Our study aimed to assess the methodological strengths and weaknesses of erectile dysfunction clinical practice guidelines (CPGs) for individuals using the AGREE II tool. Erectile dysfunction related CPGs were identified from three databases: the National Guideline Clearinghouse, the Guidelines International Network, and PubMed between 2000 and 2020. We designed an independent assessment for each of the erectile dysfunction related CPGs using the AGREE II tool. Four appraisers performed these assessments. The literature search identified 8 CPGs that met our inclusion criteria. The evaluation of the AGREE II domains of each individual revealed that the median scores of domains related to applicability were quite low (39%). Also, the median scores of domains related to the rigour of development and the stakeholder involvement were relatively low (53% and 63%). We determined the highest median scores in three AGREE II domains: clarity of presentation (80.5%), editorial independence (77%), and scope and purpose (89.5%). We found that the European Association of Urology (EAU), the American Urological Association (AUA), and the British Society for Sexual Medicine (BSSM) guidelines had >60% in >4 domains and that their average AGREE II scores were over 70%. In the Canadian Diabetic Association (CDA) and the Japanese Society for Sexual Medicine (JSSM) guidelines, we found that >4 domains were >60%, but their average AGREE II scores were below 70%. The British Medical Journal (BMJ), the Canadian Urologic Association (CUA), and the Malaysian Urologic Association (MUA) guidelines had >60% in <3 domains. We highly recommended EAU, AUA and BSSM guidelines, while we moderately recommended CDA and JSSM guidelines. BMJ, CUA and MUA guidelines were weakly recommended. The quality of the guidelines for erectile dysfunction was variable according to AGREE II. We noted significant deficiencies in the methodological quality of the CPGs developed by different organisations in the areas of applicability and rigour of development.
Herbal medicine long has been used in the management of sexual dysfunction, including erectile dysfunction. Many patients have attested to the efficacy of this treatment. However, is it evidence-based medicine? Studies have been done on animal models, mainly in the laboratory. However, randomized controlled trials on humans are scarce. The only herbal medications that have been studied for erectile dysfunction are Panax ginseng, Butea superba, Epimedium herbs (icariin), Tribulus terrestris, Securidaca longipedunculata, Piper guineense, and yohimbine. Of these, only Panax ginseng, B. superb, and yohimbine have published studies done on humans. Unfortunately, these published trials on humans were not robust. Many herbal therapies appear to have potential benefits, and similarly, the health risks of various phytotherapeutic compounds need to be elucidated. Properly designed human trials should be worked out and encouraged to determine the efficacy and safety of potential phytotherapies.
Sex has always been a taboo subject in Asian society. However, over the past few years, awareness in the field of men's sexual health has improved, and interest in sexual health research has recently increased. The epidemiology and prevalence of erectile dysfunction, hypogonadism and premature ejaculation in Asia are similar in the West. However, several issues are specific to Asian males, including culture and beliefs, awareness, compliance and the availability of traditional/complementary medicine. In Asia, sexual medicine is still in its infancy, and a concerted effort from the government, relevant societies, physicians and the media is required to propel sexual medicine to the forefront of health care.
Introduction: Anxiety and depression are both associated with increased morbidity in diabetic population, especially those afflicted with foot ulcer, whereas Erectile Dysfunction (“ED”) and Female Sexual Dysfunction (“FSD”) are amongst the common complication found in diabetes. This study aimed to determine the prevalence of anxiety and depression as primary outcome and sexual dysfunction (“SD”) as a secondary outcome in diabetic patients with and without foot ulcer (“DFU”).
Methods: A cross-sectional study was conducted in Hospital Raja Permaisuri Bainun Ipoh, Perak, where 164 diabetic patients were recruited for the purpose of this study. Hospital Anxiety and Depression Scale (“HADS”) were utilised to measure anxiety and depression. International Index for Erectile Function 5 (“IIEF-5”) and the Malay version of Female Sexual Function Index (“MVFSFI”) were used to detect SD. Simple and multiple logistic regressions were referred to in order to evaluate the factors associated with anxiety, depression and SD.
Results: In the group with foot ulcer, 36.8% had depressive and anxiety risk respectively compared to without the foot ulcer, 37.5% and 38.5% respectively. Male gender (AOR=6.3,p=0.002,95%CI 1.975, 20.205) and having lower education status (AOR=6.0,p=0.018,95%CI1.36,26.59,) was associated with foot ulcer. High prevalence of SD found in foot ulcer group (52.6%,p=0.006). Those with depression (OR=4.421,95% CI 1.08,18.16,p=0.039) and male gender (OR=18.42,p<0.01,95%CI5.5,-61.62) predicts present of SD.
Conclusion: Depression and anxiety prevalent were similar for both with and without diabetic foot ulcer. Several significant predictor factors were identified for DFU group, for anxiety and depression risk and for SD in a diabetes patient. Further studies are required to establish the directional nature of this relationship.
Keywords: Depression, Anxiety, Diabetic food ulcer (DFU), Erectile Dysfunction (ED), Female Sexual Dysfunction (FSD)
Study site: outpatient clinic of medical and orthopedic departments in Hospital Raja Permaisuri Bainun (HRPB) Ipoh, Perak, Malaysia
One of the major causes of erectile dysfunction (ED) is an endothelial vascular disorder. This meta-analysis is performed to determine the efficacy of aspirin on erectile function in men with vasculogenic ED. For this purpose, CENTRAL, MEDLINE, and reference lists of articles up to November 2019 were searched. Randomized controlled trials (RCTs) were selected that compared aspirin with placebo in men of any ethnicity with vasculogenic ED. A total of 58 trials were retrieved. Finally, two trials of 214 men fulfilled our selection criteria. High selection and detection bias were identified for one trial. The participants showed a significant improvement in erectile function when they took aspirin (mean difference: 5.14, 95% CI [3.89, 6.40], and I2 = 0%). Although the present meta-analysis suggested that aspirin has a significant effect on the improvement of erectile function, there were limited RCTs available on this topic and doses of aspirin varied. Additional studies are needed to support findings from this meta-analysis. Aspirin needs to be considered by practitioners when prescribing drugs for vasculogenic ED.
Male sexual dysfunctions (MSDs) often remain undiagnosed and untreated in Asia compared to Europe due to conservative cultural and religious beliefs, socioeconomic conditions, and lack of awareness. There is a tendency for the use of traditional medicines and noncompliance with and reduced access to modern healthcare. The present systematic review compared the incidence and factors of MSD in European and Asian populations. English language population/community-based original articles on MSDs published in MEDLINE from 2008 to 2018 were retrieved. A total of 5392 studies were retrieved, of which 50 (25 Asian and 25 European) were finally included in this review. The prevalence of erectile dysfunction (ED) (0%-95.0% vs. 0.9%-88.8%), low satisfaction (3.2%-37.6% vs. 4.1%-28.3%), and hypoactive sexual desire disorder (HSDD) (0.7%-81.4 vs. 0%-65.5%) was higher in Asian than in European men, whereas the prevalence of anorgasmia (0.4% vs. 3%-65%) was lower in Asian than in European men. Age was an independent positive factor of MSD. In European men over 60 years old, the prevalence of premature ejaculation (PE) decreased. The prevalence of MSD was higher in questionnaires than in interviews. The significant factors were age, single status, low socioeconomic status, poor general health, less physical activity, cardiovascular diseases, diabetes, obesity, lower urinary tract symptoms, prostatitis, anxiety, depression and alcohol, tobacco, and drug use. The prevalence of MSD differed slightly in Asian and European men. There is a need to conduct large studies on the various Asian populations for the effective management of MSD.
Erectile dysfunction is common in adult men, particularly those with hypertension and diabetes. The present study determines the effectiveness of angiotensin receptor blocker (ARB) drugs on erectile function in hypertensive male adults. For this purpose, CENTRAL and MEDLINE and reference lists of the articles were searched. The randomized controlled trials (RCTs) were selected that compared ARBs with conventional therapy or no treatment in men of any ethnicity who were presented with hypertension and/or diabetes. A total four trials that had 2,809 men were included. Three trials reported adequate random sequence allocation, two reported adequate blinding. Attrition bias is low in one of the included studies. All three studies are of low risk of selective reporting bias. There was an improvement in sexual activity with ARBs (valsartan) (mean difference (MD): 0.71, 95% Confidence Interval (CI) 0.66 to 0.76, I2 statistic = 0%). However, the erectile functions did not increase significantly in ARBs (losartan or telmisartan) treated men as compared to control or placebo (n = 203 vs n = 232; MD: 1.36; 95% CI: -0.97 to -3.69; I2 statistic = 80%). These results suggested that ARBs significantly improved sexual activity among hypertensive men. However, the erectile function was not significantly improved in ARBs treated men as compared to the control or placebo-treated. There were limited studies available. Hence, additional studies are needed to support findings from this review. ARBs should be considered when prescribing antihypertensive drugs to men.
Introduction. This study aims to evaluate the effectiveness of Tualang honey on sperm parameters, erectile function, and hormonal and safety profiles. Methodology. A randomized control trial was done using Tualang honey (20 grams) and Tribestan (750 mg) over a period of 12 weeks. Sperm parameters including sperm concentration, motility, and morphology were analyzed and erectile function was assessed using IIEF-5 questionnaire. Hormonal profiles of testosterone, FSH, and LH were studied. The volunteers were randomized into two groups and the outcomes were analyzed using SPSS version 18. Results. A total of 66 participants were involved. A significant increment of mean sperm concentration (P < 0.001), motility (P = 0.015) and morphology (P = 0.008) was seen in Tualang honey group. In Tribestan group, a significant increment of mean sperm concentration (P = 0.007), and morphology (P = 0.009) was seen. No significant differences of sperm concentration, motility, and morphology were seen between Tualang honey and Tribestan group and similar results were also seen in erectile function and hormonal profile. All safety profiles were normal and no adverse event was reported. Conclusion. Tualang honey effect among oligospermic males was comparable with Tribestan in improving sperm concentration, motility, and morphology. The usage of Tualang honey was also safe with no reported adverse event.
Eurycoma longifolia is reputed as an aphrodisiac and remedy for decreased male libido. A randomized, double-blind, placebo controlled, parallel group study was carried out to investigate the clinical evidence of E. longifolia in men. The 12-week study in 109 men between 30 and 55 years of age consisted of either treatment of 300 mg of water extract of E. longifolia (Physta) or placebo. Primary endpoints were the Quality of Life investigated by SF-36 questionnaire and Sexual Well-Being investigated by International Index of Erectile Function (IIEF) and Sexual Health Questionnaires (SHQ); Seminal Fluid Analysis (SFA), fat mass and safety profiles. Repeated measures ANOVA analysis was used to compare changes in the endpoints. The E. longifolia (EL) group significantly improved in the domain Physical Functioning of SF-36, from baseline to week 12 compared to placebo (P = 0.006) and in between group at week 12 (P = 0.028). The EL group showed higher scores in the overall Erectile Function domain in IIEF (P < 0.001), sexual libido (14% by week 12), SFA- with sperm motility at 44.4%, and semen volume at 18.2% at the end of treatment. Subjects with BMI ≥ 25 kg/m(2) significantly improved in fat mass lost (P = 0.008). All safety parameters were comparable to placebo.
INTRODUCTION: Erectile dysfunction (ED), lower urinary tract symptoms (LUTS), cardiovascular disease (CVD), depression, and androgen deficiency are common conditions affecting aging men over 50 years. However, data were limited in developing countries.
AIMS: To investigate the prevalence of ED, LUTS, chronic diseases, depression, androgen deficiency symptoms, and lifestyle of aging men in Malaysia, and to examine their associations with sociodemographic factors.
MAIN OUTCOME MEASURES: ED, LUTS, chronic diseases, depression, positive Androgen Deficiency in the Aging Male (ADAM) questionnaire
METHODS: A randomized survey of 351 men using structured questionnaires consisting of self-reported medical conditions, International Index for Erectile Function-5, International Prostate Symptom Score, Geriatric Depression Scale-15, and St Louis University questionnaire for ADAM. Blood samples were taken for glucose, lipid, prostate specific antigen (PSA), and hormones.
RESULTS: Mean age was 58+/-7 years. Prevalence of ED was 70.1% (mild ED 32.8%, mild to moderate ED 17.7%, moderate ED 5.1%, and severe ED 14.5%). There were 29% of men with moderate and severe LUTS; 11.1% had severe depression; 25.4% scored positive on ADAM questionnaire; 30.2% self-reported hypertension, 21.4% self-reported diabetes mellitus; 10.8% self-reported coronary artery disease; 19.1% were smokers; and 34% consumed alcohol. There were 78.6% of men that are overweight and obese; 28.8% had a fasting blood sugar (FBS) >or=6.1 mmol/L, 70.1% had total cholesterol >5.2 mmol/L, 19.1% had total testosterone >or=11.0 nmoL/L, 14.0% had calculated free testosterone <0.0225 nmoL/dL; 4% had PSA >4 microg/L; 9.4% had insulin-like growth factor-1 (IGF-1) level below age specific range, 5.1% had abnormal sex hormone binding globulin (<15 nmoL/L and >70 nmol/L). ED was found to be significantly associated with LUTS, depression (P<0.001 respectively). Similarly, LUTS was significantly associated with depression and ADAM questionnaire status (P<0.001 respectively); and ADAM questionnaire status was also significantly associated with depression (P<0.001).
CONCLUSION: ED, LUTS, depression, and androgen deficiency symptoms are common in urban aging men. As these conditions are possibly interrelated, strategies for early disease prevention and detection are warranted when one disease presents.
We report a study which defined the prevalence of erectile dysfunction (ED) among men with ischaemic heart disease. We recruited 510 men with established ischemic heart disease and interviewed these men using the International Index of Erectile Dysfunction (IIEF-5) questionnaire to determine the presence and severity of ED. Presence of ED was defined as IIEF-5 score of less than 22. The mean age was 60.5 years (range 36-92 years; SD: +9.58). 461 (90.4%) men reported some degree of ED of which two third of them had moderate to severe ED. The prevalence of ED increased significantly with age. Age above 60 years was the only significant risk factor. Non-statistically significant but important risk factors included diabetes, hypertension, diuretics and oral hypoglycemic agents. ED is very common among men with ischemic heart disease. The prevalence and severity increased significantly with age above 60 years old.
Erectile function (EF) is a prerequisite for satisfactory sexual intercourse (SI) and central to male sexual functioning. Satisfactory SI eventually initiates orgasm - a biopsychophysiological state of euphoria - leading to a sense of bliss, enjoyment and positive mental well being. For a psychiatrist, treating ED is self-propelled to harmonize these pleasurable experiences alongside with encouragement of physical wellness and sensuality. Hence, the role of PDE-5i is pivotal in this context and constitutes a therapeutic challenge. PDE-5i work via the dopaminergic-oxytocin-nitric oxide pathway by increasing the availability of endothelial's guanosine monophosphate (GMP), immediately causing relaxation of the penile smooth muscle and an erection. The PDE-5i, like sildenafil, vardenafil and tadalafil, are effective in the treatment of ED with some benefits/ flexibilities and disadvantages compared to other treatment modalities. Prescribed PDE-5i exclusively improve EF, fostering male's self-confidence and self-esteem. Treatment failures are associated with factors such as absent (or insufficient) sexual stimulation, psychosexual conflicts and the co-existence of medical disorders. Managing ED requires dealing with underlying medical diseases, addressing other co-morbid sexual dysfunctions like premature ejaculation (PE), and educating the patient on healthy life-styles. Furthermore, by dealing with interpersonal dynamics within the couple and embracing adequate lifestyles (managing stress and revising one's sexual scripts), PDE-5i treatment benefits may be enhanced. In this review, we propose a holistic conceptual framework approach for psychiatric management of patients with ED.
OBJECTIVE: To determine the efficacy of Tongkat Ali (Eurycoma longifolia) herbal extract on erectile function improvement.
METHODS: Comprehensive electronic databases were searched from inception through October 2014. Randomized controlled trials investigating Tongkat Ali compared to placebo were included. Outcome of interest was the improvement of erectile dysfunction. The difference of changes from baseline of the outcome between Tongkat Ali and placebo was pooled using weighted mean difference (WMD). Methodological quality of included studies was assessed using Jadad's quality scale and Cochrane's risk of bias.
RESULTS: Of the 342 articles identified, 2 studies involving a total of 139 participants were analyzed. No significance between group difference was found in the mean WMD of the change in the 5- item version of the international index of erectile function (IIEF-5) at week-12 (0.91; 95% CI: -1.50 to 3.33 with I(2)=89.5%, P-value=0.002) with statistical heterogeneity. Based on the subgroup analysis, significant improved IIEF-5 score of 2.15 (95% CI 1.03-3.27) was found in subjects with lower baseline IIEF-5 score, but this was not seen among those with higher baseline IIEF-5 score.
CONCLUSION: Based on current evidence, the herbal extract of Tongkat Ali may have clinical effect on erectile function. However, more efficacy trials are warranted to further support current evidence.
KEYWORDS: Alternative medicine; Erectile dysfunction; Eurycoma longifolia; Extract; Root; Tongkat Ali
OBJECTIVE: To evaluate the impact of the modified ileal neobladder reconstruction on lifestyle, voiding habits and functional outcome in Asian patients.
PATIENTS AND METHODS: Twenty-seven Asian patients (25 men and two women, mean age 59 years, range 41-76) underwent modified ileal neobladder reconstruction after radical cystectomy for carcinoma of the bladder. The mean (range) follow-up was 21 (3-75) months. All patients were evaluated retrospectively using case notes, reviews, interviews and voiding charts; 18 patients underwent urodynamic studies.
RESULT: Twenty-five patients (93%) achieved diurnal and 23 (85%) nocturnal continence within 6 months. Of the 19 patients who were in employment before surgery, 15 continued to be economically active afterward; 26 patients (96%) reported no change in their daily living activities. Of 16 men who reported being potent pre-operatively only four retained some residual erectile function. Twenty-three patients were interviewed about their voiding habits and satisfaction with the outcome of surgery. Fourteen patients had no sensation of reservoir fullness and of the 21 men, 13 had to squat or sit to void effectively. The mean (range) voiding frequency was 5 (4-8) during the day and 2 (0-4) during sleep. Twenty-two patients were satisfied with the overall outcome.
CONCLUSIONS: The modified ileal bladder provides a high urinary continence rate with minimal changes in daily living activities and occupational status. The functional outcome was very satisfactory and accepted well, despite some changes in reservoir sensation, voiding posture and erectile function. The method is a viable option for reconstruction after cystectomy in Asian patients.
OBJECTIVES: To examine the prevalence, characteristics, and impact of sexual dysfunction in our primary care referral population.
METHODS: Participants seeking treatment for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) were recruited from general urology clinics. The subjects completed the National Institutes of Health-Chronic Prostatitis Symptom Index, International Index of Erectile Function-5, and selected questions from the University of Washington Symptom Score. Additional information on demographics and medical and treatment history were also obtained. Sexual dysfunction was defined as self-reported erectile dysfunction (ED) or ejaculatory difficulty, or both.
RESULTS: Of 296 participants with CP/CPPS, 214 (72.3%) reported sexual dysfunction. The National Institutes of Health-Chronic Prostatitis Symptom Index total score averaged 22.5 +/- 6.9 for participants with sexual dysfunction compared with 20.4 +/- 7.8 for participants who did not report sexual dysfunction (P = 0.03). Of the 214 participants with sexual dysfunction, 54 (25.0%) complained of ED only, 71 (33.4%) complained of ejaculatory difficulties only, and 89 (41.6%) complained of both ED and ejaculatory difficulties. Men reporting both ED and ejaculatory difficulty reported worse CP/CPPS symptoms (analysis of variance, P = 0.042) and worse quality of life (analysis of variance, P = 0.006) than men without sexual dysfunction.
CONCLUSIONS: Sexual dysfunction was reported by almost three quarters of patients with CP/CPPS. Patients with CP/CPPS and sexual dysfunction experienced substantially worse symptoms, particularly worse quality of life, than other patients with CP/CPPS. Sexual dysfunction merits consideration as an important aspect of CP/CPPS and a potential outcome measure.
Sildenafil citrate (Viagra), a selective inhibitor of cGMP-specific phosphodiesterase type-5, has been used as an oral therapeutic drug for erectile dysfunction. The present paper is a clinical study of the success rate and side-effects of the use of sildenafil in a multi-racial population in Singapore.
Safety and tolerability of sildenafil citrate was assessed in a population subset of 60 Singaporean men with erectile dysfunction taken from the Asian Sildenafil Efficacy and Safety Study (ASSESS-I), a double-blind, placebo-controlled, flexible-dose study. The men, from two centres, with > or = 6 months' history of erectile dysfunction, were randomized to two treatment arms for 12 weeks. One group (30 patients) received sildenafil (initial dose 50 mg taken 1 h before sexual activity for the first 2 weeks, increased to 100 mg or decreased to 25 mg, according to efficacy and/or tolerability). The remaining 30 patients received a matching placebo. Incidence and type of adverse effects were evaluated at 2, 4, 8 and 12 weeks. Nine patients (30.0%) on sildenafil (33.1% in the full ASSESS-I study) and one patient (3.3%) on placebo (22.8% in the full ASSESS-I study) experienced treatment-related adverse events, the most frequent being headache in the sildenafil group (reported by five patients [16.7%]; 11.0% in the full ASSESS-I study). Flushing, visual disturbance, dizziness, insomnia, myalgia and back pain each occurred in one patient in the sildenafil group (3.3%); in the placebo group, one patient (3.3%) had headache. Importantly, the incidence of cardiovascular and respiratory system adverse events were relatively less than in the full ASSESS-I population (cardiovascular 3.3% in the present study versus 10.2% in the full ASSESS-I population; respiratory 3.3% versus 5.5%). All adverse events were transient and mild, and did not lead to treatment withdrawal. There was no effect on sitting blood pressure, heart rate or standard laboratory parameters; more importantly, there was no incidence of myocardial infarction, stroke or priapism. These results should reassure Singaporean patients and their physicians of the safety of sildenafil for erectile dysfunction.