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Prostate cancer is the most common non-skin cancer in men and a leading cause of cancer death in the western world [1]. Fortunately, several treatment options are available regarding both localized and disseminated cancer [2, 3]. Meanwhile, quality of life in general and sexual health in particular is affected for most patients at every step of the way from diagnosis to advanced treatments [4, 5]. Importantly, sexuality has significance, which reaches far beyond simple pleasure. Thus, it is tied to important quality of life aspects such as the feeling of masculinity, relationship stability, and the expression of intimacy [5].

When considering future directions in improving sexual function for prostate cancer patients, it’s easy to get lost in dreams about regenerative medicine and to look for one tool to fix all problems. Low intensity extracorporal shock wave therapy (Li-ESWT) and stem cells have been the subject of the majority of studies, with platelet rich plasma injections representing a third option. However, as we’ve seen in the paper by Lund et al., the data in this area are very preliminary and almost exclusively include animal studies and safety data in humans [1]. Among the few clinical trials, the data has not convincingly shown improvements in erectile function at or above the established minimal clinically significant difference. Thus, the most positive predicate the area can receive at the moment is that it is “promising” and regenerative medicine for restoration of sexual function following prostate cancer treatments is unlikely to reach the clinic in any foreseeable future. Meanwhile, it may be reasonable to focus on much simpler avenues for supporting and improving sexual function in our patients.

Google Trends (GT) is a free, easily accessible search tool which can be used to analyze worldwide “big data” on the relative popularity of search terms over a specific period of time. To determine worldwide public interest in Peyronie’ disease (PD), erectile dysfunction (ED), premature ejaculation (PE) treatments, their penetrance, variation, and how they compare over time. Worldwide search-engine trends analysis included electronic Google queries from people who searched PD, ED, and PE treatments options from January 2004 to October 2018, worldwide. Join-point regression (JPR) has been performed. Comparison annual relative search volume (ARSV), average annual percentage change (AAPC) and temporal patterns were analyzed to assess loss or gain of interest. Our results showed that for PD it has been a decreased interest for Drug (AAPC: −3.1%, p < 0.01), ESWT (AAPC: −3.1%, p < 0.01), and vacuum therapy (AAPC: −1.2%, p < 0.01). In the field of ED, we observed trends toward an increased interest in prosthetic surgical treatment (AAPC: +1.7%, p = 0.4), for prostaglandins (AAPC: +0.7%, p = 0.7), for traction (AAPC: +0.6%, p = 0.1) and for ESWT (AAPC: +1.8%, p = 0.4), but without statistical significance. On the contrary, we observed a slight reduction of search for Vacuum device (AAPC: −1 %, p < 0.01). The interest in PE decreased from 2004 to today (AAPC: −1%, p < 0.01), for surgical treatment (AAPC: −3.1%, p < 0.01), drug treatment (AAPC: −3.1%, p < 0.01), and for psychotherapy (AAPC: −6.7%, p < 0.01). On the contrary, the interest in spray drugs has increased significantly (AAPC: +5.1%, p < 0.01). Patients are searching the web for sexual diseases treatment options. Understanding people inquisitiveness together with degree of knowledge could be supportive to guide counseling in the decision-making-process and put effort in certifying patient information, avoiding them to fall in the pernicious trap of ‘fake-news’.

Erectile dysfunction (ED) is defined as the inability to attain and maintain erection of the penis sufficient to permit satisfactory sexual activity. ED most commonly affects men from 40 years of age with a clear age-associated increase in prevalence. The condition may have significant negative impact on quality of life for both the patients and their partners. Over recent years, low-intensity shockwave therapy (LIST) has gained popularity in the treatment of ED, based on the assumption that LIST application may result in neoangiogenesis and thus increased blood flow to the corpora cavernosa. The increasing usage of LIST is contrasting with current guidelines, with the EAU guideline on ED stating that LIST can be used in mild organic ED patients or poor responders to PDE5I’s, but with a weak strength of recommendation. In the AUA guideline on ED, the panel makes a conditional recommendation of grade C that LIST should be considered investigational. In this review, we will briefly review practice patterns, and critically discuss the evidence based on which these guideline statements have been made.

In this narrative review we summarize neglected side effects of curative intended treatment for prostate cancer. They include climacturia, arousal incontinence (AI), orgasmic disturbances such as altered orgasmic sensation, anorgasmia, and orgasm-associated pain (dysorgasmia), ejaculatory dysfunction, and morphological penile alterations in the form of shortening and deformity. Even though they have not received as much interest as erectile dysfunction (ED) or urinary incontinence, these side effects have been shown to negatively impact patient’s quality of life. They are common and rates of climacturia after radical prostatectomy (RP) range from 20% and 45%, less after external beam radiation therapy (EBRT). Decreased orgasmic sensation ranges from 3.9% to 60% after RP and between 36–57% after EBRT. Dysorgasmia ranges from 9.5–15% for both RP and EBRT. Anejculation after EBRT ranges from 11–71% and rates of penile shortening are reported between 0 and 100%. There are no internationally validated questionnaires that adequately asses these side effects. This is necessary if we are to align patient and partner expectations properly and consequently manage them optimally. Neglected side effects should be discussed with patients and their partners preoperatively, as they are associated with bother and may lead to patient’s avoiding sexual activity.

Low intensity extracorporal shock wave therapy (Li-ESWT) may induce tissue regeneration, neo-angiogenesis and improve endothelial function. This has shown promise in the treatment of erectile dysfunction (ED). The aim of this narrative review was to describe potential therapeutic areas of Li-ESWT in sexual medicine other than ED. An extensive literature search and review of the most recent guidelines revealed that Li-ESWT has been used in the treatment of Peyronie’s disease (PD) and is being investigated as a method of improving stem cell therapy. In PD, Li-ESWT has been shown to decrease pain but no clinically relevant benefits regarding plaque size or penile curvature have been shown in randomized clinical trials. For stem cell optimization, only two preclinical studies have been conducted within the realm of sexual medicine. These show that application of Li-ESWT to the tissue after stem cell transplantation may increase the erectile response following cavernous nerve or diabetes damage. More research is needed to bring this concept from bench to bedside. In addition to this, Li-ESWT has shown promise in pelvic pain and it’s effects on testicles have been preliminarily investigated in preclinical studies.

Erectile dysfunction (ED) is a common side effect to radical prostatectomies, even with nerve-sparing procedures. To ameliorate the problem so-called “penile rehabilitation” programs have been developed. The most widely used method of this is subscribing sildenafil or other PDE5-inhibitors to patients following surgery. This is based on a theory that these drugs may increase penile oxygenation and provide antiapoptotic factors (primarily NO and cGMP), thus protecting the penile tissue in a period with reduced nerve function following the surgery. Preclinical studies have confirmed the potential of sildenafil in this context and early human trials have suggested that a steady ingestion of sildenafil might protect the structural integrity of the penis. However, subsequent well-designed trials have not been able to confirm the initial findings. This fits well with sildenafil’s mechanism of action because it does not actually induce erections or the production of either nitric oxide or cGMP. Rather, the drug enhances effects of an erectile response induced by neurotransmitters from the cavernous nerves. Therefore, sildenafil should no longer be offered as a sole means of penile rehabilitation. Rather, more research is needed, and clinicians need to apply a broader concept of sexual rehabilitation in postprostatectomy ED.

Background One-fourth of men older than 70 years have lower urinary tract symptoms (LUTS) that impair their quality of life. Transurethral resection of the prostate (TURP) is considered the gold standard for surgical treatment of LUTS caused by benign prostatic hyperplasia (BPH) that cannot be managed conservatively or pharmacologically. However, TURP is only an option for patients fit for surgery and can result in complications. Transurethral microwave thermotherapy (TUMT) and prostatic artery embolisation (PAE) are alternative minimally invasive surgical therapies (MISTs) performed in an outpatient setting. Both treatments have shown to reduce LUTS with a similar post-procedure outcome in mean International Prostate Symptom Score (IPSS). It is however still unknown if TUMT and PAE perform equally well as they have never been directly compared in a randomised clinical trial. The objective of this clinical trial is to assess if PAE is non-inferior to TUMT in reducing LUTS secondary to BPH. Methods This study is designed as a multicentre, non-inferiority, open-label randomised clinical trial. Patients will be randomised with a 1:1 allocation ratio between treatments. The primary outcome is the IPSS of the two arms after 6 months. The primary outcome will be evaluated using a 95% confidence interval against the predefined non-inferiority margin of + 3 points in IPSS. Secondary objectives include the comparison of patient-reported and functional outcomes at short- and long-term follow-up. We will follow the patients for 5 years to track long-term effect. Assuming a difference in mean IPSS after treatment of 1 point with an SD of 5 and a non-inferiority margin set at the threshold for a clinically non-meaningful difference of + 3 points, the calculated sample size was 100 patients per arm. To compensate for 10% dropout, the study will include 223 patients. Discussion In this first randomised clinical trial to compare two MISTs, we expect non-inferiority of PAE to TUMT. The most prominent problems with MIST BPH treatments are the unknown long-term effect and the lack of proper selection of candidates for a specific procedure. With analysis of the secondary outcomes, we aspire to contribute to a better understanding of durability and provide knowledge to guide treatment decisions. Trial registration ClinicalTrials.gov NCT05686525. Registered on January 17, 2023, https://clinicaltrials.gov/study/NCT05686525 .

Patient survival following childhood cancer has increased with contemporary radiation and chemotherapy techniques. However, gonadotoxicity associated with treatments means that infertility is a common consequence in survivors. Novel fertility preservation options are emerging, but knowledge about these options amongst urologists and other medical professionals is lacking. Pre-pubertal boys generally do not produce haploid germ cells. Thus, strategies for fertility preservation require cryopreservation of tissue containing spermatogonial stem cells (SSCs). Few centres worldwide routinely offer this option and fertility restoration (including testicular tissue engraftment, autotransplantation of SSCs and in vitro maturation of SSCs to spermatozoa) post-thaw is experimental. In pubertal boys, the main option for fertility preservation is masturbation and cryopreservation of the ejaculate. Assisted ejaculation using penile vibratory stimulation or electroejaculation and surgical sperm retrieval can be used in a sequential manner after failed masturbation. Physicians should inform boys and parents about the gonadotoxic effects of cancer treatment and offer fertility preservation. Preclinical experience has identified challenges in pre-pubertal fertility preservation, but available options are expected to be successful when today’s pre-pubertal boys with cancer become adults. By contrast, fertility preservation in pubertal boys is clinically proven and should be offered to all patients undergoing cancer treatment.Treatment for childhood cancer can cause infertility in patients who survive to adulthood. Jensen et al. discuss the options for fertility preservation in pre-pubertal and pubertal boys, covering preservation of spermatozoa and testis tissue, as well as psychological and ethical issues, and current challenges to fertility preservation.