Journal of Men's Health

Erectile dysfunction (ED) and vascular disease often co-exist, especially in men over 40 years of age. Endothelial dysfunction is recognised as being the common denominator. Since the endothelium is present throughout the arterial tree, dysfunction at one point that is symptomatic (erectile dysfunction) may be a marker for silent problems elsewhere (coronary arteries). The literature linking ED to silent vascular disease has grown with a consistent message – a man with ED and no cardiac symptoms is a cardiac (or vascular) patient until proved otherwise. ED precedes a chronic or acute cardiac presentation of chest pain by an average of 2–3 years. Since ED shares the same risk factors as coronary disease, the opportunity to use ED as a reason for aggressive risk factor reduction is now the focus of further study – can a man with ED have his coronary event avoided?

Phosphodiesterase type 5 (PDE5) inhibitors are, today, the first treatment option for erectile dysfunction (ED). However, efficacy does not exceed 70%, while the drop-out rate is high. Therefore, salvage strategies and second/third line treatment options are necessary to restore erectile response in such patients. This literature review of the currently available data on non-responders to PDE5 inhibitors aims to discuss key issues that physicians address in everyday clinical practice. These issues include the definition of treatment failure, the identification of factors that affect treatment outcome and the management strategy for non-responders to PDE5 inhibitors. Medication, clinical and patient/partner related issues have been identified as factors related to treatment failure. Treatment outcome assessment is based not only on quality of erectile response, but also on side effect profiles and patient satisfaction. Proper instructions for PDE5 inhibitor administration and psychosexual counselling may convert a substantial number of non-responders to responders. Inappropriate use of PDE5 inhibitors is a major issue in clinical practice. Non-responders may be converted to responders after careful assessment of the proper use of a PDE5 inhibitor. Treatment options for true non-responders are under investigation and include chronic administration of PDE5 inhibitors (everyday, low dose use), switchover from one drug to another or combination treatments. Management strategies must identify patient and partner needs and expectations and involve them in the decision-making.

Sexual dysfunction is a common experience for both men and women. Its management and treatment is often limited by patient and physician ignorance. In addition, medical and interventional organ-focussed therapies in medicine often fail to treat the individual as a whole person, and systemically clinicians often fail to recognise the importance of assessing whether the relationship (when present) is in need of professional input. This article reviews recent clinical advances in the management of men, women and couples with sexual problems using both medical and psychological interventions.

Androgen preparations are indicated for the treatment of male hypogonadism. The re-establishment of normal testosterone (T) levels in hypogonadal men has been shown to result in improved libido, erectile quality and mood and to have positive effects on body composition and other parameters. Several treatment options exist for hypogonadal patients; the most commonly used include injectable intramuscular testosterone esters such as testosterone enanthate administered at intervals of 2–3 weeks, which often leads to temporary fluctuations in serum testosterone levels. A novel injectable testosterone ester, testosterone undecanoate (TU), is as effective and safe as the standard injectable formulation and requires only four injections per year in long-term treatment while maintaining serum T levels within the physiological range. Recent data confirm the safety and efficacy of long-term TU therapy in patients treated over a period of up to 7.5 years and show the positive impact of testosterone on the cavernosal tissues that are pathologically altered due to androgen deficiency in an animal model and in humans. Men with erectile dysfunction and low serum testosterone may benefit from testosterone administration and the combination of phosphodiesterase 5-inhibitors and testosterone may be indicated in men who do not respond sufficiently to testosterone alone.

Background: We conducted a multicenter trial in patients with prostate specific antigen (PSA) levels from 2 to 10 ng/ml to validate the recently presented Vienna Nomogram developed to define the optimal number of biopsy cores required for prostate cancer detection based on PSA, patient age and prostate volume. This should optimize not only cancer detection but also eliminate the need for repeat biopsies. The Nomogram was employed and compared to a matched group of patients undergoing a standard octant biopsy protocol.

Methods: A total of 1,337 patients were prospectively evaluated: 767 underwent standard transrectal ultrasound-guided needle sextant and two transition zone biopsies of the prostate (standard protocol). Patients with benign disease on initial biopsy underwent repeat biopsies within 1 to 2 months. A total of 570 patients underwent prostate biopsy using the Vienna Nomogram. Uni- and multivariate statistical analysis using SAS (Cary, North Carolina) and ROC curves were used to compare both techniques. In addition morbidity was evaluated as defined by early and delayed morbidity on the basis of a patient-based questionnaire and registered morbidity at follow up.

Results: Of the 1,337 patients in the standard group, (31.4%) had prostate cancer (Pca): 22.4% on first and 8.0% on repeat biopsy. In comparison, cancer detection using the Vienna Nomogram was 40.2% after the first set of biopsies, which was significantly superior (p = 0.002) to the octant biopsy technique and even superior to a combination of first and repeat biopsy. Using the cumulative logistic plot analysis the probability of a positive first/repeat biopsy was analyzed. Morbidity was significantly lower in the Vienna Nomogram group as compared to the first + repeat biopsy protocol.

Conclusions: The Vienna Nomogram is an easy tool for selecting the optimal number of prostate biopsy cores based on patient age, PSA and volume. This may solve the problem of optimizing biopsy core numbers. Cancer detection is significantly improved and repeat biopsies may thus become unnecessary. Early and delayed morbidity is also significantly reduced suggesting an advantage not only in terms of improved cancer detection and economics but also in patient acceptance and morbidity.

Background: The objective of this study was to compare testicular self-examination (TSE) practice in 13 European countries over a 10-year period. Testicular cancer predominantly affects young men. It is rare but on the increase and is most common in Caucasian ethnic groups living in industrialised nations, particularly northern Europe. Stage and prognosis are related to early diagnosis and TSE has been advocated to help achieve this. Over the last 15 years there have been efforts to increase disease awareness and self-examination practice. Recent reductions in patients’ delay in seeking help have been attributed to the success of this education, although no evidence has been available to substantiate this claim.

Methods: Data from two successive international surveys in male student populations in Europe (n = 4322, n = 4358) carried out in 1990 and 2000, respectively, are described.

Results: Although TSE practice rates are low, there have been significant increases over this 10-year period.

Conclusions: Increased TSE may reflect greater awareness of testicular cancer and could contribute to more timely help-seeking.

Although psychoanalysis was the first-choice treatment for premature ejaculation (PE) between 1920 and 1960, hardly any reports on its efficacy have been published. Moreover, a scientific debate about its findings has never been fully developed. The recent progress that has been made in the classification of three different PE syndromes creates a new opportunity for psychoanalytic investigations of men with complaints of PE, distinguished by the actual duration of their intravaginal ejaculation latency time (IELT). The term premature-like ejaculatory dysfunction has been introduced to distinguish men with self-perceived PE at normal and long IELT durations from those men with lifelong, acquired and normal variable PE. Psychoanalytic research may contribute to a better understanding of the consequences of objective early ejaculations on the unconscious mental life of men with the four forms of PE. By integrating neurobiological, clinical and epidemiological data of ejaculatory performance, a revival of psychoanalytic research of PE in the four distinct, classified PE groups, will probably contribute to a deeper insight in to the unconscious mental life of men affected by PE.

Treatments based on complementary medicine have gained significant ground in oncology. Patients are mainly interested in adequate support, reduction of the side effects of clinical medicine, strengthening their immune system and enhancing quality of life both during and after chemotherapy and irradiation treatments. In the last few years, a number of complementary strategies for the treatment of prostate cancer have been evaluated and published in international journals. These studies allow us to present today, with scientific accuracy, the initial results of complementary treatment methods, describe their contraindications and interactions, and discuss a safe individualized therapy with the patient. In Western Europe and the USA, immunomodulatory, anti-oxidative and herbal therapies, in particular, have been investigated and published. Of these, we discuss mistletoe therapy, enzyme therapy, carotinoids, lycopene, vitamin A, C, E, selenium, phytoestrogens, PC-SPES, physical therapy and relaxation techniques and psychological therapy. Several studies have demonstrated the improvement in quality of life and the value of complementary medicine as an adjunct to chemotherapy or radiotherapy. Based on fruitful communication and cooperation with the treating oncological urologist, internist/oncologist or radiotherapist, complementary therapy might serve as a valuable and useful supportive measure for prostate cancer patients.

Elderly men with clinical and laboratory evidence of androgen deficiency are eligible for testosterone treatment.

With proper monitoring this is acceptably safe.

In the first year of testosterone treatment there should be a digital rectal examination of the prostate and measurement of prostate specific antigen every three months, thereafter yearly.

The rate of increase of prostate specific antigen (PSA) levels is more significant than its absolute values.

Levels of haemoglobin and the haematocrit should be monitored.