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Socioeconomic Factors, Urological Epidemiology and Practice Patterns
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERN
Re: Are There Symptom-Specific Testosterone Thresholds in Aging Men? J. E. Lackner, E. Rücklinger, G. Schatzl, G. Lunglmayr and C. W. Kratzik Department of Urology, Krankenhaus Hietzing mit Neurologischem Zentrum Rosenhügel, Ludwig Boltzmann Institute für Urologie und Andrologie, Statistical Analysis and Methodological Consulting KEG, and Department of Urology, Medical University of Vienna, Vienna and Karl Landsteiner Institute of Andrology, Mistelbach General Hospital, Mistelbach, Austria BJU Int 2011; Epub ahead of print.
Objective: To study the association between specific clinical symptoms (e.g. low libido and erectile dysfunction) and testosterone levels and age in order to define symptom-specific testosterone thresholds. Materials and Methods: Serum samples for testosterone determination were obtained from 675 healthy men. Participants underwent urological examination and completed the Aging Males Symptoms scale, the Beck Depression Index and the International Index of Erectile Function. Overall scores and those from individual questions from the questionnaires were evaluated. Testosterone levels in men with symptoms were compared with those in men without symptoms. The risks of clinical symptoms were evaluated using univariate, multiple multinomial regression analyses and Bonferroni correction. Results: Significant associations between testosterone levels and a number of androgen deficiency symptoms were seen at testosterone levels of 13.5–14.4 nmol/L, but multiple logistic regression analysis revealed confounding effects with age. Symptoms such as loss of libido, lack of vigour and sexual dysfunction were associated with age rather than with testosterone. Erectile dysfunction was reported at testosterone levels between 14.65 nmol/L and 14.8 nmol/L, but was again significantly associated with age rather than testosterone levels. The severity of symptoms significantly increased with decreasing testosterone levels using univariate analysis, but only the relationship with psychological symptoms remained significant after Bonferroni correction. Conclusion: In aging males, androgen deficiency symptoms were reported at normal levels of testosterone, but age was an important confounder. Symptom-specific testosterone thresholds could not be defined. Editorial Comment: Hypogonadism has been associated with a number of symptomatic clinical conditions, including decreased libido and impairments in muscle and bone health. This study sought to identify threshold levels of testosterone associated with sexual dysfunction, loss of libido and depression in a cohort of 675 men (mean age 51.5 years). Clinical symptoms, particularly psychological symptoms, were seen in some men even with normal testosterone levels. Age was identified as a confounding variable. It would be interesting to see results from similar research in even older men (older than 65 or 75 years) to see if the same effect is maintained. Directional causality was unclear. Does sexual dysfunction lead to depression in older men? Or do psychological factors result in worse sexual function? Additional work will be necessary to clarify these questions. Tomas L. Griebling, M.D., M.P.H.
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Patient Expectations Prior to Coloplast Titan Penile Prosthesis Implant Predicts Postoperative Satisfaction A. C. Kramer and A. Schweber Department of Surgery, Division of Urology, University of Maryland School of Medicine, Baltimore, Maryland J Sex Med 2010; 7: 2261–2266.
Introduction: Managing and understanding expectations of patients prior to inflatable penile prosthesis (IPP) surgery is a critical. Clinicians vary in the way they explain the operation, and patients
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have varied expectations prior to surgery. Aims: The goal is to understand the role that preoperative counseling and patients’ realistic understanding of IPP surgery play in determining postoperative satisfaction. Methods: 21 Patients underwent IPP surgery, and received a preoperative expectations survey, then, 4 months later, gave a single score of 1–100 (1 is very dissatisfied, 100 is extremely satisfied). Main Outcome Measures: The results were correlated with an R(2) value and visualized on a scatter plot. This significance is tested using a two-tailed test. Results: Lower preoperative expectations scores correlated almost linearly with higher satisfaction scores after surgery. The R (Pearson) value was ⫺0.489, with an R(2) of 0.239. This was significant using a two-tailed test, with a P value of 0.0245. Conclusion: Giving patients an accurate description of the procedure and setting realistic expectations leads to higher postoperative satisfaction. Editorial Comment: The results of this study seem relatively obvious but are worth highlighting. Patients with lower preoperative expectations report greater satisfaction after penile prosthesis surgery. Therefore, it is incumbent on providers to help patients set realistic expectations regarding the postoperative experience. This is particularly true in erectile dysfunction but likely applies across the spectrum of urological disease. Patients undergoing any urological procedure that has significant long-term quality of life effects (such as radical prostatectomy, radical cystectomy, sling procedures and transurethral prostatectomy, to name a few) likely would benefit from better preoperative counseling aimed at setting more realistic postoperative expectations. David F. Penson, M.D., M.P.H.
Trauma, and Genital and Urethral Reconstruction Re: Time Course of Recovery of Erectile Function After Radical Retropubic Prostatectomy: Does Anyone Recover After 2 Years? F. Rabbani, J. Schiff, M. Piecuch, L. H. Yunis, J. A. Eastham, P. T. Scardino and J. P. Mulhall Department of Urology, Montefiore Medical Center, Bronx, New York J Sex Med 2010 7: 3984 –3990.
Introduction: Given the paucity of literature on the time course of recovery of erectile function (EF) after radical prostatectomy (RP), many publications have led patients and clinicians to believe that erections are unlikely to recover beyond 2 years after RP. Aims: We sought to determine the time course of recovery of EF beyond 2 years after bilateral nerve sparing (BNS) RP and to determine factors predictive of continued improved recovery beyond 2 years. Methods: EF was assessed prospectively on a 5-point scale: (I) full erections; (II) diminished erections routinely sufficient for intercourse; (III) partial erections occasionally satisfactory for intercourse; (IV) partial erections unsatisfactory for intercourse; and (V) no erections. From 01/1999 to 01/2007, 136 preoperatively potent (levels 1–2) men who underwent BNS RP without prior treatment and who had not recovered consistently functional erections (levels 1–2) at 24 months had further follow-up regarding EF. Median follow-up after the 2-year visit was 36.0 months. Main Outcome Measures: Recovery of improved erections at a later date: recovery of EF level 1–2 in those with level 3 EF at 2 years and recovery of EF level 1–3 in those with level 4 –5 EF at 2 years. Results: The actuarial rates of further improved recovery of EF to level 1–2 in those with level 3 EF at 2 years and to level 1–3 in those with level 4 –5 EF at 2 years were 8%, 20%, and 23% at 3, 4, and 5 years postoperatively, and 5%, 17%, and 21% at 3, 4, and 5 years postoperatively, respectively. Younger age was predictive of greater likelihood of recovery beyond 2 years. Conclusion: There is continued improvement in EF beyond 2 years after BNS RP. Discussion of this prolonged time course of recovery may allow patients to have a more realistic expectation.
Re: Are There Symptom-Specific Testosterone Thresholds in Aging Men? J. E. Lackner, E. Rücklinger, G. Schatzl, G. Lunglmayr and C. W. Kratzik Department of Urology, Krankenhaus Hietzing mit Neurologischem Zentrum Rosenhügel, Ludwig Boltzmann Institute für Urologie und Andrologie, Statistical Analysis and Methodological Consulting KEG, and Department of Urology, Medical University of Vienna, Vienna and Karl Landsteiner Institute of Andrology, Mistelbach General Hospital, Mistelbach, Austria BJU Int 2011; Epub ahead of print.
Objective: To study the association between specific clinical symptoms (e.g. low libido and erectile dysfunction) and testosterone levels and age in order to define symptom-specific testosterone thresholds. Materials and Methods: Serum samples for testosterone determination were obtained from 675 healthy men. Participants underwent urological examination and completed the Aging Males Symptoms scale, the Beck Depression Index and the International Index of Erectile Function. Overall scores and those from individual questions from the questionnaires were evaluated. Testosterone levels in men with symptoms were compared with those in men without symptoms. The risks of clinical symptoms were evaluated using univariate, multiple multinomial regression analyses and Bonferroni correction. Results: Significant associations between testosterone levels and a number of androgen deficiency symptoms were seen at testosterone levels of 13.5–14.4 nmol/L, but multiple logistic regression analysis revealed confounding effects with age. Symptoms such as loss of libido, lack of vigour and sexual dysfunction were associated with age rather than with testosterone. Erectile dysfunction was reported at testosterone levels between 14.65 nmol/L and 14.8 nmol/L, but was again significantly associated with age rather than testosterone levels. The severity of symptoms significantly increased with decreasing testosterone levels using univariate analysis, but only the relationship with psychological symptoms remained significant after Bonferroni correction. Conclusion: In aging males, androgen deficiency symptoms were reported at normal levels of testosterone, but age was an important confounder. Symptom-specific testosterone thresholds could not be defined. Editorial Comment: Hypogonadism has been associated with a number of symptomatic clinical conditions, including decreased libido and impairments in muscle and bone health. This study sought to identify threshold levels of testosterone associated with sexual dysfunction, loss of libido and depression in a cohort of 675 men (mean age 51.5 years). Clinical symptoms, particularly psychological symptoms, were seen in some men even with normal testosterone levels. Age was identified as a confounding variable. It would be interesting to see results from similar research in even older men (older than 65 or 75 years) to see if the same effect is maintained. Directional causality was unclear. Does sexual dysfunction lead to depression in older men? Or do psychological factors result in worse sexual function? Additional work will be necessary to clarify these questions. Tomas L. Griebling, M.D., M.P.H.
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Patient Expectations Prior to Coloplast Titan Penile Prosthesis Implant Predicts Postoperative Satisfaction A. C. Kramer and A. Schweber Department of Surgery, Division of Urology, University of Maryland School of Medicine, Baltimore, Maryland J Sex Med 2010; 7: 2261–2266.
Introduction: Managing and understanding expectations of patients prior to inflatable penile prosthesis (IPP) surgery is a critical. Clinicians vary in the way they explain the operation, and patients
1411
1412
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
have varied expectations prior to surgery. Aims: The goal is to understand the role that preoperative counseling and patients’ realistic understanding of IPP surgery play in determining postoperative satisfaction. Methods: 21 Patients underwent IPP surgery, and received a preoperative expectations survey, then, 4 months later, gave a single score of 1–100 (1 is very dissatisfied, 100 is extremely satisfied). Main Outcome Measures: The results were correlated with an R(2) value and visualized on a scatter plot. This significance is tested using a two-tailed test. Results: Lower preoperative expectations scores correlated almost linearly with higher satisfaction scores after surgery. The R (Pearson) value was ⫺0.489, with an R(2) of 0.239. This was significant using a two-tailed test, with a P value of 0.0245. Conclusion: Giving patients an accurate description of the procedure and setting realistic expectations leads to higher postoperative satisfaction. Editorial Comment: The results of this study seem relatively obvious but are worth highlighting. Patients with lower preoperative expectations report greater satisfaction after penile prosthesis surgery. Therefore, it is incumbent on providers to help patients set realistic expectations regarding the postoperative experience. This is particularly true in erectile dysfunction but likely applies across the spectrum of urological disease. Patients undergoing any urological procedure that has significant long-term quality of life effects (such as radical prostatectomy, radical cystectomy, sling procedures and transurethral prostatectomy, to name a few) likely would benefit from better preoperative counseling aimed at setting more realistic postoperative expectations. David F. Penson, M.D., M.P.H.
Trauma, and Genital and Urethral Reconstruction Re: Time Course of Recovery of Erectile Function After Radical Retropubic Prostatectomy: Does Anyone Recover After 2 Years? F. Rabbani, J. Schiff, M. Piecuch, L. H. Yunis, J. A. Eastham, P. T. Scardino and J. P. Mulhall Department of Urology, Montefiore Medical Center, Bronx, New York J Sex Med 2010 7: 3984 –3990.
Introduction: Given the paucity of literature on the time course of recovery of erectile function (EF) after radical prostatectomy (RP), many publications have led patients and clinicians to believe that erections are unlikely to recover beyond 2 years after RP. Aims: We sought to determine the time course of recovery of EF beyond 2 years after bilateral nerve sparing (BNS) RP and to determine factors predictive of continued improved recovery beyond 2 years. Methods: EF was assessed prospectively on a 5-point scale: (I) full erections; (II) diminished erections routinely sufficient for intercourse; (III) partial erections occasionally satisfactory for intercourse; (IV) partial erections unsatisfactory for intercourse; and (V) no erections. From 01/1999 to 01/2007, 136 preoperatively potent (levels 1–2) men who underwent BNS RP without prior treatment and who had not recovered consistently functional erections (levels 1–2) at 24 months had further follow-up regarding EF. Median follow-up after the 2-year visit was 36.0 months. Main Outcome Measures: Recovery of improved erections at a later date: recovery of EF level 1–2 in those with level 3 EF at 2 years and recovery of EF level 1–3 in those with level 4 –5 EF at 2 years. Results: The actuarial rates of further improved recovery of EF to level 1–2 in those with level 3 EF at 2 years and to level 1–3 in those with level 4 –5 EF at 2 years were 8%, 20%, and 23% at 3, 4, and 5 years postoperatively, and 5%, 17%, and 21% at 3, 4, and 5 years postoperatively, respectively. Younger age was predictive of greater likelihood of recovery beyond 2 years. Conclusion: There is continued improvement in EF beyond 2 years after BNS RP. Discussion of this prolonged time course of recovery may allow patients to have a more realistic expectation.