Have you read? Best of the best: Clinical Research

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

Sansone A, Mollaioli D, Ciocca G, Colonnello E, Limoncin E, Balercia G and Jannini EA. “Mask Up to Keep It Up”: Preliminary Evidence of the Association Between Erectile Dysfunction and COVID-19. Andrology 2021; 9: 1053-105.

ED as the hallmark of endothelial dysfunction, could be a short- or long-term complication of COVID-19. Additionally, being ED a clinical marker and predictor of non-communicable chronic diseases, particularly cardiovascular, subjects with ED could potentially have a higher risk of contracting COVID-19. This article aims to to investigate the prevalence of ED among subjects with a reported diagnosis of COVID-19 and to measure the association of COVID-19 and ED. Data from the Sex@COVID online survey (between April 7 and May 4, 2020, Italy) to retrieve a sample of Italian male sexually active subjects with reported SARS-CoV-2 infection. A matching sample of COVID-19-negative male sexually active subjects was also retrieved using propensity score matching in a 3:1 ratio. 100 subjects were included in the analysis (25 COVID-positive; 75 COVID-negative). The prevalence of ED, measured with the SHIM, was significantly higher in the COVID+ group (28% vs. 9.33%; p = 0.027). Logistic regression models confirmed a significant effect of COVID-19 on the development of ED, independently of other variables affecting erectile function, such as psychological status, age, and BMI. Likewise, subjects with ED were more likely to have COVID-19, once corrected for age and BMI. On top of well-described pathophysiological mechanisms, there is preliminary evidence in a real-life population of ED as a risk factor of developing COVID-19 and possibly occurring because of COVID-19. Universal vaccination against the COVID-19 and the personal protective equipment could possibly have the added benefit of preventing sexual dysfunctions.

Mollaioli D, Sansone A, Ciocca G, et al. Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout. J Sex Med 2021;18:35e49.

The COVID-19-related lockdown has profoundly changed human behaviors and habits, impairing general and psychological well-being. A case-control study was performed through a web-based survey and comparing subjects of both genders with (group A, N= 2,608) and without (group B, N= 4,213) sexual activity during lockdown. Anxiety and depression scores were significantly lower in subjects sexually active during lockdown. Logistic regression models showed that lack of sexual activity during lockdown was associated with a significantly higher risk of developing anxiety and depression (OR: 1.32 and 1.34, respectively). This study elucidated the protective role of sexual activity for psychological distress, as well for relational and sexual health. Main limitations were the web-based characteristics of the protocol and the retrospective nature of prelockdown data on psychorelational and sexual health of subjects recruited. COVID-19 lockdown dramatically impacted on psychological, relational, and sexual health of the population. In this scenario, sexual activity played a protective effect, in both genders, on the quarantine-related plague of anxiety and mood disorders.

Men’s health

Towe M, El-Khatib F, Osman M et al. “Doc, If It Were You, What Would You Do?”: A Survey of Men’s Health Specialists’ Personal Preferences Regarding Treatment Modalities. Int J Impot Res 2021; 33: 303–310.

Men’s Health is a urological subspecialty that is at the forefront of innovation, but little data exist evaluating the attitudes that andrologists have toward the current treatment modalities available for managing Men’s Health conditions. A survey of 37 questions asking what providers would choose as treatment for common conditions was distributed online via Survey Monkey to members of the SMSNA and ESSM. A total of 115 respondents completed the survey after an initial screening question. For erectile dysfunction (ED), 40%, 38%, and 33% of providers indicated that they would use tadalafil daily, tadalafil on demand, or sildenafil on demand, respectively, as first-line PDE5i therapy. Furthermore, a total of 74% would elect to undergo LiSWT therapy [67%], PRP injections [15%], and stem cell injections [15%]. Sex/behavioral therapy was preferred for both premature (36%) and delayed (52%) ejaculation. Approximately 44% of respondents indicated that they would undergo Collagenase Clostridium Histolyticum injections for Peyronie’s Disease in the acute phase. In the setting of hypogonadal symptoms with borderline low total testosterone levels (300–400 ng/dL), 69% of respondents would pursue testosterone therapy. The prostatic lift procedure was the preferred procedure for men seeking symptom resolution with preservation of ejaculatory function. Many Men’s Health specialists would pursue the least invasive options before considering procedural intervention for any given condition. Providers may shift their treatment preferences toward newer treatment modalities as longer term data become available.

Male sexual (Dys)funtion

Bañuelos Marco B, García Heil JL. Circumcision in Childhood and Male Sexual Function: A Blessing or a Curse? Int J Impot Res 2021; 33: 139-148.

Male circumcision (MC) is the first planned surgical procedure ever performed. Nowadays many of these procedures are not necessarily carried out in a medical environment, therefore the real number remains unknown but it is estimated that one third of the men are circumcised. Some authors argue the negative impact of MC on men psychology and sexual life, but objective data are lacking. A non-systematic narrative review was performed including articles between 1986 and 2019. Although many authors support the hypothesis that circumcision status has an impact on sexual functioning, a negative outcome has not yet been entirely proven. Circumcision might affect how men perceive their body image, and consequently affect their sexual life. We should consider this when analyzing the literature about MC and sexual dysfunction, as many of the results are based on specific populations with different attitudes towards this procedure. Sexual function consists of many elements that not only relate to measurable facts such as anatomy, somatosensory and histology. An objective evaluation of the impact of circumcision on sexuality is still challenging, as it affects a wide variety of people that confront sexuality differently due to their sociocultural and historical background. Therefore, individuals can either perceive their circumcision status as a blessing or a curse depending on the values and preferences of the different communities or social environments where they belong.

Capogrosso P, Jensen CFS, Rastrelli G, et al. Male Sexual Dysfunctions in the Infertile Couple – Recommendations From the European Society of Sexual Medicine (ESSM). Sex Med 2021; 9: 100377.

Sexual dysfunctions (SDs) have been frequently reported among male partners of infertile couples due to psychogenic, relational and/or organic issues related with the inability to conceive. Likewise, male infertility (MI) could be a consequence of sexual dysfunctions. This article aims to review the evidence on the prevalence and treatment of male SDs in men of infertile couples and provide clinical recommendations on behalf of the ESSM. ED has been reported in 9% to 62% of male partners of infertile couples, with severe impairment observed in only 1% to 3% of ED cases. Moreover, worse semen parameters have been associated with greater ED severity. PDE5is can be safely used to treat ED among patients seeking fatherhood. Male partners of infertile couples are at higher risk of PE. Retrograde ejaculation (RE) and anejaculation are a cause of MI and can be managed with electroejaculation (EEJ) or penile vibratory stimulation (PVS) or, alternatively, with oral treatments, however the latter with limited documented success. Low sexual desire has been reported by one third of men of infertile couples. In conclusion, ED could significantly affect male partners of infertile couple; PDE5is should be suggested to ensure an effective and satisfactory sexual relationship of the couple. Anejaculation and RE should be considered as a possible cause of MI and treated accordingly. Low sexual desire is frequently reported among men of infertile couple and could be a symptom of other systemic conditions or psychological distress.

Erectile dysfunction

Nunes AP, Seeger JD, Stewart A, et al. Cardiovascular Outcome Risks in Patients With Erectile Dysfunction Co-Prescribed a Phosphodiesterase Type 5 Inhibitor (PDE5i) and a Nitrate: A Retrospective Observational Study Using Electronic Health Record Data in the United States. J Sex Med 2021; XX: XXX−XXX.

PDE5i are first-line therapy for ED. Approximately 1−4% of PDE5i recipients co-possess nitrates, despite this combination potentially producing clinically significant hypotension. Real-world data in these patients and insights into prescriber rationales for co-prescription are limited. This study investigated whether PDE5i and nitrate co-possession is associated with increased rates of CV outcomes. Adult males with ED and PDE5i prescription and males with nitrate prescription were identified from a U.S. electronic health record database (2012−2016). Quantitative comparisons were made between patients with ED and co-possession (ED + PDE5i + nitrate), only nitrate possession (ED + nitrate and nitrate only [with- out ED]), and only PDE5i possession (ED + PDE5i). Over 168,000 patients had ≥1 PDE5i prescription (»241,000 possession periods); >480,000 patients had ≥1 nitrate prescription (»486,000 possession periods); and 3,167 patients had 3,668 co-possession periods. Non-significantly different or lower rates of CV outcomes were observed for co-possession periods vs ED + nitrate and nitrate only periods. Most CV outcome rates were non-significantly different between co-possession and ED + PDE5i periods (myocardial infarction, hospitalized unstable angina and fainting were higher with co-possession). From qualitative assessment of patient records with co-possession, 131 of 252 (52%) documented discussion with a physician regarding co-possession; 69 of 131 (53%) warned or instructed on safely managing these contraindicated medications. Findings from this real-world study indicate that co-possession of nitrate and PDE5i prescriptions is not associated with increased rates of CV outcomes, relative to possession of nitrates alone. Co-exposure of PDE5i and nitrates should continue to be avoided; however, co-possession of PDE5i and nitrate prescriptions is not necessarily associated with increased CV risk. Co-possession can be successfully managed in suitable circumstances.

Ejaculatory dysfunction

Reisman, Y. Clinical Experience with Post-Orgasmic Illness Syndrome (POIS) Patients – Characteristics and Possible Treatment Modality. Int J Impot Res 2021; 33: 556–562.

Post-orgasmic illness syndrome (POIS) is a rare condition that includes a cluster of post-ejaculatory symptoms with debilitating physical and psychological consequences. The prevalence and incidence of POIS remain unknown as well as the pathophysiology of the syndrome, and there are no well-studied recognized treatment modalities. The current retrospective observational study describes a series of 14 highly selected patients who were actively looking for medical help as POIS has a significant effect on patients and partners. Mean age was 34.07 ± 6.65 years. The majority of patients had only one symptom in common – extreme fatigue. The most prevalent complaints were head pressure/heaviness, nose congestion and muscle tension; all patients suffered from more than one symptom. POIS started on average within 30 min of ejaculation and lasted for 3.5 days. The patients reported emotional and psychosocial burden of their symptoms, which also influence their partner and relationships. Immunoglobulin-E measurements did not show elevated levels and/or significant increase within 24 h after ejaculation. Silodosin, a highly selective alpha1A-blocker, which actually causes anejaculation, was effective treatment in 57% of the patients.

Female sexual health

Padoa A, Glick Fishman N, Tsviban A et al. Vaginal Postcoital Injuries Requiring Surgical Intervention: A Case Series and Literature Review. Int J Impot Res 2021; 33: 110-117.

This single-center case series describes clinical features and management of women who required surgical repair of vaginal injuries following consensual intercourse. Between January 2008 and December 2017, 20 women underwent hemostatic suturing for vaginal injuries following intercourse. Mean age was 27.6 ± 12.5 (range, 16–63) years, 5 (25%) women were parous, 13 (65%) women used no contraception, and 1 (5%) used birth control pills. Three patients (15%) were postmenopausal. Eight injuries (40%) occurred following first-time intercourse, two (10%) occurred after intercourse with a new partner. Median time from bleeding onset to admission was 12h (range, 2–24h) . One patient (5%) was hemodynamically unstable and required treatment with packed cells. Median time from admission to surgery was 56 (range, 15–540) min. The laceration site was identified at the vaginal fornix in nine (45%) patients, at mid-vagina in four (20%), at the hymenal ring, or the posterior fourchette in six (30%). Tear of a longitudinal vaginal septum was identified in one patient (5%). To conclude, vaginal postcoital injuries are a rare occurrence, nevertheless they may involve significant blood loss and therefore require prompt evaluation and treatment. Once the patient is hemodynamically stable, psychosexual assessment and support should be offered to the patient and her partner.


Svanström Röjvall A, Buchli C, Flöter Radestad A, et al. Impact of Androgens on Sexual Function in Women With Rectal Cancer − A Prospective Cohort Study. J Sex Med 2021; 18:1374-1382.

Women treated for rectal cancer are at risk of sexual dysfunction and impaired ovarian androgen production. This prospective study aims to investigate a possible association between serum levels of endogenous androgens and sexual function in women with rectal cancer. Women diagnosed with stage I−III rectal cancer were consecutively included and prospectively followed. The primary outcome measure was the mean change observed in the FSFI total score when the serum androgen levels changed with one unit. Secondary outcomes were the corresponding mean changes in the FSFI domain scores: sexual desire, arousal, lubrication, orgasm, satisfaction, and pain/discomfort. In the 99 participants, the median FSFI total score decreased from 21.9 (range 2.0 − 36.0) to 16.4 (3.5 − 34.5) and 11.5 (2.0 to 34.8) at 1 and 2-years follow-up. After adjustment for age, partner, psychological well-being, preoperative (chemo)radiotherapy, and surgery, total testosterone and androstenedione were significantly associated with FSFI total score. Testosterone was significantly associated with the FSFI-domains lubrication and orgasm, free testosterone with lubrication, androstenedione with all domains except desire and satisfaction, and dehydroepiandrosterone sulphate with none of the domains. In conclusion, testosterone and androstenedione were associated with sexual function in female rectal cancer patients. The results are of interest for future intervention studies and contribute to the understanding of sexual problems, which is an essential component of the rehabilitation process in pelvic cancer survivors.


Flesia L, Fietta V, Foresta C, Monaro M. “What Are You Looking For?” Investigating the Association Between Dating App Use and Sexual Risk Behaviors. Sex Med 2021; 9: 100405.This article aims to investigate the association between dating app use and sexual risk behaviors since evidence is still scant and inconclusive. 1.278 Italian respondents completed an online questionnaire assessing demographics, motives and patterns of dating app use, sexual behaviors and sexually transmitted infections (STIs) diagnoses. Active users, even more than former app users, were more likely to report risky behaviors and STI diagnoses than non-users (x2 = 26.37, P <.001). Installing the apps to find friends or romantic partners was associated with less protected and unprotected inter-
courses. Installing the apps to find sexual partners predicted higher odds of unprotected sexual activity, hook-ups and STIs diagnoses. Accessing apps more frequently and more years of usage was associated with reporting risky sexual behaviors and STI diagnoses among active users.


Falcone M, Blecher G, Anfosso M, Christopher AN, Ralph DJ. Total Phallic Reconstruction in the Genetic Male. Eur Urol 2021; 79: 684-691

This is a large retrospective tertiary referral centre analysis of a series of genetic male patients with penile insufficiency (PI) either due to congenital micropenis, or from traumatic or surgical amputation was conducted. Radial artery forearm free flap (RAFFF) was conducted as a multistaged procedure: (1) Total phallic reconstruction (TPR), (2) glans sculpting with second stage urethroplasty when indicated, and (3) penile prosthesis implantation.
A total of 108 patients were enrolled. The median age was 32.5 yr and median follow-up was 78.5 mo. A primary anastomotic urethroplasty was performed in 90 patients (83.4%) and a staged procedure in the remainder. Four patients experienced an acute arterial thrombosis, leading to complete loss of the phallus in two. Immediate surgical exploration saved the flap in two cases of venous thrombosis. Urethral complication occurred in 49.1% of patients. The multivariate logistic regression analysis showed an association (p = 0.04) between the staged urethral reconstruction and the incidence of urethral complications. The limitations of the study are its retrospective nature and the lack of control.
Despite the high incidence of postoperative complications and the possible need for revisions, TPR in the genetic male with PI using a RAFFF yields satisfactory aesthetic and functional results.