Best of the 2008 Sexual Medicine Society of North America

8. RIU0466_12-14.qxd 12/14/09 5:39 PM Page 213 MEETING REVIEW Best of the 2008 Sexual Medicine Society of North America Highlights From the Sexual Medicine Society of North America, October 16-19, 2008, Toronto, Ontario, Canada [Rev Urol. 2009;11(4):213-215 doi: 10.3909/riu0466] © 2009 MedReviews®, LLC Key words: Erectile dysfunction • Gene splicing • PDE5 inhibitors • Sexual medicine he 9th annual meeting of the Sexual Medicine Society of North America brought together both clinicians and basic science investigators from North America and around the world. Various topics of sexual medicine were covered in both state-of-the-art lectures and in podium and poster sessions. This review highlights the important and novel takeaway messages from this highly interactive meeting with the hope that the reader will be able to incorporate these new observations into his or her daily practice. T Basic Science and Genetics in Sexual Medicine The first half day of the meeting was dedicated primarily to the important Reviewed by Jacob Rajfer, MD, University of California at Los Angeles, Los Angeles, CA. role basic science plays in the development of sexual medicine. This was exemplified by lectures on how relaxation of the smooth muscle in the corpora occurs on a biochemical level, and how this observation has been translated into a currently ongoing clinical study by investigators from New York. In this study, gene manner that the primarily clinical audience was able to understand how the results of such technology may allow the clinician to temporally regulate a variety of biochemical processes within the body (eg, corporal smooth muscle relaxation). For example, a patient would be able to take an oral pill (eg, tetracycline) and New gene-splicing technology may allow the clinician to temporally regulate a variety of biochemical processes within the body. therapy, specifically the hSlo gene, is being used to upregulate those genes involved in the enhancement of smooth muscle relaxation in the corpora that are presumed to be deficient in men with erectile dysfunction (ED).1 New gene-splicing tools, such as small interfering RNA (siRNA) technology, were reviewed in such a once the pill was absorbed by the circulation it would activate the erectile response via this siRNA technology. This effect on the corporal tissue could be made to last for a predetermined finite length of time or could possibly be programmed to allow the corporal tissue to be responsive to a sexual stimulus until the system was turned off by taking another pill. VOL. 11 NO. 4 2009 REVIEWS IN UROLOGY 213 8. RIU0466_12-14.qxd 12/14/09 5:39 PM Page 214 Sexual Medicine Society continued Phosphodiesterase Type 5 Inhibitors Arthur Burnett, MD, of Johns Hopkins University School of Medicine (Baltimore, MD), reviewed how basic science observations of phosphodiesterase type 5 (PDE5) levels in certain mice in his laboratory provided the insight to propose a new clinical paradigm for the treatment of priapism.2 From this research, a clinical trial that studied the use of daily PDE5 inhibitors to upregulate PDE5 levels in the corpora to treat recurring priapism was developed. ED and Cardiovascular Risk The second day of the meeting was primarily directed at the interface that is occurring between practitioners of sexual medicine (primarily urologists) and those who practice various areas of general medicine (usually those in primary care, cardiology, and internal medicine). This theme was reiterated throughout the meeting both in lectures and poster sessions.3,4 The primary focus here was on the recent and recurring findings that ED seems to be a marker of developments within the cardiovascular system. Indeed, data from primary care and cardiology investigators demonstrate that the onset of ED appears to be a risk factor for the emergence of a major cardiac event; ED symptoms on average appear approximately 5 years prior to the cardiac event. This was shown in data not only from the United States but also from the United Kingdom, suggesting that this is a universal event rather than a regionally specific one. As a result, suggestions were made both by Martin Miner, MD, from Providence, RI, and Graham Jackson, MD, from London, UK, that protocols should be put in place to consider all new ED patients as potential present or future cardiac patients. This was supported by data that showed that most patients (ap- 214 VOL. 11 NO. 4 2009 proximately 60%) who present with ED also have hypertension, either treated or untreated, in addition to the well-known risks that this vasculopathy presents. What was not resolved at this meeting is specifically what the urologist should do with a new patient who presents with ED. Should all patients be referred to a cardiologist for a workup? Should the urologist act as internist and order the screening tests him- or herself? Although there was no consensus, the data were leaning toward the conclusion that patients with ED should have baseline levels of blood pressure, serum testosterone, waist circumference, HbA1c or fasting blood sugar, fasting lipid profile, and possibly C-reactive protein measured. It is assumed that within the coming year or 2, more specific recommendations regarding which screening tests (as some other medications are in the United Kingdom). Although there was a cost by the patient to the pharmacy to obtain the initial 2 prescriptions, the study showed that most of the patients who went to the pharmacy to obtain their initial PDE5 inhibitor prescriptions failed to follow-up with their physicians, which was a requirement for patients to obtain any further PDE5 inhibitor prescriptions. Although the results of this study can be interpreted in many ways, it is obvious that there are patients (some of whom traveled over 300 miles to get their prescriptions) who still do not want to consult with a physician about their ED. The aforementioned study seems apropos because sildenafil citrate (Viagra; Pfizer, New York, NY) will be going off-patent some time in 20125 and there is a possibility that this class of drugs (PDE5 inhibitors) may be made available to patients There is a possibility that PDE5 inhibitors may be an appropriate class of drugs to be made available to patients over the counter. should be performed on those patients who present with ED will follow. Over-the-Counter Access to ED Medication Another interesting aspect of this meeting was a lecture given by Ian Eardley, MD, from Leeds, UK, in which he discussed a study that was performed by the National Health Service in the United Kingdom in conjunction with several Boots pharmacies in the Manchester, UK, area. This study attempted to determine how patients would respond to the ability to obtain their initial PDE5 inhibitors directly from the pharmacy rather than from a physician. This study was performed to gain some insight into whether, in the future, PDE5 inhibitors could be prescribed by pharmacists rather than physicians REVIEWS IN UROLOGY over the counter (OTC). Support for this concept was given in a poster session a day later by Vera Stecher, of Pfizer, who showed in pooled data from 67 double-blind, placebocontrolled studies that the drug at the 50-mg and 100-mg doses was very safe in men over age 65 and 75 years.6 Of interest, these elderly men, when compared with younger men, had a decreased incidence of headache and nasal congestion, but an increase in the incidence of dyspepsia. Although all the US Food and Drug Administration (FDA)–approved PDE5 inhibitors have been shown both in clinical trials and in practice to be safe and effective, whether the FDA will ever consider the PDE5 inhibitors as an OTC drug at some time in the future remains to be determined. 8. RIU0466_12-14.qxd 12/14/09 5:39 PM Page 215 Sexual Medicine Society Sexual Dysfunction in Women Peyronie’s Disease Another interesting report came from Irwin Goldstein, MD, and his group in San Diego, CA, which addressed sexual dysfunction in women.7 Essentially, the group believes that the use of oral contraceptives (OCPs) is one of the major causes of hy- Many lectures and posters dealt with the topic of Peyronie’s disease (PD). According to several different posters, it appears as if some investigators are considering the use of PDE inhibitors together with L-arginine in the treatment of patients with PD.8,9 The sci- 2. 3. The use of oral contraceptives is one of the major causes of hypoactive sexual disorder in women. 4. poactive sexual disorder in women. The evidence provided suggested that the use of these drugs results in not only a short-term increase in sex hormone–binding globulin (SHBG), but also a long-term effect, even years after the drugs have been dis- entific rationale is that PDE inhibitors and L-arginine, when used on a daily basis, act as antifibrotic agents. Reports during the meeting suggest that the drugs are being used in 2 different settings: (1) when the patient is being observed early in the disease course 5. 6. Some investigators are considering the use of PDE inhibitors together with L-arginine in the treatment of patients with Peyronie’s disease. 7. continued. The clinical import of this observation is that testosterone levels in women, which are related to sexual desire, remain suppressed for years because of the high affinity binding of the testosterone to the SHBG. The investigators suggested that the ideal contraceptive in young women may be the intrauterine device rather than OCPs, and treatment with testosterone supplementation in these women may improve their sexual desire. and (2) when the patient is being treated with intralesional therapy or during the postoperative period. Most of the data presented consisted of small numbers of patient and nonrandomized trials, so it is still undecided whether the use of these agents will become more accepted in clinical practice over time. References 1. Davies K, Calenda G, Tong Y, et al. Identification of molecular markers of erectile function. Poster 8. 9. #2 presented at the 9th annual meeting of the Sexual Medicine Society of North America. J Sex Med. 2009;6(suppl 1):7. Burnett A, Pierorazio P. Corporal “snake” maneuver: modification of corporoglanular shunt surgery for ischemic priapism. Poster #104 presented at the 9th annual meeting of the Sexual Medicine Society of North America. J Sex Med. 2009;6(suppl 1):37. Mohamed O, Berookhim B, Bar-Chama N, et al. The use of Endo-Pat 2000© as a marker for endothelial dysfunction in patients presenting with erectile dysfunction. Poster #22 presented at the 9th annual meeting of the Sexual Medicine Society of North America. J Sex Med. 2009; 6(suppl 1):13. Shabsigh R, Kaufman J, Magee M, et al. Low awareness of erectile dysfunction in men at risk for cardiovascular disease: should we be doing more? Poster #42 presented at the 9th annual meeting of the Sexual Medicine Society of North America. J Sex Med. 2009;6(suppl 1):19. United States Patent and Trademark Office Web site. Patent terms extensions. http://www.uspto .gov/patents/resources/terms/156.html. Accessed November 5, 2009. Goldstein I, Stecher V. Sildenafil—a decade of safety and tolerability data. Poster #77 presented at the 9th annual meeting of the Sexual Medicine Society of North America. J Sex Med. 2009; 6(suppl 1):29. Goldfischer E, Clayton AH, Goldstein I, et al. Decreased Sexual Desire Screener© (DSDS©) for diagnosis of hypoactive sexual desire disorder in women. Poster #13 presented at the 9th annual meeting of the Sexual Medicine Society of North America. J Sex Med. 2009; 6(suppl 1):10. Grober E, Bacal V. Combination PDE inhibitors (pentoxifylline & sildenafil) and L-arginine in the treatment of Peyronie’s disease: a pilot study. Poster #81 presented at the 9th annual meeting of the Sexual Medicine Society of North America. J Sex Med. 2009;6 (suppl 1):31. Abern M, Levine L. Intralesional verapamil injections with and without penile traction and oral therapies for management of Peyronie’s disease. Poster #87 presented at the 9th annual meeting of the Sexual Medicine Society of North America. J Sex Med. 2009;6(suppl 1):32. VOL. 11 NO. 4 2009 REVIEWS IN UROLOGY 215