News

Have you read? Best of the Best: Clinical Research

Recent Issue: ESSM Today # 44

Download the recent issue of ESSM Today with all images and graphics.

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

Chung E, Jiann BP, Nagao L, et al. Provision of Sexual Medicine Services During the Coronavirus Disease-2019 Pandemic: An Asia Pacific Society of Sexual Medicine (APSSM) Position Statement. J Sex Med 2020; 8: 325-326.

COVID-19 pandemic has caused an unprecedented healthcare crisis with various governmental healthcare policies enforced to redirect medical prioritization and minimize the spread of infection. Recognizing that the COVID-19 crisis will be protracted, it is important that clinicians and the healthcare industry continue to adapt existing resources and review contingency plan amidst this uncertain and difficult times. The APSSM supports ongoing precautionary healthcare measures implemented by various institutions and governmental policies to contain and eliminate COVID19 infection:

  1. Telehealth services in countries where telemedicine services are legally applicable— telephone or video call when appropriate for consultations between clinicians and patients;
  2. Online educational webinar and other social media platforms to inform and educate patients;
  3. Recategorization of surgical cases to prioritize more urgent andrology cases and classify certain procedures into low or high risk based on intensive care unit capabilities;
  4. Adopt a pragmatic approach and optimize medical therapy to avoid the need for surgery;
  5. Regular discussion with colleagues regarding how long treatments can be deferred and how to redefine treatment options and timing;
  6. Maintain strict personal protective equipment coverage and adherence to local infectious disease guideline when dealing with potential patients with COVID-19;

Clinicians are encouraged to modify and adapt various strategies that will continue to provide, support, and treat sexual health-related conditions in a safe and efficient manner.

Zattoni, F., Gül, M., Soligo, M. et al. The Impact of COVID-19 Pandemic on Pornography Habits: A Global Analysis of Google Trends. Int J Impot Res (2020). https://doi.org/10.1038/s41443-020- 00380-w

As the COVID-19 spread globally, social distancing, self-isolation/quarantine, and national lockdowns have become crucial to control the pandemic. However, these measures may also lead to increases in social isolation, loneliness, and stress, which can alter the consumption of pornography habits. The aim of the study was thus to explore the interest pattern in pornography and coronavirus-themed pornography during the COVID-19 outbreak. Google Trends® was employed to determine the most popular porn websites (Porn, XNXX, PornHub, xVideos, and xHamster), and coronavirus-themed pornography worldwide and in six nations with different COVID-19 outbreak and self-isolation recommendations. The authors analyzed every search trend on Google® from January 9, 2020 to May 25, 2020 using “joint point regression analysis”. Comparisons of week relative search volume (WRSV) and temporal patterns were analyzed to assess the change of interest in search terms during nations lockdowns.

The research trend of almost every keyword increased with significant inflection points for those nations with a straight “stay at home orders” (China, Italy, Spain, and France). “PornHub” and “Porn” showed the highest increase of interest worldwide with an average weekend percentage change (AWPC) of 4.9 and 3.8, respectively. The mean WRSV for keywords in USA and Sweden did not show a similar increase as the other nations. The WRSV percentage change with the historical data had a peak during the straight nations’ lockdowns (p < 0.01). All the nations had a significant increase in WRSV coronavirus-themed pornography for each keyword (p<0.01). This study used big data technology to collect worldwide trend of interest, however, data were anonymous and did not allow analysis of subpopulation groups. In conclusion, the authors demonstrated an increased interest in pornography and coronavirus-themed pornography after the outbreak of COVID-19 in nations with a straight “stay at home orders”.

Porpiglia F, Checcucci E, Autorino R, et al. Traditional and Virtual Congress Meetings During the COVID-19 Pandemic and the Post-COVID-19 Era: Is it Time to Change the Paradigm? Eur Urol. 2020; 78 (3): 301- 303.

In this article the authors address the influence of COVID-19 on the cancellation or delay of major congress meetings listing the negative consequences but also highlighting the advantageous aspects:
Negative consequences: giving the high virulence of COVID-19, gathering thousands of attendees in a single venue would be inappropriate; continuing medical education has been disrupted; the economic damage to scientific societies and industry partners appears to be huge; human contact, affections, and emotions are almost impossible to reproduce on an online platform; many formal and most informal interactions among faculty, delegates, scientific societies, and industries could be at risk, potentially reducing the opportunities for networking; moreover, the role of the scientific societies themselves could also be jeopardized, considering the economic implications of such reorganization;
Positive aspects: the possibility of organizing a virtual congress using online technology seems to be attractive and safe; the new digital platforms available allow advanced virtual integration among users, giving opportunities for exchange of remote information; interactive video and audio capabilities allow real-time interaction; the advent of hyperefficient telecommunication networks (satellite, 5G) guarantees the transmission of highquality images offering an optimal visual experience, with an image quality close to reality; moreover, these technologies allow the creation of virtual communities in which “social-virtual” events, at which participants meet to discuss a common topic, can be organized; attendees can potentially deliver the same scientific contribution as at a live event without the need to move from their workplace; industries can also add commercial spots during online meetings. A completely web-based event can be planned.

Ideally, a union between people and technology should be created. All the unlimited potential of the digital world should be gradually integrated into the real world, leading to a “hybrid” event. A real agora should be merged with a virtual agora, whereby meeting attendees enjoy the virtual content provided and interact with it in real time (Fig. 1B). By the end of the COVID-19 emergency, we should enjoy a new reality in which technology and sociality go together in order to offer a more engaging and adaptable scientific congress experience, allowing more flexible and dynamic use of content, modulated to the needs of each attendee.

Duran MB, Yildirim O, Kizilkan Y, et al. Variations in the Number of Patients Presenting with Andrological Problems During the COVID-19 Pandemic and the Possible Reasons for These Variations: A Multi-Center Study, Sexual Medicine (2021). https://doi.org/10.1016/ j.esxm.2020.100292.

COVID-19 pandemic caused unprecedented restrictions in outpatient services and surgical practices in urology as in other medical branches as well as in all areas of life. The article reflects the investigation of the variations in the presentations of male patients with sexual and reproductive health problems to the outpatient urology clinics during the COVID-19 pandemic and the understanding of the underlying factors for these variations, if any, across 12 urologic centers in Turkey from February to June, 2020. The patients were divided into two groups: those who presented to the outpatient clinic from February 1, 2020 to March 11, 2020 comprised the “pre-COVID-19 pandemic period” group, whereas those who presented to the outpatient clinic from March 12, 2020 to June 1, 2020 comprised the “COVID-19 pandemic period” group and compared with each other. Andrological problems were detected in 721 of 4.955 male patients included in the study. During the COVID-19 pandemic period, there was a significant increase in andrological diagnosis in these patients compared with the pre-COVID-19 pandemic period [n=293 (17%) vs. n=428 (13.2%), p<0.001, respectively]. Similarly, there was a statistically significant increase in the number of patients diagnosed with male reproductive or sexual health problems during the COVID-19 pandemic period [n=107 (6.2%) vs. n=149 (4.6%), p=0.016 and n=186 (10.8%) vs. n=279 (8.6%), p=0.013, respectively]. The number of patients diagnosed with erectile dysfunction during the pandemic was also significantly higher than the pre-COVID-19 pandemic period [n=150 (8.7%) vs. n=214 (6.6%), p=0.008]. Presentations to the outpatient urology clinics due to andrological problems markedly increased during the pandemic period. Although these problems are of multifactorial origin, psychogenic factors are also considered to significantly trigger these problems.

SEXUAL HEALTH AND TECHNOLOGIES

Fode M, Nolsøe AB, Jacobsen FM, et al. Quality of Information in YouTube Videos on Erectile Dysfunction. J Sex Med 2020; 8: 408-413.

The authors aimed to assess the quality of information regarding ED in 100 english YouTube videos sorted by relevance. Videos containing medical information were evaluated using the Patient Education Materials Assessment Tool (PEMAT) and the DISCERN quality criteria for consumer health information. The PEMAT evaluates the understandability and actionability of materials as a percentage. The DISCERN assesses the quality of information by a scale from 1 (serious or extensive shortcomings) to 5 (minimal shortcomings). The median number of total views was 22,450 (range 591-20.255.133) and the median number of views/month was 654 (range 9-723.398). 42% of the videos were posted by professional medical institutions, and 21% were posted by individual medical professionals. Most videos were aimed at the general public or patients suffering from ED. The median PEMAT understandability and actionability scores were both 100. The median DISCERN score was 2 (range 1-5) with 80.4% receiving a score of 3. Overall, 28% of the videos contained direct misinformation. DISCERN scores were higher in videos produced by medical institutions (P 1⁄4 .0104), not selling specific products (P 1⁄4 .007) and not promoting alternative medicine (P= .0002). The number of subscribers was an independent predictor of views/month (P < .0001). In conclusion, patients may be exposed to videos of poor quality when searching for information about ED on YouTube. The medical community needs to adapt a strategy to improve the quality of online medical information.

Dooley AB, Houssaye N de la, Baum N. Use of Telemedicine for Sexual Medicine Patients. Sex Med Rev 2020; 8: 507-517.

Telemedicine (TM) will play a significant role in contemporary practices that diagnose and treat sexual medicine patients. Although only a small percentage of urologists, sex therapists, social workers, psychiatrists, gynecologists, and urogynecologists currently use TM, many more practices are going to embrace this technology in the near future. This article discusses the process for implementing TM in sexual medicine with minimal time, energy, effort, and expense. Authors also examine compliance and legal issues associated with implementing TM in practice and how to code for TM services based on regulatory guidelines. Dooley et al. state that many patients with sexual medicine problems are no longer going to accept the antiquated method of healthcare involving making an appointment, visiting a brick-and-mortar facility, the requirement of having a physical examination and that the new normal will be communicating with patients by utilizing TM.

Russo, G.I., di Mauro, M., Cocci, A. et al. Consulting “Dr. Google” for Sexual Dysfunction: A Contemporary Worldwide Trend Analysis. Int J Impot Res 32, 455–461 (2020). https://doi.org/10.1038/ s41443-019-0203-2

Google Trends (GT) is a free, easily accessible search tool which can be used to analyze worldwide “big data” on the relative popularity of search terms over a specific period of time. To determine worldwide public interest in Peyronie’ disease (PD), erectile dysfunction (ED), premature ejaculation (PE) treatments, their penetrance, variation, and how they compare over time. Trends analysis included electronic Google queries from people who searched PD, ED, and PE treatments options from January 2004 to October 2018, worldwide. Comparison annual relative search volume (ARSV), average annual percentage change (AAPC) and temporal patterns were analyzed to assess loss or gain of interest. Our results showed that for PD it has been a decreased interest for Drug (AAPC: −3.1%, p < 0.01), ESWT (AAPC: −3.1%, p < 0.01), and vacuum therapy (AAPC: −1.2%, p < 0.01). In the field of ED, we observed trends toward an increased interest in prosthetic surgical treatment (AAPC: +1.7%, p = 0.4), for prostaglandins (AAPC: +0.7%, p=0.7), for traction (AAPC: +0.6%, p=0.1) and for ESWT (AAPC: +1.8%, p=0.4), but without statistical significance. On the contrary, we observed a slight reduction of search for vacuum device (AAPC: −1 %, p < 0.01). The interest in PE decreased from 2004 to today (AAPC: −1%, p < 0.01), for surgical treatment (AAPC: −3.1%, p < 0.01), drug treatment (AAPC: −3.1%, p < 0.01), and for psychotherapy (AAPC: −6.7%, p < 0.01). On the contrary, the interest in spray drugs has increased significantly (AAPC: +5.1%, p < 0.01). Patients are searching the web for sexual diseases treatment options. Understanding people inquisitiveness together with degree of knowledge could be supportive to guide counseling in the decision-making-process and put effort in certifying patient information, avoiding them to fall in the pernicious trap of ‘fakenews’.

Ciocca G, Robilotta A, Fontanesi L, et al. Sexological Aspects Related to Tinder Use: A Comprehensive Review of the Literature. Sex Med Rev 2020; XX: 1-12.

Tinder is the most popular and used meeting application for dating. However, its impact on sexual behavior and sexual health has not yet been thoroughly investigated. The authors intent to review the current empirical knowledge, published in the last 5 years, on the sexual health and sexual behavior effects related to Tinder use. They found that sociosexuality, that is, sexual activities outside a committed relationship, to be the main predictor for casual sex in the Tinder users. The sexual aims appeared gender-influenced: men used Tinder mostly for casual sex compared with women. With respect to other dating apps, it has been also found that the Tinder use is less related to the risk of STI’s. However, specific personality traits related to dark personality (ie, the association of Machiavellianism, narcissism, and psychopathy) were more frequently reported among male Tinder users. This review highlights the need of further studies on Tinder as a new, pivotal virtual place to promote sex education and sexual health.

ERECTILE DYSFUNCTION

Rodriguez KM, Kohn TP, Kohn JR, et al. Shift Work Sleep Disorder and Night Shift Work Significantly Impair Erectile Function. J Sex Med 2020; 17: 1687-1693.

This article examines the association between shift work sleep disorder (SWSD) and erectile dysfunction (ED) in shift workers. Men presenting to a single andrology clinic between January 2014 and July 2017 completed validated questionnaires: IIEF, PHQ-9, and the nonvalidated SWSD Questionnaire. Men were also asked about shift work schedule, comorbidities, PDE5i use, and testosterone use. Men with SWSD have worse erectile function, with men who work night shifts having even poorer erectile function. These findings suggest that circadian rhythm disturbance may significantly impact erectile function. While testosterone therapy may partly reverse the effects of SWSD, shift work is a potential risk factor for ED and should be assessed for as part of the evaluation of men with ED.

Rastrelli G, Yannas D, Mucci B, et al. Family History for Cardio-Metabolic Diseases: A Predictor of Major Adverse Cardiovascular Events in Men With Erectile Dysfunction. J Sex Med 2020;XX:1-12.

Family history (FH) of cardiovascular (CV) disease is a known CV risk factor. However, it is rarely considered for CV risk stratification. Furthermore, FH for metabolic diseases is generally overlooked. The aim of this study was to evaluate, in a population of men with ED, whether FH for cardio-metabolic diseases could provide insights into metabolic and sexual features and predict the occurrence of forthcoming major adverse CV events (MACE). A consecutive series of 4,693 individuals (aged 51.3 ± 13.3 years) attending an Andrology clinic for ED was studied. A subset of these (n= 1,595) was evaluated retrospectively for MACE occurrence over a mean follow-up of 4.2 ± 2.5 years. An increased number of FH factors were associated with worse erectile function, impaired penile dynamic peak systolic velocity, and lower testosterone levels. Investigating FH for cardio-metabolic diseases is a quick and easy task that could help clinicians in identifying, among individuals with ED, those who deserve careful evaluation of CV and metabolic risk factors. Moreover, considering FH for CV risk stratification could predict MACEs in individuals who, according to conventional CV risk factors, would be erroneously considered at low risk.

TESTOSTERONE DEFICIENCY

Lo EM, Rodriguez KM, Pastuszak AW, Khera M. Alternatives to Testosterone Therapy: A Review. Sex Med Rev 2018; 6: 106-113.

Although testosterone therapy (TTh) is an effective treatment for hypogonadism, recent concerns regarding its safety have been raised. In 2015, the US FDA issued a warning about potential cardiovascular risks resulting from TTh. Fertility preservation is another reason to search for viable alternative therapies to conventional TTh, and the authors revise the role and limitations of non-testosterone treatments for hypogonadism. Medical therapies examined include hCG, aromatase inhibitors, and SERMs. Nondrug therapies that are reviewed include lifestyle modifications including diet and exercise, improvements in sleep, decreasing stress, and varicocele repair. The high prevalence of obesity and metabolic syndrome in the US suggests that disease modification could represent a viable treatment approach for affected men with hypogonadism. These alternatives to TTh can increase testosterone levels and should be considered before TTh.

PEYRONIE’S DISEASE

Fernández-Pascual E, Manfredi C, Torremadé J, et al. Multicenter Prospective Study of Grafting With Collagen Fleece TachoSil in Patients With Peyronie’s Disease. J Sex Med 2020;XX: 1-8.

A xenograft consisting of equine collagen coated with human fibrinogen and thrombin (TachoSil; Baxter, CA) has recently been introduced in grafting procedures for PD. This article describes the results of a multicenter prospective registry between May 2016 and March 2018 (10 centers) on patients with PD undergoing plaque incision and grafting (PIG) or plaque excision and grafting (PEG) with collagen fleece TachoSil, to evaluate the efficacy and safety of this procedure. A total of 52 patients were enrolled in the study. The mean (SD) preoperative penile curvature was 72.8º (17.0). PIG was the preferred technique (80.8%). Intraoperatively, complete curvature correction was achieved in 92.3%, and no significant penile shortening was recorded in 80.8% of subjects. Subjective penile shortening was reported in 83.3% of patients at 6 months. No statistically significant difference from the baseline was found in IIEF- 5 and EHS at 3 or at 6 months, although 16.7% of men experienced a worsening of IIEF-5 scores and 14.3% required de novo PDE5i use. 6 months after surgery, 78.5% of men were satisfied with intervention. Swelling and ecchymosis/hematoma were the most common perioperative complications (40.4%). 2 cases (3.8%) of wound infection were recorded. At 6 months, 35.7% of patients reported mild penile hypesthesia. The results confirm the high success rate of grafting with TachoSil, and the surgeon perceived low percentage of penile shortening. Grafting with TachoSil after PIG/PEG in patients with PD is an effective and safe procedure. Among the main advantages of this technique, there are ease of use of the graft and reduced operative time. The main limitations were the short follow-up and the relatively small sample size.

PRIAPISM

Zhao H, Dallas K, Masterson J, et al. Risk Factors for Surgical Shunting in a Large Cohort With Ischemic Priapism. J Sex Med 2020;XX: 1-6.

Ischemic priapism is treated with a stepwise algorithm, but some patients may benefit from immediate shunt placement. This study aimed to identify risk factors for surgical shunt placement in a large series of 143 patients with ischemic priapism (169 encounters) in a singles institution from January 2010 to December 2018. 26 (15%) encounters resulted in a surgical shunt. Patients treated with a shunt had longer priapism durations than those without (median 36 vs 10 hours, P < .001). Independent predictors of a surgical shunt on multivariate logistic regression were the duration of priapism in hours (OR: 1.05, P < .001) and history of prior priapism (OR: 3.15, P= .045). Receiver operating characteristic curve analysis using priapism duration to predict the need for shunt generated an area under curve of 0.83. A duration of 24 hours correlated to a sensitivity of 0.77 and specificity of 0.90. Most (74%) of the priapism were due to intracavernosal injections so the results may not be generalizable to populations with different priapism etiologies. These results can aid urologists in the counseling and decisionmaking process of these challenging cases.

FEMALE SEXUAL HEALTH

Horvath Z, Smith BH, Sal D, et al. Body Image, Orgasmic Response, and Sexual Relationship Satisfaction: Understanding Relationships and Establishing Typologies Based on Body Image Satisfaction. Sex Med 2020; 8: 740-751.

This study explored the role of body image dissatisfaction on orgasmic response during partnered sex and masturbation and on sexual relationship satisfaction in a sample of 257 Norwegian women. The study also described typologies of women having different levels of body image satisfaction. Body image dissatisfaction, along with a number of covariates, predicted higher levels of “problems with orgasm” during both partnered sex and masturbation, with no significant difference in the association depending on the type of sexual activity. Varying levels of body image dissatisfaction/satisfaction were associated with differences in orgasmic incidence, difficulty, and pleasure during partnered sex; with one orgasmic parameter during masturbation; and with sexual relationship satisfaction. In conclusion, body image dissatisfaction and likely concomitant psychological distress are related to impaired orgasmic response during both partnered sex and masturbation and may diminish sexual relationship satisfaction. Women with high body image dissatisfaction can be characterized by specific sexual response patterns.

ONCOSEXOLOGY

Borges RC, Tourinho-Barbosa RR, Glina S, Macek P, Mombet A, Sanchez-Salas R, Cathelineau X. Impact of Focal Versus Whole Gland Ablation for Prostate Cancer on Sexual Function and Urinary Continence. J Urol. 2021 Jan; 205(1): 129- 136.

Focal instead of whole gland ablation for prostate cancer has been proposed to decrease treatment morbidity. From 2009 to 2018, 346 patients underwent HIFU or cryotherapy for prostate cancer. Urinary continence was defined as use of no pads and sexual potency as enough erection for sexual penetration. 195 post-focal therapy and 105 post-whole gland therapy patients were included in analysis. No significant difference was seen in baseline IPSS and IIEF-5 scores. In multivariate models focal therapy was the most important factor related to sexual potency at 3 (OR 7.7) and 12 months (OR 3.9). Median IIEF-5 score at 3 months was 12 and 5 (p <0.001), and at 12 months was 13 and 9 (p=0.04) in focal therapy and whole gland therapy groups, respectively. Focal therapy was the only factor related to continence (OR 0.7, p <0.001). Focal ablation instead of whole gland therapy is the most important factor related to better sexual and urinary continence recovery after HIFU and cryotherapy for prostate cancer.

BEHAVIOR

Roels R, Janssen E. Sexual and Relationship Satisfaction in Young, Heterosexual Couples: The Role of Sexual Frequency and Sexual Communication. J Sex Med 2020; 17: 1643-1652.

This research aimed to examine the contribution of sexual frequency and sexual communication to sexual and relationship satisfaction in the early stages of couple relationships in a sample of 126 young, heterosexual couples (mean age 23.3 years, average relationship duration 1.9 years) measured by the Quality of Sex Inventory and the Couple Satisfaction Index. Only sexual communication, not sexual frequency, predicted relationship satisfaction in a sample of young, heterosexual couples. No significant partner or gender effects were found. These findings lend support to the notion that couples could benefit from focusing on non-behavioral processes (eg, sexual communication), rather than sexual behavior per se, when pursuing a fulfilling partnership.

SURGERY

Shaeer O, Soliman Abdelrahman IF, Mansour M, et al. Shaeer’s Punch Technique: Transcorporeal Peyronie’s Plaque Surgery and Penile Prosthesis Implantation. J Sex Med 2020; XX: 1-5.

Penile prosthesis implantation in cases of severe Peyronie’s disease may require plaque excision/ incision and grafting, which may require mobilization of the neurovascular bundle or urethra, posing the risks of penile hyposensitivity or urethral injury, and is time-consuming, possibly increasing infection risk. Shaeer and his group describes their own punch technique for transcorporeal debulking of Peyronie’s plaques during PPI which were performed in 26 patients. After corporotomy and dilatation, Peyronie’s plaques were punched out from within the corpora cavernosa using the punch forceps (Figure 2), and then a penile prosthesis was implanted.

Comparison to a matching retrospective group of 18 patients operated upon by plaque excision-grafting (EG) and penile prosthesis implantation was performed. Average preoperative curvature angle was 58.1 ± 11.7 in the Punch group and 58 ± 14.8 in the EG group, p=0.99. After surgery, all patients had a straight penis. No tunical perforations, urethral injuries, or extrusions were noted. Average additional operative time for Punch technique ranged from 5 to 10 minutes (7.3 ± 1.7), in contrast to the EG group where plaque surgery duration was 50.8 minutes ± 11.1, an 85% difference, p < 0.0001. Septal plaques in the latter group could not be removed. In the PPI-Punch group, penile sensitivity was preserved in all patients, compared with the excision/grafting group, with 7 of 18 patients reporting hypoesthesia of the glans. Infection occurred in 1 of 26 patients in the PPI-Punch group, compared with 2 of 18 patients in the EG group. Satisfaction with length on a 5-point scale was 3.8 ± 0.9 in the punch group, versus 3.1 ± 1.1 in the EG group. The proposed technique seems minimally invasive and prompt, possibly decreasing the known complications of plaque surgery and PPI including sensory loss and providing brief plaque surgery time.

X