About a year ago, a major retrospective study showed that men prescribed erectile dysfunction (ED) drugs, such as sildenafil (Viagra) had markedly higher rates of sexually transmitted diseases.  This relationship, however, could have more to do with behavior than with ED drug use.

Anupam Jena, MD, PhD, of Massachusetts General Hospital in Boston and colleagues analyzed insurance claims for 1.4 million men ages 40 and older (mean age 61) and found that users of prescription ED drugs developed STDs at a rate of 214.9 per 100,000, with HIV cases accounting for 70 percent of the total, compared with 106 per 100,000 among men not using these drugs.

Data for the retrospective cohort study came from pharmacy claims in 44 large employers’ health plans from 1997 to 2006. About 34,000 men ages 40 and older in the database had received at least one prescription for an ED drug, and 1.38 million had not.

Users had higher rates of several comorbidities including cancer, depression, diabetes, high cholesterol, and hypertension by about 50% in each case.

The data, however, showed that STD rates among the ED drug users were higher than in nonusers even before the men received their first prescription, suggesting that it was the users’ behavior, not the drugs, which was the responsible for the relationship.  The authors reported these findings in the Annals of Internal Medicine.

The authors believe that the “use of ED drugs by middle-aged and older patients may serve as a simple screening tool for physicians to use in identifying those patients who may benefit from reminders about safe sexual practice.”

The reported that HIV/AIDS rates in people older than 50 years in 2005 were higher than for people in their 20s, and these rates have increased in older people while rates among other age groups have decreased.

According to CDC statistics, other STDs are less common in people over 40 compared with younger individuals, with little change in the rates from 2004 to 2008.

Jena and colleagues found little difference when they examined quarterly STD diagnosis rates in the year before the first prescription for ED drugs versus the following year.

Some limitations for this study were no data on frequency of sexual encounters, practices, or number or gender of partners; potentially inaccurate or incomplete data on ED drug use; probable underestimates of actual STD incidence, due to nondiadnosis or care outside of the health plan; and complex “sexual network effects” and uncertain risks per encounter.

According to the results of a small clinical study at Fox-Chase Cancer Center in Philadelphia, a simple, inexpensive home test for erectile dysfunction showed a good correlation with prostate cancer patients’ and partners’ subjective assessments of their sex life.

Objective measures of nocturnal tumescence, erectile dysfunction (ED), and overall sexual function had significant associations for up to a year with the “stamp” test, a do-it-yourself nocturnal penile tumescence assessment.  This test supplements subjective information provided by patients and their sexual partners.  The findings were presented by Lanea Keller, MD, at the American Society for Radiation Oncology.  Dr. Keller found that after high-dose IMRT (intensity-modulated radiation therapy), both the patient’s and the partner’s perception of their overall sex life was reflected by a positive stamp test as well as their own perception of erectile dysfunction.

After radiation therapy for localized prostate cancer, men often have concerns about sexual function.  According to Keller, the information clinicians use to assess erectile and other aspects of sexual function comes mainly from standardized questionnaires, which elicit responses that may be subjective.

Adding the results of an objective test, which involves a strip of postage stamps, could help in the assessment and decision making related to sexual function.  The test involves a man wrapping a strip of postage stamps around the base of the penis.  If he has a normal nocturnal tumescence response, the stamps separate at one or more of the perforations, resulting in a positive test.  Ninety-four prostate cancer patients were evaluated using this test.  The men completed the Expanded Prostate Cancer Index Composite (EPIC) and International Index of Erectile Function (IIEF) questionnaires at baseline and at six, 12, and 24 months after treatment. During the weeks that they completed the questionnaires, the patients also performed stamp tests on various nights.  Their partners also completed an IIEF partner questionnaire at the same time intervals.  The correlation between patients’ and partners’ questionnaire responses and the stamp test was analyzed.

The median age of the patients was 62.5.  Ninety-seven percent of the patients had stage T1c or T2a cancer.  Keller reported that 68 patients had positive stamp tests at baseline. The number of positive tests declined to 33 at six months, 32 at 12 months, and 30 at 24 months.  A positive stamp test at baseline had no relationship with patients’ or partners’ overall satisfaction with their sex life. At all of the follow-up periods, the stamp test had one or more significant or borderline-significant associations with the subjective assessments of sexual function and satisfaction.

At all three time intervals after IMRT, a positive stamp test was associated with patients’ overall satisfaction with their sex life, the partner’s perception of the patient’s erectile dysfunction, and partners’ overall satisfaction with their sex life.  A positive stamp test’s correlation with subjective measures tended to be strongest at one year.

In a report published earlier this year in the Journal of Urology, researchers found that regular use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with erectile dysfunction (ED).  The research team had gone into this study thinking that they would find that NSAIDS would actually have a protective effect because they protect against heart disease, which is linked to ED.  Previous data had suggested a potential relationship between inflammation and erectile dysfunction.  If this relationship were causal, NSAID use should be inversely associated with ED.  Instead, the authors found just the opposite.

The study began back in 2002 when the California Men’s Health Study enrolled a large, ethnically diverse cohort of male members of Kaiser Permanente managed care plan between the ages of 45 and 69 years old.  Researchers used a questionnaire to evaluate ED and automated pharmacy data and self-reported use to evaluate NSAID exposure.

NSAID use was present in 47.4% of the 80, 966 participants, and moderate or severed was reported in 29.3% of the participants.  Both NSAID use and ED are strongly correlated with age.  Regular NSAID use increased from 34.5% in men between the ages of 45 to 49 years to 54.7% in men between the ages of 60 to 69 years old.  ED increased from 13% to 42% between these two age groups.  Researchers found that a positive association was still present after adjusting for age, race/ethnicity, smoking status, diabetes mellitus, hypertension, hyperlipidemia, peripheral vascular disease, coronary artery disease, and body mass index.

Possible problems with this study include cross-sectional design, potential participation bias, and low original participation rate.  Further studies are needed to reveal the actual relationship between ED and NSAID.

The U.S. Food and Drug Administration is calling for new warning labels on part of a class of medications used to primarily treat enlarged prostate called 5-alpha reductase inhibitors (5-ARI). This new warning is based on the results of two large prostate cancer trials where it shows that the medications may raise the risk of developing an aggressive form of prostate cancer. The drugs involved include popular medications sold under brand names Proscar and Propecia (sold by Merck & Co.) and Avodart and Jalyn (sold by GlaxoSmithKline).

Propecia, a lower dose version of Proscar and is prescribed to treat hair loss in men is updating its label even though it was not included in the trials. FDA said “the applicability of the Avodart and Proscar studies to Propecia is currently unknown.”

FDA is advising doctors not to start patients on these drugs until prostate cancer and other urological conditions have been ruled out. Prostate cancer can mimic the symptoms of an enlarged prostate.

Recent research has also shown that Proscar, Propecia and Avodart are all associated with increased risk of erectile dysfunction in men who take the medications.

According to FDA, between 2002 and 2009 almost 5 million men were prescribed one of these medications and of these nearly 3 million men were between the ages of 50 and 79.

“What both studies show conclusively is there is about 1% increase in being diagnosed with high-grade prostate cancer if you got these drugs even though you are less likely to get a low-grade cancer. You have to weigh the 24% reduction against the 1% increased incidence of high-grade disease.” says Dr. Anthony D’Amico, chief of genitourinary radiation oncology at Brigham and Women’s Hospital in Boston. He added, “These drugs should only be used in men who have an additional indication to take them beyond prostate cancer prevention.”

Dutasteride (Avodart), a drug frequently prescribed to treat enlarged prostate and Finasteride (Proscar and Propecia); a drug frequently prescribed to treat hair loss may contribute to erectile dysfunction, depression and loss of libido. Symptoms may even persist after the medication stopped.

This is according to a study led by Abdulmaged M. Traish, a professor of biochemistry and urology at Boston University School of Medicine. The team searched for available medical literature for reports of sexual side effects associated with Finasteride and Dutasteride. Of the men taking the drugs, 8% reported erectile dysfunction and 4.2% reported reduced libido while those taking the placebo only 4% of men reported erectile dysfunction and 1.8% of men reported reduced libido. The researchers also noted that reduced ejaculation, reduced semen volume and depression were also reported by some men.

The drugs (Dutasteride and Finasteride) work by blocking androgen but androgen is needed for erectile function, libido and ejaculation, and for just feeling good.

Traish said “as a physician you have a responsibility to take the time and explain to your patient that maybe not everyone will have these side effects, but you may, and in some cases they are irreversible””.

Dr. Bruce R. Kava, an associate professor of urology at the University Of Miami Miller School Of Medicine agreed that “these drugs do cause some of these problems but they haven’t convinced me yet, based on the data, because they don’t have any long term data”. He added that most urologists discuss potential side effects with their patients but usually “don’t discuss long term consequences that are irreversible, because most of us have not been aware of any long term problems from these drugs”.

One of the most recognized side effects of prostatectomy is erectile dysfunction. However, post-surgery penile length shortening (PLS) is known to occur in up to three-fourths of men. Penile length returns to preoperative length by nine months postoperatively, a study found.

The study, by Jason D. Engel, MD, of George Washington University Hospital, Washington, DC, and collaborators enrolled 127 patients who underwent robot-assisted laparoscopic radical prostatectomy (RALRP) for prostate cancer. Of these, 94 completed an 11-month follow-up period. Subjects had a mean age of 56.5 years. The baseline mean stretched penile length (SPL) prior to surgery was 11.77 cm.
At one month postoperatively, the length had decreased to 11.13 cm. However, mean SPL was not significantly different from baseline at nine, 10, and 11 months, according to a report in the Journal of Endourology.

Why does the radical prostatectomy damage the penis so much? “The operation removes the prostate and seminal vesicles and removing these structures leaves a gap that is sometimes filled by pulling the penis up into the body, effectively shortening it,” says Dr. Hennenfent. “In addition, nerve branches, arteries, and veins in the pelvis are always severed by the radical prostatectomy. These missing structures can no longer nourish the penis and it atrophies. One study suggests that the erectile tissue in the penis actually dies off after the radical prostatectomy.”

The central theme to emerge from men who responded to the study was “resignation”, a conveyed awareness of their inability to return to a pre-cancerous lifestyle. Men adapted to the changes of having prostate cancer. All participants focused on the bigger picture and this allowed them to coexist with a diagnosis of prostate cancer. To focus on the bigger picture, they took into consideration past experiences, current state of affairs and hypothesized how potential outcomes would impact upon them. Family relations were prioritized, especially spousal communication. In addition, three sub-themes were identified; unaltered masculinity, the unimportance of penile length shortening and erectile dysfunction as a speed bump. None of the men perceived changes in their own evaluation of masculinity after noticing PLS after radical prostatectomy. While men saw themselves as being unable to perform a “masculine” role in procuring coitus, this did not mean that they saw themselves as unmanly. The men also felt that PLS was unimportant, in part due to the fact that they all experienced erectile dysfunction. It is unclear how PLS might impact potent men in this regard. Finally, all men identified return of erectile function as the event that would improve satisfaction with penile function.

The researchers concluded that “Patients should be counseled that penile length might decrease after radical prostatectomy.”

Researchers have recently found an association between erectile dysfunction (ED) and a greater risk for cardiovascular events. Patients with ED who were treated with telmisartan, ramipril, or both were at greater risk for cardiovascular events than other patients on the same medications.

Study results revealed that men with baseline ED experienced a doubled rate of all-cause mortality during a 4 year follow-up. This rate is in comparison to men who had mild or no ED, according to a study published online in Circulation.

“The present data clearly show that ED is closely associated with an increased risk for all-cause deaths, as well as the primary composite outcome of cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure,” said Michael Bohm, MD, of the University of the Saarland, Saarbrucken, Germany, and colleagues.

“The evaluation of ED in the medical history as an early symptom of endothelial dysfunction and atherosclerosis and as a predictor of death and future cardiovascular events might be relevant to identify patients at particularly high risk of experiencing a cardiovascular event.”

The study evaluated a subgroup of 1,549 men who had participated in either the ONTARGET study, which looked at the effectiveness of a ramipril/telmisartan combination in patients with cardiovascular disease, or the TRANSCEND study, which examined the effects of telmisartan in patients who were intolerant of ACE inhibitors.

An ED questionnaire was used for the study and contained the five-item short form of the International Index of Erectile Function (IIEF) and the Kolner (Cologne) Evaluation of Erectile Dysfunction scores. Questionnaires were obtained from all patients at baseline, at year two, and at the next-to-last follow-up visit.

The results showed that patients with ED at baseline were more likely to die of cardiovascular causes or MI and tended to have higher risks for heart failure and stroke, “but the observed trends toward increased risk were not significantly different,” noted the authors.

The researchers also looked at the effects of the study drugs on ED.

“There were no significant differences in IIEF scores or the changes in scores at the run-in, two-year, and penultimate visits among the treatment groups in either ONTARGET or TRANSCEND,” they said. In addition, “over time, there were also no differences in onset of new ED due to either treatment.”

“It is likely that the presence of ED identifies individuals whose cardiovascular disease might be far more advanced than evaluated by other clinic parameters alone,” concluded the authors.

They added that the association was particularly close with regard to all-cause and cardiovascular death: “According to the IIEF scores in the present study, there was an increased risk in patients with mild to severe ED, and we observed a stepwise increase in risk depending on the severity of ED.”

Hope is still alive for men’s sexual function after prostatectomy. Mainly, those men who are still experiencing erectile function two years after surgery may still see an improvement in function. This improvement may leave men able to sufficiently function during sexual intercourse.

“The message to patients who have erectile dysfunction—even those who have failed to have erections after surgery—is that improvement does occur in a substantial number of men,” says researcher Jeffrey Schiff, MD, a resident in urology at the State University of New York Downstate Center in Brooklyn, New York.
According to Dr. Schiff, nearly one-third of men with marginal erectile function and one-fourth of men with serious erectile dysfunction after surgery continue to have improvement in erectile function on follow-up visits, even 24 months after the surgery was performed.

Schiff and fellow researchers examined the medical records of 128 men who had a radical prostatectomy and were evaluated for erectile function at follow-up visits to the doctor. The men were asked to rate their level of erectile function on a 5-level scale, with 1 corresponding to normal function and 5 representing no erections.

Before the surgery, two-thirds of the men evaluated themselves at level 1, meaning they had normal erectile function. The remaining one-third said they had diminished erections, but were still able to have intercourse.
After surgery, however, 51 men had rated themselves at level 3, meaning “partial erections occasionally satisfactory for intercourse.” At subsequent follow-up visits, 10% of these men had normal functioning and 22% recovered enough to have intercourse, although they did have diminished erections.

Eighty-seven men rated themselves at level 4 or 5, corresponding to partial erections not sufficient for intercourse, or no erections two years after surgery. Of these men, 1.1% recovered to normal erections and 10% recovered diminished erections, routinely sufficient for intercourse. Thirteen percent recovered partial erections occasionally satisfactory for intercourse.

Although those men who experienced the most severe erectile dysfunction still did not see any improvement after three years, men who had partial erections that were occasionally sufficient for intercourse continued to make progress for up to four years after surgery, explains Schiff.

“It’s common for men to have erectile dysfunction after prostatectomy and this shows they shouldn’t get discouraged if sexual functioning doesn’t come back right away,” says AUA spokesman Ira Sharlip, MD, of the University of California, San Francisco. “Even after two years, many will still improve.”

One confounding factor of the study is that about half the men in the study who suffered from sexual dysfunction took ED drugs like Viagra.

“This was not a controlled experiment, so we don’t’ know if these drugs were helpful in overcoming erectile dysfunction,” says the study’s head, Farhang Rabbani, MD, associate professor of urology at Montefiore Medical Center.