian scenario since it was one of the most European affected countries. The shortage of health personnel to manage the emergency has been so evident that it was necessary to allocate even urologists to departments intended for the management and treatment of patients with COVID-19. Similarly, in the worst scenarios, urological and other nonmedical specialization departments have been turned into medical departments due to the lack of beds. Shared international strategies are important to avoid potential collateral damages from the pandemic in patients with urological diseases.

Tang K, Gaoshan J, Babatunde A. Sexual and Reproductive Health (SRH): A Key Issue in the Emergency Response to the Coronavirus Disease (COVID-19) Outbreak. Reproductive Health 2020; 17: 59

SRH and rights is a significant public health issue during the epidemics. The novel coronavirus is new to humans, and only limited scientific evidence is available to identify the impact of the disease COVID-19 on SRH, including clinical presentation and outcomes of the infection during pregnancy, or for persons with STI/HIV-related immunosuppression. Beyond the clinical scope of SRH, we should not neglect the impacts at the health system level and disruptions or interruptions in regular provision of SRH services, such as pre and postnatal checks, safe abortion, contraception, HIV/AIDS and STIs. Furthermore, other aspects merit attention such as the potential increase of gender-based violence and domestic abuse, and effects of stigma and discrimination associated with COVID-19 and their effects on SRH clients and health care providers. Therefore, there is an urgent need for the scientific community to generate sound clinical, epidemiological, and psychosocial behavioral links between COVID-19 and SRH and rights outcomes.

Turban JL, Keuroghlian AS, Mayer KH. Sexual Health in the SARS-CoV-2 Era. Ann Intern Med 2020. doi:10.7326/M20-2004 [published online, May 8]

This article published in an Internal Medicine journal intent to produce recommendations about sexual practices during SARS-CoV-2 pandemic:

Baldasserre E. An Andrologist in the Front Line COVID-19 Team. IJIR 2020 [published online, May 19]

This paper describes the journey of an Italian andrologist from Valle D’Aosta during the SARS-COV-2 outbreak and how the wards were adapted to treat the infected patients. The author gives some tips about how can an andrologist work in a COVID-19 area and how it’s possible to make a real contribution in supporting and treating patients.

Torremade J, Martinez-Salamanca JI. Challenges in the Practice of Sexual Medicine in the Time of COVID-19. J Sex Med 2020 1-3 [article in press, May 5]

From the spanish point of view, the COVID-19 surge forced health-care systems to elaborate contingency plans and restructure their facilities in order to cope with the peak of coronavirus cases in the best possible conditions. Torremade and Martinez-Salamanca underline the role of telemedicine for caring of the patients and its advantages in such a pandemical crisis as a low-cost resource and flexible follow-up adapted to the needs of the patient. On the other hand, many operating rooms have been converted into intensive care units with priority given only to emergencies and oncologic surgeries which couldn’t be delayed, according to different societies recommendation. In the field of andrology and sexual medicine only testicular cancer and cryopreservation were considered procedures that couldn’t be delayed. This will result in an increase in surgery waiting lists with a significant impact on the quality of life of untreated patients. Sexual medicine departments will need to adapt their surgical programs and come up with efficient models that absorb the accumulated demand efficiently and use strategies based on minimally invasive procedures. Models based on outpatient clinics also seem more necessary than ever as they reduce the contact of the patient with the hospital and therefore reduce the risk of contact between patients and professionals. Meanwhile residency training and fellowship programs have been drastically affected (between 41,1% and 81,2% for clinical activities and 44,2% to 62,1% for surgical activities. Congresses and scientific events had to be canceled, postponed of changed to virtual format which may be the main source of training during times of pandemic. Talking about research there were many limitations and interruptions on ongoing studies with the consequent delay of its results. The predicted economic crisis may limit public and private resources allocated to research and the field of sexual medicine must be prepared for an environment where obtaining resources will become more competitive.

Luria M and Nesher SP. Challenges in the Practice of Sexual Medicine in the Time of COVID-19. J Sex Med 2020 1-3 [article in press, May 10]

An expert opinion document from Israel about the coronavirus outbreak and its influence on sexual health and function. The authors underline the lack of scientific-based evidence in this specific field. The psychological impact of the quarantine and the viral disease has developed an entire spectrum of emotions while some people enjoy the slower pace life while some cannot wait to go back to routine. Some have increased sexual desire while other have none. While on quarantine sexual behaviors might have changed and may include the increase of pornography-watching as reported by Pornhub. As advocated by NYC Health Department, masturbation could be the safest sex practice during these times. Some specific populations as older adults may have a more impaired sexual function even after the end of isolation as they have higher incidence of sexual dysfunction and may not have easy access to medical facilities or telemedicine. Orthodox Jewish communities might also be confronted with religious dilemmas since intimate relations between couples are vital and male masturbation is not allowed. In the sexual medicine and therapeutic setting there are concerns and difficulties about the use of telemedicine in this particular area while some patients are refraining from getting medical attention to acute and chronic problems. On the other hand, “bad times bring out the best in us” and it’s believed that the field of sexual medicine can grow from this being more flexible, adaptable and creative and the authors think that the current situation may facilitate the inclusion or extension of sexual medicine into the curricula of medical schools and residency programs and the validation and expansion of sexual well-being in the broadest sense of the word.

Miranda EP, Nascimento B, Torres LO, Glina S. Challenges in the Practice of Sexual Medicine in the Time of COVID-19. J Sex Med 2020 1-3 [article in press, May 13]

Sexual medicine practice was also significantly impacted in Brazil with decreasing consultations and procedures. Nonetheless, many patients were in profound suffering due to sexual complaints and urged to obtain medical counseling despite the critical global situation and therefore, given the link between mental and sexual health it is expected that patients may be at a greater risk of decompensating preexisting sexual dysfunctions. On the other hand, predictable economic recession has the potential to undermine accessibility to sexual medicine services mainly in the private setting and consequently impact the income of many professionals. During the pandemic many sexual medicine experts were allocated to work in the frontline and public sexual medicine referral centers have been closed down with a projected overloading on the public system which will be greater as the longer the situation lasts. Non regulation of telemedicine is a barrier for patients, providers and insurance companies and may also undermine the doctor-patient relationship due to lack of privacy, overheard conversations and emotional bond with the professional. The impact extends to elective surgeries, follow-ups or even academic and research endeavors. The bright side of new technologies is that they can overcome the lack of physical contact in the future and long-distance patients can have easy access to sexual medicine experts. As interviews are the main core of sexual medicine practice, telemedicine might be more easily applied within our specialty. In addition, other professionals such as psychologists and nutritionists have been allowed to perform online consultations for years, and their successful experience in Brazil could be a model for sexual medicine to build on. Medical conferences may also become hybrid and benefit from online participation of both lecturers and attendees thus reducing some costs and increase attendance.

Carvalho J, Pascoal P. Challenges in the Practice of Sexual Medicine, Sex Therapy, and Sexual Counseling in the Time of COVID-19. J Sex Med 2020 1-8 [article in press, May 19]

This paper gives an expert opinion about clinical sexology challenges and produces recommendations in the context of COVID-19 and about issues regarding clinicians’ professional demands (to establish guidelines and evaluation of e-Health protocols implemented in sexual medicine as well to provide formative and networking possibilities), societal dimensions (to promote gender equality and facilitate access to people at risk of sexual victimization, discrimination, or any form of social exclusion based on gender or sexual orientation), relationship dimensions (to consider new family configurations and specific stressors resulting from COVID-19 like unemployment, domestic overload, endorsement of new roles within the family system; to consider and normalize partners’ expectations about relationships’ dynamics during crisis, including discrepancies in sexual desire or any form of sexual expression; to consider lack of privacy, forced separation of intimate partners, absence of usual erotic cues, or lack of partner; to consider intimate abusive relationships) and individual dimensions (to consider the comorbidity between mental health problems like depressive states and sexual dysfunction and differentiate sexual complaints from sexual symptoms emerging within primary psychopathological conditions due to COVID-19; to consider cognitive distraction during sexual activity with a special focus on body image issues, contamination worries, or any theme resulting from the current scenario; to consider the interplay role between emotional regulation, dysfunctional coping mechanisms like alcohol consumption or out of control pornography consumption and risky sexual behaviors or violence).

Taniguchi H, Hisasue S, Sato Y. Challenges in the Practice of Sexual Medicine in the Time of COVID-19 in Japan. J Sex Med 2020 1-2 [article in press, May 29]

In February 2020 Japan ranked as the second highest in the number of COVID-19 cases, after the Diamond Princess cruise ship docked at Yokohama port but the country has rapidly contained the surge of coronavirus which increased the interest on why Japan has such low numbers of COVID-19 despite its high population density (Tokyo has 2.4 times higher population density than New York) and aged society. Some reasons were speculated such as Japanese cultural issue, immunity, ACE-2 receptor expression, HLA with immune resistance and BCG vaccination. Regarding to Japanese customs they do not involve handshaking, hugging or kissing when greeting. In addition, many Japanese wear cloth or paper face masks in the winter to avoid transmission of respiratory infections. From the point of view of sexuality, it is suggested that Japan is the country with least frequent sexual intercourse in the world. With the outbreak of COVID-19 the Japanese government decided to apply health insurance coverage for online medical treatment from April. Patients could get their medication through their mails. Patients undergoing elective surgeries started to be submitted to preoperative PCR test while patients in need of an emergency surgery should undergo a lung CT-scan as well. Prioritizing health care the International Olympic Committee decided to postpone the Olympics and Paralympics in Japan to the next year. WMSM 2020 in Yokohama was also rescheduled to November 15-17th, 2021.

Li W, Li G, Xin C, et al. Changes in Sexual Behaviors of Young Women and Men During the Coronavirus Disease 2019 Outbreak: A Convenience Sample from the Epidemic Area. J Sex Med 2020 1-4 [article in press, April 22]

This study aimed to obtain a preliminary understanding of the changes in people’s sexual behavior, as a result of the pandemic, and explore the context in which they manifest. A sample of 270 men and 189 women completed an online study-specific questionnaire. While there was a wide range of individual responses, the results showed that 44% of participants reported a decrease in the number of sexual partners and about 37% of participants reported a decrease in sexual frequency. During the height of the COVID-19 outbreak, overall sexual activity, frequency, and risky behaviors declined significantly among young men and women in China.

Illiano E, Trama F, Constantini E. Could COVID-19 Have an Impact on Male Fertility? Andrologia 2020; 52: e13654

The pandemic caused by SARS- CoV-2 has led to several hypotheses of functional alteration of different organs. The direct influence of this virus on the male urogenital organs is still to be evaluated. However, some hypotheses can already be made, especially in the andrological field, for the biological similarity of the SARS-CoV and SARS-CoV2. As well as SARS-CoV, SARS CoV-2 uses the ACE2 as a receptor to enter human cells. It was found that ACE2, Angiotensin (1-7) and its MAS receptors are present, over in the lung, also in the testicles, in particular in Leydig and Sertoli cells. A first hypothesis is that the virus could enter the testicle and lead to alterations in testicular functionality. A second hypothesis is that the binding of the virus to the ACE2 receptor, could cause an excess of ACE2 and give rise to a typical inflammatory response. The inflammatory cells could interfere with the function of Leydig and Sertoli cells. Both hypotheses should be evaluated and confirmed, in order to possibly monitor fertility in patients COVID-19+.

Jacob L, Smith L, Butler L, et al. COVID-19 Social Distancing and Sexual Activity in a Sample of the British Public. J Sex Med 2020 1-8 [article in press, May 3]

On 23rd March 2020, the UK government released self-isolation/social distancing guidance to reduce the risk of transmission of SARS-CoV-2. The aim of this article was to investigate, through an online survey, the levels and correlates of sexual activity during COVID-19 self-isolation/social distancing in a sample from the UK under such official guidance. Sexual activity was measured using the following question: “On average after self-isolating how many times have you engaged in sexual activity weekly?” In a sample of 868 UK adults self-isolating owing to the COVID-19 pandemic, the prevalence of sexual activity was lower than 40%. Those reporting particularly low levels of sexual activity included females, older adults, those not married, and those who abstain from alcohol consumption. Interventions to promote health and well-being during the COVID-19 pandemic should consider positive sexual health messages in mitigating the detrimental health consequences in relation to self-isolation/ social distancing and should target those with the lowest levels of sexual activity.

Newman P, Guta A. How to Have Sex in an Epidemic Redux: Reinforcing HIV Prevention in the COVID‐19 Pandemic. AIDS and Behavior 2020 [published online June 4]

Sexual health is a fundamental determinant of health and wellbeing and all persons – including gay, bisexual, and other GBMSM – have the right to enjoy a safe and pleasurable sexual life with access to comprehensive information, affirmative care, and an enabling legal and sociopolitical environment. The COVID-19 pandemic threatens to disrupt HIV programs and global progress toward UNAIDS 90–90-90 targets. The unprecedented repurposing of health services and resources to address COVID-19, along with necessary restrictive public health measures, present a spectrum of psychological, sociocultural, structural, and biomedical concerns for sexual health and HIV prevention. In this Note, the authors draw on lessons learned from four decades of the HIV response with GBMSM communities and programs of research, to advocate carefully recalibrated, community-engaged approaches to reinforcing HIV prevention in the COVID-19 pandemic.

Sexual Health and Technologies

Kirana PS, Gudeloglu A, Sansone A, et al. E-Sexual Health: A Position Statement of the European Society for Sexual Medicine. J Sex Med 2020 1-8 [article in press, March 12]

The aim of this document is to present the ESSM current position statement on e-sexual health which include the use of information and communication technologies for sexual health including sexual health care, surveillance, education, knowledge, and research. Quality indicators have to be applied on Web pages that provide sexual health information, e-learning can increase educational opportunities for professionals, online treatment interventions can be effective but needs to be available to the public, and online health research can provide access to difficult to reach populations. The ESSM acknowledges the necessity for the use of information and communication technologies to meet the sexual health needs of citizens and patients and also the professional needs of sexual healthcare providers, in an evidence-based manner. ESSM also believes that e-sexual health can provide opportunities for the improvement of the sexual health of the population.

Sexual Dysfunction

Pyke RE. Sexual Performance Anxiety. Sex Med Reviews. J Sex Med 2020; 8: 183-190.

SPA is one of the most prevalent sexual complaints; yet, no diagnosis is recognized for either gender. Thus, research into treatment has been minimal. This article intents to review (2000-2018) the prevalence of SPA and its relation to sexual dysfunctions and anxiety disorders. Compare SPA to (non-sexual) performance anxiety and social anxiety (PA/SA). SPA affects 9-25% of men and contributes to PE and psychogenic ED. SPA affects 6-16% of women and severely inhibits sexual desire. SPA causes or maintains most common sexual dysfunction. No treatments are well proven, although CBT, mindfulness meditation training, and serotonergic anxiolytics (buspirone, trazodone, gepirone) have potential, and PDE5i are effective for psychogenic ED and PE. Several phytotherapies also appear to have potential.

Female Sexual Function

Romero-Otero J, Lauterbach R, Aversa A et al. Laser-Based Devices for Female Genitourinary Indications: Position Statements From the European Society for Sexual Medicine (ESSM). J Sex Med 2020; 17: 841-848

Laser-based technologies have been commercially marketed as “wonder treatments” without a sufficient and adequate body of evidence. In addition, on July 30, 2018, the FDA issued a warning regarding the safety of the use of laser-based devices for the following indications: vaginal “rejuvenation” or cosmetic vaginal procedures, vaginal conditions and symptoms related to menopause, urinary incontinence, and sexual function. An ESSM panel of experts aimed to perform a thorough review on these topics and summarize the results in several short statements according to the level of evidence. Despite the high heterogeneity of studies and its limitations, the committee released several statements regarding the use of laser-based devices for genitourinary indications. Available data in the clinical setting are still poor, and the impact of these technologies on vaginal symptoms and signs has not been clearly established. It is too early in the evolution and research of laser-based devices to make decisive recommendations regarding vaginal treatments. There is grave need to carry out randomized controlled trials with proper design for safety reasons, possible harm, and short/long-term benefits for the different indications studied.

Transgender Sexual Function

T’Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position Statement “Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction”. J Sex Med 2020; 17: 570-584.

There is a general lack of recommendations for and basic information tailored at sexologists and other health-care professionals (HCPs) for when they encounter trans people in their practice. This expert panel prepared an up-to-date overview on trans health care with attention for sexual function and satisfaction. It is recommended that HCPs working with trans people recognize the diversity of genders, including male, female, and nonbinary individuals. In addition, HCPs assessing gender diverse children and adolescents should take a developmental approach that acknowledges the difference between prepubescent gender diverse children and pubescent gender diverse adolescents and trans adults. Furthermore, trans people seeking gender-affirming medical interventions should be assessed by HCPs with expertise in trans health care and gender-affirming psychological practice. If masculinization is desired, testosterone therapy with monitoring of serum sex steroid levels and signs of virilization is recommended. Similarly, if feminization is desired, we recommend estrogens and/or antiandrogen therapy with monitoring of serum sex steroid levels and signs of feminization. HCPs should be aware of the influence of hormonal therapy on sexual functioning and satisfaction and of potential sexual problems during all surgical phases of treatment.

Male Sexual Function

Cihan A, Kazaz IO, Yildirim Ö, et al. Changing Aspects of Male Sexual Functions Accompanying Treatment of Benign Prostatic Hyperplasia with Silodosin 8 mg Per Day. J Sex Med 2020; 17: 1094-1100

This retrospective multicenter study aimed to investigate functional changes in erectile and ejaculatory aspects of male sexuality under Silodosin 8 mg per day treatment for BPH based on IPSS, PEP male and SHIM questionnaires and estimated IELT. Despite several male patients having dry orgasms due to Silodosin-induced anejaculation, the majority experienced improved erectile function in the third month of treatment.

Premature Ejaculation

Alghobary M, Gaballah M, El-Kamel M et al. Oral Dapoxetine versus Topical Lidocaine as On-Demand Treatment for Lifelong Premature Ejaculation: A Randomized Controlled Trial. Andrologia 2020; 00: e13558

This trial aimed to assess the efficacy of on-demand oral dapoxetine (60 mg) versus topical lidocaine (10% spray) treatments for lifelong PE. IELT validated AIPE, SHIM and frequency of intercourse/week were recorded at the baseline and after 12 weeks treatment period of the first medication before two weeks washout period and then crossing over. Results showed that both medications significantly increased both IELT and AIPE scores compared with the baseline being significantly better with topical lidocaine (63.44 s, 179.4 s versus 21.87 s, p < .05). Significant decrease of SHIM score was recorded with lidocaine but not with dapoxetine. Global Efficacy Question for the patient’s assessment of the effectiveness of drugs showed that lidocaine was described as being effective by 43 cases and ineffective by 12 cases, oral dapoxetine was described as being effective by 16 cases and ineffective by 39 cases. From these accumulated data, it is concluded that topical lidocaine is more effective on-demand therapy for lifelong PE compared with oral dapoxetine.


Osmonov D, Christopher AN, Blecher GA, et al. Clinical Recommendations from the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances. J Sex Med 2020; 17: 210-237

The aim of this study was to review the evidence associated with IPP implantation and provide clinical recommendations on behalf of the ESSM. 130 peer-reviewed studies and systematic reviews were included. The panel provided statements exploring patients and partner expectations, satisfaction in male and phalloplasty cohorts, the impact of penile length, girth and implant type, reservoir placement, the influence of comorbidities, and social circumstances. In the preoperative setting, it is fundamental to identify and interact with difficult patients with the intention of enhancing the surgeon’s ability to establish the surgeon-patient relationship, reduce physical and legal risk, as well as enhancing patient satisfaction. To address this need, the mnemonic Compulsive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric (“CURSED”) has been suggested to identify patients who are at high risk of dissatisfaction. The current recommendations suggest improving glycemic control in patients with diabetes. Available evidence suggests evaluating transplant recipients with the criteria of Barry, consisting of stable graft function for >6 months, avoidance of intra-abdominal reservoir placement, and low-dose immunosuppression. HIV status does not represent a contraindication for surgery. Smoking, peripheral vascular disease, and hypertension may be associated with an increased risk of revision surgery. Patients with spinal cord injury may receive IPP. Patients aged >70 years, as well as obese patients, can be offered IPP. The IPP implantation can be performed in patients with stable Peyronie’s disease. Ectopic high submuscular reservoir placement can be considered as an alternative method. This ESSM position statement provides recommendations on optimization of patient outcome by patient selection, and individualized peri and intra-operative management. ESSM encourages centers to collaborate and to create prospective, multicenter registries in order to address this topic of increasing importance.

Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020; 17: 1025-1032

IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs. Database analysis of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States from 2013 to 2019 and comparative surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups. 923 patients were included for this analysis, with 73% having ASC-based surgery and 27% hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs. 120 minutes, P < .001) and surgical (68 vs. 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs. 4.4%). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). In conclusion, ASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk.