A research report submitted to the Faculty of Health Sciences at the University of the Witwatersrand in partial fulfillment of the requirements for the qualifications of MMed (Urology) 2017 / Background: Erectile dysfunction is one of the most important sequelae of pelvic fractures and may be transient or permanent. It can range from weak erections to severe sexual dysfunctions. Importantly, erectile dysfunction is more prevalent when the pelvic fracture is associated with urethral injury. Methods:  This was a retrospective study of patient records, with a prospective questionnaire arm for patients admitted to the hospitals with a pelvic fracture between 01/07/2011 to 30/04/2015.  The electronic databases of the Orthopedic Department at Helen Joseph Hospital and the Male Sexual Dysfunction Clinic at Charlotte Maxeke Johannesburg Academic Hospital were accessed for patients' contact details, by using the name and hospital number of each patient.  Each patient was contacted telephonically with an open speaker in a presence of a witness/translator. The information sheet was read to the patient before the telephonic consent was obtained.  After consent was obtained, patients were asked to verbally complete the International Index of Erectile Function score questionnaire. Results A total of 53 patients participated in the study, of which (43.4%) reported erectile dysfunction. The majority of patients indicated a recovery of erectile function between 2 8 | P a g e to 8 months after the injury. Most were found to still suffer from other forms of sexual impairment like orgasmic dysfunction and sexual satisfaction. However, sexual desire seemed to be preserved. Patients with sexual dysfunction were more likely to have had a urethral injury as well as a more severe fracture. Conclusions In our sample of 53 patients almost half reported sexual dysfunction after a pelvic fracture. Importantly, patients with urethral damage and a severe pelvic fracture should be followed up, as the risk of sexual dysfunction is high in these particular patients. / MT2017

MMed (Urology), Faculty of Health Sciences, University of the Witwatersrand / The metabolic syndrome has recently become one of the major public health challenges and results from the increasing prevalence of obesity. Erectile dysfunction (ED) affects up to half of men over the age of forty. Men with co-morbid disease and risk factors including cardiovascular disease, hypertension, dyslipidaemia and depression all report a higher prevalence of ED. The current study investigated the prevalence of the metabolic syndrome in one hundred men with (ED) presenting to the Male Sexual Dysfunction Clinic at the Johannesburg Hospital. Participants underwent a thorough history taking and examination session which included the International Index of Erectile Function Score. Several fasting biochemistry and hormonal tests were performed. Participants were divided by race into three groups. Data was recorded in EXCEL and reported as mean±std or as a number (frequency). Where applicable, correlation between variables was determined. The prevalence of the metabolic syndrome was 39%, with the highest prevalence (54%) in the group comprising Asian, Coloured and Chinese participants. Eighty percent of participants had moderate-severe (ED), with a mean duration of 3,8 years. Glucose and HbA1c were strong predictors of ED duration. Severity of ED was not influenced by the presence of the metabolic syndrome. Men presenting with ED may represent an ideal patient group to screen for the metabolic syndrome, and therefore for cardiovascular disease, especially for those men within the asymptomatic period.

Background and Purpose: The Massachusetts Male Aging Study found 52% of men aged 40 to 70 years suffered from erectile dysfunction (ED). Approximately two millions men in Taiwan were ED suffers, only 10% of them had taken Viagra®. The potential market is very attractive to pharmatheutical industry. By law, ED medicines are prescriptive drugs; in practice, more than 80% of ED drugs were sold without prescription in Taiwan. The launch of Levitra® and Cialis® has boosted the competition in the ED drug market. The purposes of this study are 1) to compare the marketing strategies of Viagra®, Levitra® and Cialis®, 2) to analyze factors influencing physicians¡¦ prescription, 3) to analyze factors affecting drug purchasers¡¦ decision, and 4) to survey the preference of drugstores owners on selling these drugs. Materials and Methods: The first step is face-to-face, in-depth interviews with product mangers to understand their marketing strategies. We will ask them to rate the significance of factors (e.g. efficacy, safety, price) affecting physicians¡¦ and patients¡¦ preference. Product mangers will be requested to rate the importance and relevance of the way product messages delivered to doctors¡¦ prescription behaviors. Questionnaires will be mailed to all urologists in Taiwan to survey factors they concerned when prescribing. We use mailing questionnaires and face-to-face interviews to assess the impact of drug efficacy, duration, safety, etc. on drug purchasers¡¦ decision. Drugstores owners will be interviewed to understand their favor in promoting certain drug. Comparative studies will be done to evaluate the difference between product mangers, physicians and patients. Results The marketing strategy of Pfizer is to emphasize the well-documented efficacy and long-term safety of Viagra® by seminars for physicians. Educational talks will be given to the public to explore the potential consumers. The goal of Bayer is to urge the silent ED suffers search for medical help, and to convince physicians that Levitra® is the drug of choice for ED patients. Eli-Lilly put almost all their marketing efforts and resources in drugstores. Drug efficacy and safety are most important factors influencing physicians¡¦ prescription. Approximately 85% of urologists surveyed favor Viagra®, 21% have safety concern on Cialis®. Most urologists considered Levitra® as alternative of Viagra® when failed. All product mangers overestimate the impact of key opinion leaders, literature, and seminars on physicians¡¦ prescription behaviors. Patients¡¦ survey disclosed that drug efficacy and safety are most important factors affecting drug purchasing. As compared to physicians, patients have more concern on the time of onset and duration. About 20% of drug purchasers are not ED suffers; 62% of purchasing is sporadic, one third of Viagra® users have the attempt to try other ED drugs. The drugstores owners have no specific preference for any drugs. Conclusions The extension of life expectancy and open discussion of male ED problem had resulted in tremendous growth of ED drug market. The launch of new drug may stimulate the selling amount in short run; the long-term market shares depend mainly on the drug efficacy and safety. In our study, we found that safety profile is the main concern for both physicians and drug purchasers. We believed that Viagra® may stay as the market leader, while Levitra® may have only small market share. Certain groups of drug purchasers, especially fake ED suffers and those who with multiple sex-partners will have high brand loyalty to Cialias®.

Introduction: Evidence from 3 randomized controlled trials in South Africa, Uganda and Kenya showing that male circumcision can reduce heterosexual transmission of HIV from infected females to their male sexual partners by up to 60% has led to a dramatic increase in the demand for circumcision in most African countries hard-hit by the HIV pandemic. Among communities where circumcision is not routinely practiced, this has created anxieties around possible deleterious effects of circumcision on erectile function. Most studies that have been conducted to explore the relationship between male circumcision and erectile function have yielded conflicting results (6-8, 14, 15). This study aimed to compare erectile function in circumcised and uncircumcised men in Lusaka, Zambia. Aim/objectives: To compare erectile function in circumcised and uncircumcised adult men aged 18 years and above in Lusaka, Zambia. Methods: Design: In this cross sectional survey, a total of 478 participants (242 circumcised and 236 uncircumcised) comprising patients, health workers and other men visiting the 4 study sites between 1/6/13 and 30/9/13 were handed the IIEF-5 questionnaire to complete. Information about participants’ age, relationship status, education level, smoking, alcohol use and medication use was also collected. The study included sexually active men older than 18 years living in Lusaka, Zambia. Males younger than 18 years, those lacking sexual experience and, those with serious mental and physical conditions were excluded from the study. Setting: Outpatient departments of 4 primary health care facilities in Lusaka, Zambia. Main Outcome Measure: Erectile function scores were calculated for the 2 groups. Normal erectile function was defined as an IIEF-5 score ≥22 (out of a possible maximum score of 25) points. Results: Circumcised men had higher average erectile function scores compared to their uncircumcised counterparts, U=23062.50, Z=3.64, p<0.001. The prevalence of ED was lower in circumcised men (56%) compared to that in uncircumcised ones (68%), 2 (N182) =7.52, df=1, p<0.05. Erectile function scores were similar in those circumcised in childhood compared to those circumcised in adulthood, 2 (N242) =0.29, df=1, p=0.59. The groups did not differ significantly in age, relationship status, smoking, alcohol use and medication use. However, a statistically significant difference was observed in education levels with the circumcision group showing higher levels, 2 (N478)=19.05, df=6, p<0.005. Conclusion: The higher erectile function scores in circumcised men observed in this study show that circumcision does not confer adverse effects on erectile function in men. Circumcision can thus be considered without concern about worsening erectile function. However, a prospective study in a similar cultural context is needed to confirm these findings.

Medicalization as a Trojan Horse: Changes in Erectile Enhancement Advertising By Robert D Wood, M.S. A Thesis submitted in partial fulfillment of the requirements for the degree of Master of Science at Virginia Commonwealth University Virginia Commonwealth University, 2011 Major Director: Sarah Jane Brubaker, PhD, Graduate Program of Sociology This thesis investigates the medicalization of “inadequate penis size” through an analysis of online advertising of “male enhancement,” or erectile enhancement (EE) products. The process of medicalization, as defined by Peter Conrad, is the process by which non-medical problems become defined and treated as such (2007). With the advent and success of Viagra (Sildenafil) in 1998, a wave of products emerged treating erectile dysfunction and not long after followed the expansion of the market for erectile enhancement. Although several studies have been done of erectile dysfunction, there has been less research on the advertisement techniques within the erectile enhancement market. Brubaker and Johnson's article “'Pack a more powerful punch' and 'lay the pipe': erectile enhancement discourse as a body project for masculinity” dissects such advertising for overarching themes of violence, the subjugation of women, and the perpetuation of hegemonic masculinity (2008). This analysis was done in 2006, and evidence presented in this thesis suggests that the advertising techniques, particularly as they appear in erectile enhancement websites, show some dramatic differences in presentation and themes. These more recent advertisements seem to reflect a more medical approach, emphasizing an authoritative medical appearance, downplaying violent, misogynistic, or sexist undertones consistent with much of erectile enhancement advertising. This new medical approach is a metaphorical Trojan horse, sneaking in and maintaining older concepts of domination and violence. The background of hegemonic masculinity in erectile enhancement advertising is continued under the guise of medical professionalism. Through quantitative and qualitative analysis of ten erectile enhancement product websites, I show how the advertising involved in this industry has attempted to medicalize the small penis in hopes of marketing an “inadequate penis” as a more legitimate, medical concern. This study thus contributes to a better understanding of the changing social concepts of manhood, how the process of medicalization works, and how it can be seen within the area of erectile enhancement.

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Erectile performance anxiety (EPA) is a subset of sexual anxiety characterized by a fear of erectile failure. EPA has been shown to play a pivotal role in male sexual problems including premature ejaculation and erectile dysfunction (Loudon, 1998; Perelman, 2006). EPA affects approximately 14% to 23% of U.S. men across age groups (Laumann, Paik, & Rosen, 1999), and is the most common proximal cause of psychogenic ED (Hale & Strassberg, 1990; Hedon, 2003; Perelman, 1994; Rosen, 2001). Phosphodiesterase type 5 (PDE5) inhibitors such as sildenafil citrate (brand-name Viagra) are the first line of pharmacological treatment for ED. Recreational use of PDE5 inhibitors -- defined as unprescribed use with the goal of sexual enhancement and prevention of erectile failure among men without clinically significant erectile difficulties. Approximately 13.4% of young men between the ages of 18 - 30 report using PDE5 inhibitors recreationally. The most commonly reported reason for off-prescription use is to enhance one's sexual performance, i.e., longer lasting erections or impress one's sexual partner (Bechara, Casabe, De Bonis, Helien, & Bertolino, 2010; Harte & Meston, 2011; Holt, 2009; Korkes, Costa-Matos, Gasperini, Reginato, & Perez, 2008; Musacchio, Hartrich, & Garofalo, 2006). Reducing anxiety -- specifically EPA is often given as a reason for recreational use, though to a lesser extent (Korkes et al., 2008; Schnetzler, Banks, Kirby, Zou, & Symonds, 2010). However, PDE5 inhibitors do not exert a significant increase in penile tumescence among men without erectile dysfunction (Mondaini et al., 2008). The actual sexual enhancement from recreational use of PDE5 inhibitors among this population would be limited in that blood flow to the healthy erectile tissue is already optimal. The proposed study aimed to examine the effects of an erection-enhancing pill description misattribution on anticipatory anxiety and subsequent subjective and physiological sexual response to an audiovisual erotic stimulus. Participants underwent two assessments of their subjective and physiological arousal response to an erotic film after randomization to one of three conditions (erection-enhancing pill description, memory-enhancing pill description, or a no pill control). It was hypothesized that compared to those in the memory-enhancing pill group and the no pill control group, participants in the erection-enhancing pill group would respond with greater anticipatory anxiety and dampened penile tumescence in response to a subsequent no-pill erotic film presentation. Results of the study provided partial support for the hypothesized negative effects of the pill attribution manipulation. In the subset of subjects with complete pre and post-manipulation physiological data, those led to believe they ingested an erectile-enhancing herb showed a dampening of erectile tumescence to a subsequent erotic film presentation. Also, consistent with prediction, erectile performance anxiety was associated with decreased tumescence after the bogus "average" erectile performance feedback compared to baseline. These findings suggest that pill attribution may influence sexual arousal to some extent, despite methodological issues such as partial physiological data loss and believability of the pill instructional set manipulation. / text

Cigarette smoking represents the most preventable cause of morbidity and mortality in the world today, and is responsible for enormous health-related economic burdens. Among other medical sequelae, erectile impairment has been shown to be associated with chronic tobacco use. The primary aim of the present study was to provide the first empirical investigation of the effects of smoking cessation on physiological and subjective indices of sexual health. Sixty-five long-term, heavy smoking men participated in a smoking cessation program and were assessed at baseline (while smoking regularly), at mid-treatment (while using a high dose nicotine transdermal patch), and at 4-week follow-up. Physiological and subjective sexual arousal indices, as well as self-reported sexual functioning (as measured by the International Index of Erectile Functioning (IIEF)) were assessed during each visit. Intent-to-treat analyses indicated that at followup successful quitters (n = 20), compared to those who relapsed (n = 45), showed significant improvements in physiological and subjective sexual arousal. Specifically, men demonstrated enhanced erectile responses, decreased latencies to reach maximum erectile capacity, and faster onset to reach maximum subjective sexual arousal. Although participants displayed across-session enhancements in self reported sexual function, successful quitters did not show a differential improvement compared to participants who relapsed. The results of the present investigation provide the first empirical evidence that smoking cessation significantly enhances both physiological and self-reported indices of sexual health in long-term male smokers, irrespective of baseline erectile impairment. It is hoped that these results may serve as a novel and enticing means to influence men to quit smoking. Increasing successful smoking cessation in men would significantly enhance quality of life, substantially reduce premature death, and alleviate enormous economic burdens caused by smoking-related diseases. / text

Aims: To assess the diagnostic accuracy of four undiagnosed Type 2 diabetes mellitus risk scores accounting for erectile dysfunction status. Methods: This was a population-based cross-sectional study. Type 2 diabetes was defined according to a oral glucose tolerance test and self-reported physician diagnosis. Erectile dysfunction was defined according to the answer to the question, ‘Have you had difficulties obtaining an erection in the last 6 months?’ (yes/no). The risk scores used were the FINDRISC, LA-FINDRISC, American Diabetes Association score and the Peruvian Risk Score. A Poisson regression model was fitted to assess the association between Type 2 diabetes and erectile dysfunction. The area under the receiver-operating characteristic curve was estimated overall and by erectile dysfunction status. Results: A total of 799 men with a mean (sd) age of 48.6 (10.7) years were included in the study. The overall prevalence of Type 2 diabetes was 9.3%. Compared with healthy men, men with Type 2 diabetes had 2.71 (95% CI 1.57–4.66) higher chances of having erectile dysfunction. Having excluded men aware of Type 2 diabetes status (N=38), the area under the receiver-operating characteristic curve of three of the risk scores (not the American Diabetes Association score) improved among those who had erectile dysfunction in comparison with those who did not; for example, the area under the receiver-operating characteristic curve of the LA-FINDRISC score was 89.6 (95% CI 78.7–99.9) in men with erectile dysfunction and 76.5 (95% CI 68.5–84.4) overall. Conclusions: In a population-based study, erectile dysfunction was more common in men with Type 2 diabetes than in the otherwise healthy men. Screening for erectile dysfunction before screening for Type 2 diabetes seems to improve the accuracy of well-known risk scores for undiagnosed Type 2 diabetes. / Antonio Bernabe-Ortiz is a Research Training Fellow in Public Health and Tropical Medicine (103994/Z/14/Z), funded by the Wellcome Trust. / Revisión por pares

The broad goals of this dissertation were to explore possible causes of erectile dysfunction (ED), and examine outcomes associated with the condition. To address these objectives, data from the Vietnam Era Twin Study of Aging (VETSA), a longitudinal study of cognitive aging, were utilized. Previous research demonstrated moderate heritability of ED in middle-aged men, but questions remain about the replicability of these findings given that only one study exists on the topic and it utilized an unvalidated ED measure. Additionally, it is unknown to what extent genetic factors account for stability and change of ED symptomatology over time. In the first study, we conducted a longitudinal assessment of ED using the Sexual Health Inventory for Men (SHIM) administered to 668 male twins. Results revealed that the heritability (proportion of variance explained by genetic factors) of ED at both time points is moderate (0.3 –0.6). Over the past two decades ED has been recognized as primarily a disorder of vascular dysfunction. Inflammation is an important correlate of vascular dysfunction. Chapter 2 examined the association of ED with four inflammatory serum protein indices [albumin, globulin, albumin/globulin ratio (AGR), and the albumin*globulin interaction (AGI)] in 388 men free from cardiovascular disease (CVD). Results indicated that the AGR, albumin, and globulin protein levels are significantly associated with ED, even after accounting for other risk factors. Intriguingly, AGR and globulin levels were found to be more strongly associated with ED than conventional vascular risk factors, such as hypertension, high cholesterol, obesity, and smoking. As such, globulin and AGR may be useful biomarkers when diagnosing and managing ED. The simplicity and affordability of these assays make these markers particularly valuable. Given the negative impact that vascular disease has on cognition, Chapter 3 explored whether men with ED are at greater risk for experiencing cognitive decline compared to healthy peers. In total, 485 men free from CVD were administered cognitive tests across 13 domains. Tests were readministered 5 years later. Results revealed that men with ED were more likely to show significant decline on tasks of set-shifting, tool/mechanical knowledge, vocabulary, and verbal fluency.