Erectile dysfunction is a multidimensional but common male sexual dysfunction that involves an alteration in any of the components of the erectile response, including organic, relational and psychological. Roles for nonendocrine (neurogenic, vasculogenic and iatrogenic) and endocrine pathways have been proposed. Owing to its strong association with metabolic syndrome and cardiovascular disease, cardiac assessment may be warranted in men with symptoms of erectile dysfunction. Minimally invasive interventions to relieve the symptoms of erectile dysfunction include lifestyle modifications, oral drugs, injected vasodilator agents and vacuum erection devices. Surgical therapies are reserved for the subset of patients who have contraindications to these nonsurgical interventions, those who experience adverse effects from (or are refractory to) medical therapy and those who also have penile fibrosis or penile vascular insufficiency. Erectile dysfunction can have deleterious effects on a man’s quality of life; most patients have symptoms of depression and anxiety related to sexual performance. These symptoms, in turn, affect his partner’s sexual experience and the couple’s quality of life. This Primer highlights numerous aspects of erectile dysfunction, summarizes new treatment targets and ongoing preclinical studies that evaluate new pharmacotherapies, and covers the topic of regenerative medicine, which represents the future of sexual medicine.

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Introduction Non-ischemic or high-flow priapism is derived from unregulated arterial inflow within the penis, which is significantly less common and, therefore, less well characterized than ischemic or low-flow priapism. Aim We collected the most recent available data and summarized the findings. Methods All literature related to non-ischemic priapism from 2000–2018 from several databases was reviewed, and 105 articles, including any relevant referenced articles, were ultimately included. Main Outcome Methods We evaluated modality success rates, need for repeat procedures, and effects on erectile function. Results 237 cases of non-ischemic priapism were evaluated. Approximately 27% of patients underwent observation or medical management as the first treatment modality, whereas 73% underwent intervention without observation or medical management beforehand. Angiographic embolization with temporary agents was the most common intervention and generally resulted in both moderate resolution of non-ischemic priapism and moderate preservation of baseline erectile function. Patients who underwent embolization with permanent agents experienced higher rates of resolution, as well as lower rates of erectile dysfunction (ED). Conclusion Most of the literature is in the form of case reports and small case series, thus limiting the quality and quantity of evidence available to draw decisive conclusions. However, from the available data, it is reasonable to presume that patients can undergo a trial of conservative management, then pursue embolization first with temporary agents. The analysis of the data demonstrated ED rates were higher with temporary agents than permanent agents. The literature quotes ED rates as low as 5% when using temporary agents and 39% with permanent agents. Our results were, in fact, the opposite, with higher ED rates when using temporary agents vs permanent (17–33% vs 8–17%). Further studies are required to better characterize the success and outcomes of angioembolization.

Delayed orgasm/anorgasmia defined as the persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation, which causes personal distress. Delayed orgasm and anorgasmia are associated with significant sexual dissatisfaction. A focused medical history can shed light on the potential etiologies; which include: medications, penile sensation loss, endocrinopathies, penile hyperstimulation and psychological etiologies, amongst others. Unfortunately, there are no excellent pharmacotherapies for delayed orgasm/anorgasmia, and treatment revolves largely around addressing potential causative factors and psychotherapy.

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Background After radical prostatectomy (RP), erectile dysfunction, often necessitating the need for inflatable penile prosthesis (IPP) insertion, and urinary incontinence and climacturia can ensue. Aim To assess the efficacy and safety of the mini-jupette, a mesh used to approximate the medial aspects of the 2 corporotomies at the time of IPP insertion, for the management of climacturia and urine leakage in patients with minimal incontinence. Methods We conducted a pilot multicenter study of patients with post-RP erectile dysfunction and climacturia and/or mild urinary incontinence (≤2 pads/day [ppd]) undergoing IPP insertion with concomitant placement of a mini-jupette graft. Outcomes Pre- and postoperative erectile function, continence and climacturia, and overall surgical outcomes were assessed. Results 38 patients underwent the mini-jupette procedure. The mean age of the population was 65.3 years (SD = 7.7). 30 had post-RP climacturia and 32 patients had post-RP incontinence (mean = 1.3 ppd, SD = 0.8). 31 patients received Coloplast Titan, 4 received AMS 700 LGX, and 3 received AMS 700 CX IPPs. Mean corporotomy size was 2.9 cm (SD = 1.0). Mean graft measurements were 3.2 cm (SD = 0.9) for width, 3.3 cm (SD = 1.3) for length, and 11.0 cm2 (SD = 5.1) for surface area. At a mean follow-up of 5.1 months (SD = 6.9), there were 5 postoperative complications (13.2%) of which 4 required explantation. Climacturia and incontinence were subjectively improved in 92.8% and 85.7%, respectively. Mean ppd decreased by 1.3 postoperatively. Clinical Implications The Andrianne mini-jupette is a feasible adjunct to IPP placement that can be used for subsets of patients with post-RP climacturia and/or minimal incontinence. Strengths and Limitations Strengths of this study include the novel nature of this intervention, the multi-institutional nature of the study, and the promising results demonstrated. Limitations include the retrospective nature of the study and the heterogeneity of the techniques and grafts used by different surgeons involved. Conclusion Longer follow-up and larger patient cohorts are needed to confirm the long-term safety and benefits of this intervention.