#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#

Male pelvic pain syndromes and sexual dysfunction


Authors: Darius A. Paduch M. D., Ph.D. 1;  Alexander Bolyakov, MSc. 1;  Prof. MUDr. Dalibor Pacík, CSc. 2
Authors‘ workplace: Department of Urology, Weill Medical College of Cornell University, New York, NY Population Council, Center for Biomedical Research, New York, NY 1;  Urologická klinika LF MU, FN Brno 2
Published in: Urol List 2008; 6(4): 18-28

Overview

Chronic pelvic pain syndrome (CPPS) is one of the most common reason for urological evaluation in young and middle age men and often the CPPS is associated with sexual dysfunction. This state of the art review article discusses recent developments in neurophysiology of male pelvic pain, complexity of neurological signaling in pelvis and central nervous system processing, modulation of sexual function by CPPS, and introduces modern multidisciplinary and multifaceted treatment paradigms. Recent developments in sexual dysfunction like premature ejaculation and its association with prostatitis refocus our attention from psychodynamic theories to biological causes and treatment standards of premature ejaculation and sexual dysfunction associated with chronic pelvic pain syndrome. It is our believe that this update will provide useful information to clinicians and improve the quality of care, and patient's satisfaction in treatment of young men with sexual dysfunction and pelvic pain.

Key words:
prostatitis, chronic pelvic pain, premature ejaculation


Sources

1. Litwin MS et al. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999; 162(2): 369–375.

2. Nickel JC et al. The beneficial effect of alfuzosin 10 mg once daily in 'real-life' practice on lower urinary tract symptoms (LUTS), quality of life and sexual dysfunction in men with LUTS and painful ejaculation. BJU Int 2006; 97(6): 1242–1246.

3. Dean RC, TF Lue. Physiology of penile erection and pathophysiology of erectile dysfunction. Urol Clin North Am 2005; 32(4): 379–395.

4. Shabsigh R et al. Health issues of men: prevalence and correlates of erectile dysfunction. J Urol 2005; 174(2): 662–667.

5. Trinchieri A et al. Prevalence of sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome. Arch Ital Urol Androl 2007; 79(2): 67–70.

6. Lee SW et al. Adverse impact of sexual dysfunction in chronic prostatitis/chronic pelvic pain syndrome. Urology 2008; 71(1): 79–84.

7. Aubin S et al. The Association between Sexual Function, Pain, and Psychological Adaptation of Men Diagnosed with Chronic Pelvic Pain Syndrome Type III. J Sex Med 2008.

8. Marszalek M et al. Symptoms suggestive of chronic pelvic pain syndrome in an urban population: prevalence and associations with lower urinary tract symptoms and erectile function. J Urol 2007; 177(5): 1815–1819.

9. Brookes ST et al. Relationship between lower urinary tract symptoms and erectile dysfunction: results from the Boston Area Community Health Survey. J Urol 2008; 179(1): 250–255.

10. Bartoletti R et al. Introduction to chronic prostatitis and chronic pelvic pain syndrome (CP/CPPS). Arch Ital Urol Androl 2007; 79(2): 55–57.

11. Bartoletti R et al. Prevalence, incidence estimation, risk factors and characterization of chronic prostatitis/chronic pelvic pain syndrome in urological hospital outpatients in Italy: results of a multicenter case-control observational study. J Urol 2007; 178(6): 2411–2415.

12. Liang CZ et al. Prevalence of sexual dysfunction in Chinese men with chronic prostatitis. BJU Int 2004; 93(4): 568–570.

13. Smith KB et al. Predictors of sexual and relationship functioning in couples with Chronic Prostatitis/ Chronic Pelvic Pain Syndrome. J Sex Med 2007; 4(3): 734–744.

14. Ilie CP, Mischianu DL, Pemberton RJ. Painful ejaculation. BJU Int 2007; 99(6): 1335–1339.

15. Tuncel A et al. Common symptoms in men with prostatic inflammation. Int Urol Nephrol 2006; 38(3–4): 583–586.

16. Nickel JC, Elhilali M, Vallancien G. Benign prostatic hyperplasia (BPH) and prostatitis: prevalence of painful ejaculation in men with clinical BPH. BJU Int 2005; 95(4): 571–574.

17. Gonen M et al. Prevalence of premature ejaculation in Turkish men with chronic pelvic pain syndrome. J Androl 2005; 26(5): 601–603.

18. Mehik A et al. Fears, sexual disturbances and personality features in men with prostatitis: a population-based cross-sectional study in Finland. BJU Int 2001; 88(1): 35–38.

19. Stulhofer A, Bajic Z. Prevalence of erectile and ejaculatory difficulties among men in Croatia. Croat Med J 2006; 47(1): 114–124.

20. Budia A et al. Value of semen culture in the diagnosis of chronic bacterial prostatitis: a simplified method. Scand J Urol Nephrol 2006; 40(4): 326–331.

21. Van de Merwe JP et al. Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/interstitial cystitis: an ESSIC proposal. Eur Urol 2008; 53(1): 60–67.

22. Dimitrakov J et al. Pharmacologic management of painful bladder syndrome/interstitial cystitis: a systematic review. Arch Intern Med 2007; 167(18): 1922–1929.

23. Forrest JB, Nickel JC, Moldwin RM. Chronic prostatitis/chronic pelvic pain syndrome and male interstitial cystitis: enigmas and opportunities. Urology 2007; 69(4 Suppl): 60–63.

24. Baranowski AP et al. Urogenital pain-time to accept a new approach to phenotyping and, as a consequence, management. Eur Urol 2008; 53(1): 33–36.

25. Shabsigh R, Rowland D. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision as an appropriate diagnostic for premature ejaculation. J Sex Med 2007; 4(5): 1468–1478.

26. Schiavi RC, Segraves RT. The biology of sexual function. Psychiatr Clin North Am 1995; 18(1): 7–23.

27. McClure TJ. Infertility in Mice Caused by Nutritional Stress before Mating. Nature 1963; 199: 504–505.

28. Barrett EL et al. Effects of mating delay and nutritional signals on resource recycling in a cyclically breeding cockroach. J Insect Physiol 2008; 54(1): 25–31.

29. Wylie KR, Eardley I. Penile size and the 'small penis syndrome'. BJU Int 2007; 99(6): 1449–1455.

30. Jakubietz M et al. Body dysmorphic disorder: diagnosis and approach. Plast Reconstr Surg 2007; 119(6): 1924–1930.

31. Rief W et al. The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med 2006; 36(6): 877–885.

32. Malykhina AP. Neural mechanisms of pelvic organ cross-sensitization. Neuroscience 2007; 149(3): 660–672.

33. Apkarian AV et al. Human brain mechanisms of pain perception and regulation in health and disease. Eur J Pain 2005; 9(4): 463–484.

34. Grachev ID, Fredrickson BE, Apkarian AV. Abnormal brain chemistry in chronic back pain: an in vivo proton magnetic resonance spectroscopy study. Pain 2000; 89(1): 7–18.

35. Grachev ID, Fredrickson BE, Apkarian AV. Brain chemistry reflects dual states of pain and anxiety in chronic low back pain. J Neural Transm 2002; 109(10): 1309–1334.

36. Pace MC et al. Neurobiology of pain. J Cell Physiol 2006; 209(1): 8–12.

37. Cukier JM, Cortina-Borja M, Brading AF. A case-control study to examine any association between idiopathic detrusor instability and gastrointestinal tract disorder, and between irritable bowel syndrome and urinary tract disorder. Br J Urol 1997; 79(6): 865–878.

38. Pezzone MA, Liang R, Fraser MO. A model of neural cross-talk and irritation in the pelvis: implications for the overlap of chronic pelvic pain disorders. Gastroenterology 2005; 128(7): 1953–1964.

39. Berkley KJ. A life of pelvic pain. Physiol Behav, 2005; 86(3): 272–280.

40. Malykhina AP et al. Hyperexcitability of convergent colon and bladder dorsal root ganglion neurons after colonic inflammation: mechanism for pelvic organ cross-talk. Neurogastroenterol Motil 2006; 18(10): 936–948.

41. Chandler MJ et al. Differential effects of urinary bladder distension on high cervical projection neurons in primates. Brain Res 2002; 949(1–2): 97–104.

42. Takahashi R et al. Modulation of Ca2+ sensitivity regulates contractility of rabbit corpus cavernosum smooth muscle. J Urol 2003; 169(6): 2412–2416.

43. Takahashi R et al. The mechanisms for tachykinin-induced contractions of the rabbit corpus cavernosum. Br J Pharmacol 2002; 137(6): 845–854.

44. Gu J et al. Peptidergic innervation of the human male genital tract. J Urol 1983; 130(2): 386–391.

45. Crowe R et al. The human penis: an unusual penetration of NPY-immunoreactive nerves within the medial muscle coat of the deep dorsal vein. J Urol 1991; 145(6): 1292–1296.

46. Sasaki K et al. Oral gabapentin (neurontin) treatment of refractory genitourinary tract pain. Tech Urol 2001; 7(1): 47–49.

47. Soydan G, Tekes E, Tuncer M. Investigation of serotonin receptors in the isolated penile bulb of rats. Int J Impot Res 2006; 18(6): 510–516.

48. Anderson RU et al. Psychometric Profiles and Hypothalamic-Pituitary-Adrenal Axis Function in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome. J Urol 2008.

49. Hardy MP et al. Trends of reproductive hormones in male rats during psychosocial stress: role of glucocorticoid metabolism in behavioral dominance. Biol Reprod 2002; 67(6): 1750–1755.

50. Ozyuvaci E, Yanmaz Alnigenis N, Altan A. The effect of transdermal fentanyl treatment on serum cortisol concentrations in patients with non-cancer pain. J Pain Symptom Manage 2004; 28(3): 277–281.

51. Fitzgerald RC, Skingle SJ, Crisp AJ. Testosterone concentrations in men on chronic glucocorticosteroid therapy. J R Coll Physicians Lond 1997; 31(2): 168–170.

52. Roberts LJ et al. Sex hormone suppression by intrathecal opioids: a prospective study. Clin J Pain 2002; 18(3): 144–148.

53. Nickel JC et al. Psychosocial variables affect the quality of life of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome. BJU Int 2008; 101(1): 59–64.

54. Andrews CN, Piterman L. Sex and the older man – GP perceptions and management. Aust Fam Physician 2007; 36(10): 867–869.

55. Selfe SA, Matthews Z, Stones RW. Factors influencing outcome in consultations for chronic pelvic pain. J Womens Health 1998; 7(8): 1041–1048.

56. Stones RW, Lawrence WT, Selfe SA. Lasting impressions: influence of the initial hospital consultation for chronic pelvic pain on dimensions of patient satisfaction at follow-up. J Psychosom Res 2006; 60(2): 163–167.

57. Laerum E, Indahl A, Skouen JS. What is “the good back-consultation”? A combined qualitative and quantitative study of chronic low back pain patients' interaction with and perceptions of consultations with specialists. J Rehabil Med 2006; 38(4): 255–262.

58. Rehman SU et al. What to wear today? Effect of doctor's attire on the trust and confidence of patients. Am J Med 2005; 118(11): 1279–1286.

59. Macias DJ, Sarabia MJ, Sklar DP. Male discomfort during the digital rectal examination: does examiner gender make a difference? Am J Emerg Med 2000; 18(6): 676–678.

60. Dube CE et al. Men's experiences of physical exams and cancer screening tests: a qualitative study. Prev Med 2005; 40(6): 628–635.

61. Neese LE et al. Finding help for sexual problems after prostate cancer treatment: a phone survey of men's and women's perspectives. Psychooncology 2003; 12(5): 463–473.

62. Parsons S et al. The influence of patients' and primary care practitioners' beliefs and expectations about chronic musculoskeletal pain on the process of care: a systematic review of qualitative studies. Clin J Pain 2007; 23(1): 91–98.

63. Hutchinson K et al. Exploring beliefs and practice of opioid prescribing for persistent non-cancer pain by general practitioners. Eur J Pain 2007; 11(1): 93–98.

64. Burd ID, Nevadunsky N, Bachmann G. Impact of physician gender on sexual history taking in a multispecialty practice. J Sex Med 2006; 3(2): 194–200.

65. Hinchliff S, Gott M, Galena E. 'I daresay I might find it embarrassing': general practitioners' perspectives on discussing sexual health issues with lesbian and gay patients. Health Soc Care Community 2005; 13(4): 345–353.

66. Bonvicini KA, Perlin MJ. The same but different: clinician-patient communication with gay and lesbian patients. Patient Educ Couns 2003; 51(2): 115–122.

67. Pouchot J et al. Perceptions in 7700 patients with rheumatoid arthritis compared to their families and physicians. Joint Bone Spine 2007; 74(6): 622–626.

68. Mageau GA, Vallerand RJ. The coach-athlete relationship: a motivational model. J Sports Sci 2003; 21(11): 883–904.

69. Rosen RC et al. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 1997; 49(6): 822–830.

70. Parsons CL et al. Quantifying symptoms in men with interstitial cystitis/prostatitis, and its correlation with potassium-sensitivity testing. BJU Int 2005; 95(1): 86–90.

71. Rosen RC et al. Development and validation of four-item version of Male Sexual Health Questionnaire to assess ejaculatory dysfunction. Urology 2007; 69(5): 805–809.

72. Grazi RV, Wolowelsky JB. Addressing the idiosyncratic needs of Orthodox Jewish couples requesting sex selection by preimplantation genetic diagnosis (PGD). J Assist Reprod Genet 2006; 23(11–12): 421–425.

73. Guterman MA. Observance of the Laws of Family Purity in Modern-Orthodox Judaism. Arch Sex Behav 2007.

74. Ribner DS. Ejaculatory restrictions as a factor in the treatment of Haredi (Ultraorthodox) Jewish couples. Arch Sex Behav 2004; 33(3): 303–310.

75. Kinsey AC, Pomeroy WB, Martin CE. Sexual behavior in the human male. Bloomington: Ind. Indiana University Press 1998, xv, 804 p.

76. Rosenberg MT, Sadovsky R. Identification and diagnosis of premature ejaculation. Int J Clin Pract 2007; 61(6): 903–908.

77. Rosen RC et al. Correlates to the clinical diagnosis of premature ejaculation: results from a large observational study of men and their partners. J Urol 2007; 177(3): 1059–1064.

78. Roberts RO et al. Prostatitis as a risk factor for prostate cancer. Epidemiology 2004; 15(1): 93–99.

79. Nadler RB et al. Prostate-specific antigen test in diagnostic evaluation of chronic prostatitis/chronic pelvic pain syndrome. Urology 2006; 67(2): 337–342.

80. Waldinger MD. Premature ejaculation: definition and drug treatment. Drugs 2007; 67(4): 547–568.

81. Waldinger MD. Premature ejaculation: state of the art. Urol Clin North Am 2007; 34(4): 591–599.

82. Geramoutsos I et al. Clinical correlation of prostatic lithiasis with chronic pelvic pain syndromes in young adults. Eur Urol 2004; 45(3): 333–338.

83. Shoskes DA et al. Incidence and significance of prostatic stones in men with chronic prostatitis/ chronic pelvic pain syndrome. Urology 2007; 70(2): 235–238.

84. De Groat WC, Booth AM. Physiology of male sexual function. Ann Intern Med 1980; 92(2 Pt 2): 329–331.

85. Seftel AD et al. Office evaluation of male sexual dysfunction. Urol Clin North Am 2007; 34(4): 463–482.

86. Nickel JC. Alpha-Blockers for the Treatment of Prostatitis-Like Syndromes. Rev Urol 2006; 8(Suppl 4): S26–S34.

87. Cheah PY et al. Initial, long-term, and durable responses to terazosin, placebo, or other therapies for chronic prostatitis/chronic pelvic pain syndrome. Urology 2004; 64(5): 881–886.

88. Lee SW et al. Chronic prostatitis/chronic pelvic pain syndrome: role of alpha blocker therapy. Urol Int 2007; 78(2): 97–105.

89. Nickel JC et al. Treatment of chronic prostatitis/ chronic pelvic pain syndrome with tamsulosin: a randomized double blind trial. J Urol 2004; 171(4): 1594–1597.

90. Mehik A et al. Alfuzosin treatment for chronic prostatitis/chronic pelvic pain syndrome: a prospective, randomized, double-blind, placebo-controlled, pilot study. Urology 2003; 62(3): 425–429.

91. Alexander RB et al. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial. Ann Intern Med 2004; 141(8): 581–589.

92. Safarinejad MR. Safety and efficacy of tamsulosin in the treatment of painful ejaculation: a randomized, double-blind, placebo-controlled study. Int J Impot Res 2006; 18(6): 527–533.

93. Tugcu V et al. A placebo-controlled comparison of the efficiency of triple- and monotherapy in category III B chronic pelvic pain syndrome (CPPS). Eur Urol 2007; 51(4): 1113–1118.

94. Shoskes DA et al. Long-term results of multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome. J Urol 2003; 169(4): 1406–1410.

95. Seftel A, Rosen R, Kuritzky L. Physician perceptions of sexual dysfunction related to benign prostatic hyperplasia (BPH) symptoms and sexual side effects related to BPH medications. Int J Impot Res 2007; 19(4): 386–392.

96. Goktas S et al. Recovery of abnormal ejaculation by intermittent tamsulosin treatment. J Urol 2006; 175(2): 650–653.

97. Reffelmann T, Kloner RA. Sexual function in hypertensive patients receiving treatment. Vasc Health Risk Manag 2006; 2(4): 447–455.

98. Potts JM. Therapeutic options for chronic prostatitis/chronic pelvic pain syndrome. Curr Urol Rep 2005; 6(4): 313–317.

99. Wagenlehner FM, Weidner W, Naber KG. Therapy for prostatitis, with emphasis on bacterial prostatitis. Expert Opin Pharmacother 2007; 8(11): 1667–1674.

100. El-Nashaar A, Shamloul R. Antibiotic treatment can delay ejaculation in patients with premature ejaculation and chronic bacterial prostatitis. J Sex Med 2007; 4(2): 491–496.

101. McVary KT et al. Tadalafil relieves lower urinary tract symptoms secondary to benign prostatic hyperplasia. J Urol 2007; 177(4): 1401–1407.

102. Evans DT, Jaleel H, Keefe A. Retrospective review of clinical practice in chronic pelvic pain syndrome i.e. category III chronic prostatitis at two hospital sites over five years 2000–2005 (an audit). Int J STD AIDS 2007; 18(4): 276–280.

103. Dellabella M, Milanese G, Muzzonigrob G. Correlation between ultrasound alterations of the preprostatic sphincter and symptoms in patients with chronic prostatitis-chronic pelvic pain syndrome. J Urol 2006; 176(1): 112–118.

104. McVary KT. Clinical practice. Erectile dysfunction. N Engl J Med 2007; 357(24): 2472–2481.

105. Dauleh M. A possible role for phosphodiesterase 5 inhibitor in the treatment of male chronic non-inflammatory pelvic pain syndrome. Med Hypotheses 2008; 70(1): 195–196.

106. Uckert S et al. Immunohistochemical distribution of cAMP- and cGMP-phosphodiesterase (PDE) isoenzymes in the human prostate. Eur Urol 2006; 49(4): 740–745.

107. Ponholzer A, Madersbacher S. Lower urinary tract symptoms and erectile dysfunction; links for diagnosis, management and treatment. Int J Impot Res 2007; 19(6): 544–550.

108. Gajar SA et al. Inhibitory effect of sildenafil on the human isolated seminal vesicle. BJU Int 2007; 100(6): 1322–1325.

109. Glenn DR et al. Sildenafil citrate improves sperm motility but causes a premature acrosome reaction in vitro. Fertil Steril 2007; 87(5): 1064–1070.

110. Jarvi K et al. Daily Vardenafil for 6 Months Has No Detrimental Effects on Semen Characteristics or Reproductive Hormones in Men With Normal Baseline Levels. J Urol 2008.

111. Achike F.I, Kwan CY. Nitric oxide, human diseases and the herbal products that affect the nitric oxide signalling pathway. Clin Exp Pharmacol Physiol 2003; 30(9): 605–615.

112. Lebret T et al. Efficacy and safety of a novel combination of L-arginine glutamate and yohimbine hydrochloride: a new oral therapy for erectile dysfunction. Eur Urol 2002; 41(6): 608–613.

113. Benencia F, Courreges MC. Nitric oxide and macrophage antiviral extrinsic activity. Immunology, 1999. 98(3): 363–370.

114. Fugh-Berman A. Herbs and dietary supplements in the prevention and treatment of cardiovascular disease. Prev Cardiol 2000; 3(1): 24–32.

115. Capodice JL et al. Complementary and alternative medicine for chronic prostatitis/chronic pelvic pain syndrome. Evid Based Complement Alternat Med 2005; 2(4): 495–501.

116. Kaplan M et al. Use of herbal preparations in the treatment of oxidant-mediated inflammatory disorders. Complement Ther Med 2007; 15(3): 207–216.

117. Dimitrakov JD et al. Management of chronic prostatitis/chronic pelvic pain syndrome: an evidence-based approach. Urology 2006; 67(5): 881–888.

118. Aslamazov EG et al. [Cernilton in the treatment of prostatic adenoma and chronic prostatitis]. Urologiia, 2007(1): p. 52, 54–56.

119. Shoskes DA. Phytotherapy in chronic prostatitis. Urology 2002; 60(6 Suppl): 35–37.

120. MacDonald R et al. A systematic review of Cernilton for the treatment of benign prostatic hyperplasia. BJU Int 2000; 85(7): 836–841.

121. Shoskes DA et al. Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial. Urology 1999; 54(6): 960–963.

122. Shoskes DA. Phytotherapy and other alternative forms of care for the patient with prostatitis. Curr Urol Rep 2002; 3(4): 330–334.

123. Giubilei G et al. Physical activity of men with chronic prostatitis/chronic pelvic pain syndrome not satisfied with conventional treatments – could it represent a valid option? The physical activity and male pelvic pain trial: a double-blind, randomized study. J Urol 2007; 177(1): 159–165.

124. Potts J, Payne RE. Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key. Cleve Clin J Med 2007; 74 Suppl 3: S63–71.

125. Anderson RU et al. Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training. J Urol 2006; 176(4 Pt 1): 1534–1539.

126. Chen RC, Nickel JC. Acupuncture for chronic prostatitis/chronic pelvic pain syndrome. Curr Urol Rep 2004; 5(4): 305–308.

127. Lee SW et al. Acupuncture versus sham acupuncture for chronic prostatitis/chronic pelvic pain. Am J Med 2008; 121(1): 79 e1–7.

128. Napadow V et al. Hypothalamus and amygdala response to acupuncture stimuli in Carpal Tunnel Syndrome. Pain 2007; 130(3): 254–266.

129. Lee RA, West RM, Wilson JD. The response to sertraline in men with chronic pelvic pain syndrome. Sex Transm Infect 2005; 81(2): 147–149.

130. Salem EA et al. Tramadol HCL has Promise in On-Demand Use to Treat Premature Ejaculation. J Sex Med 2008; 5(1): 188–193.

131. Safarinejad MR. Once-daily high-dose pindolol for paroxetine-refractory premature ejaculation: a double-blind, placebo-controlled and randomized study. J Clin Psychopharmacol 2008; 28(1): 39–44.

132. Spigset O. Adverse reactions of selective serotonin reuptake inhibitors: reports from a spontaneous reporting system. Drug Saf 1999; 20(3): 277–287.

133. Hetrick S et al. Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents. Cochrane Database Syst Rev 2007; 3: CD004851.

134. Usala T et al. Randomised controlled trials of selective serotonin reuptake inhibitors in treating depression in children and adolescents: a systematic review and meta-analysis. Eur Neuropsychopharmacol 2008; 18(1): 62–73.

135. Arroll B et al. Efficacy and tolerability of tricyclic antidepressants and SSRIs compared with placebo for treatment of depression in primary care: a meta-analysis. Ann Fam Med 2005; 3(5): 449–456.

136. Handelsman DJ. Update in andrology. J Clin Endocrinol Metab 2007; 92(12): 4505–4511.

137. Fabbri A et al. Testosterone treatment to mimic hormone physiology in androgen replacement therapy. A view on testosterone gel and other preparations available. Expert Opin Biol Ther 2007; 7(7): 1093–1106.

138. Osborne TL, Raichle KA, Jensen MP. Psychologic interventions for chronic pain. Phys Med Rehabil Clin N Am 2006; 17(2): 415–433.

Labels
Paediatric urologist Urology
Login
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account

#ADS_BOTTOM_SCRIPTS#