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PubMed2005

Erectile dysfunction following surgical correction of Peyronie's disease and a pilot study of the use of sildenafil citrate rehabilitation for postoperative erectile dysfunction.

INTRODUCTION: Peyronie's disease (PD) is correctable by several surgical approaches including plaque incision with grafting. While the best choice of graft material remains controversial, the risk of postoperative erectile dysfunction (ED) is apparent across previous reports. AIM: We attempt to provide guidelines as to which patients may be at increased risk for developing postoperative ED after this procedure, as well as examine the role of sildenafil citrate (SC) in the postoperative period for prevention of this complication. MATERIALS AND METHODS: A retrospective review was performed on 37 patients who underwent surgical correction of PD with pericardial grafting after plaque incision. Mean follow-up was 24 months. We evaluated patient age, duration of disease, defect size, plaque location, degree of curvature, shaft narrowing, preoperative coital activity, vascular risk factors for ED, as well as preoperative erection grade and duplex ultrasound parameters. Twenty-six of these patients underwent a postoperative rehabilitation protocol of SC to enhance recovery of unassisted erections. RESULTS: Overall, 11 patients (29%) noted diminished postoperative rigidity, that compromised unassisted coitus, compared to preoperative status. Comparison of rates of ED among those with or without vascular risk factors yielded no statistically significant results. Peyronie's disease duration, patient age, defect size, plaque location, degree of curvature, and narrowing were also insignificant predictors of which patients developed ED. An increased percentage of patients who developed ED were not sexually active preoperatively compared to those that did not develop ED (58% vs. 80%). When patients were compared based on preoperative erection grade, those patients with compromised erectile function were more likely to develop postoperative ED vs. those with full erections (P < 0.05). No significant differences were found in preoperative duplex ultrasound parameters between both sets of patients. For those undergoing SC rehabilitation, 7 out of 26 (26%) developed ED in comparison to 4 out of 11 patients (36%) developing diminished rigidity when not subjected to the protocol. CONCLUSIONS: No single parameter was found that predicted the occurrence of postoperative ED with the exception of preoperative erectile status. The surgeon must carefully assess and consult each patient when considering grafting as well as consider the possible role of SC in attempting to prevent this complication.

3',5'-Cyclic-GMP Phosphodiesterases↗

PubMed2001

Fibrinogen, lipoprotein (a) and lipids in patients with erectile dysfunction. A preliminary study.

BACKGROUND: Erectile dysfunction is associated with cardiovascular risk factors (e.g. hypertension, smoking, dyslipidemia and diabetes) and is more common in patients with cardiovascular disease. We therefore assessed the prevalence of two predictors of vascular events, fibrinogen and lipoprotein-a, in patients with and without erectile dysfunction. METHODS: Men with erectile dysfunction (48 non-smokers, 48 smokers), aged 45-70 years, were compared with controls (21 non-smokers, 21 smokers) with normal erectile function and no known pathology. RESULTS: Serum total cholesterol was significantly higher in non-smokers with erectile dysfunction compared to both control non-smokers and erectile dysfunction smokers. Men with erectile dysfunction who smoked had a significantly higher plasma fibrinogen level than control smokers. Similarly, men with erectile dysfunction, who did not smoke had higher levels of plasma fibrinogen compared to both smokers and non-smokers without erectile dysfunction. No significant difference in serum lipoprotein-a values was found. CONCLUSIONS: These findings support the concept that cardiovascular risk factors are predictors of erectile dysfunction and that this may be another manifestation of vascular disease.

Aged↗

PubMed2003

Deciphering erectile dysfunction drug trials.

PURPOSE: Erectile dysfunction affects more than 20 million men in the United States. Currently, there are at least 10 novel erectogenic agents in development. It is incumbent on clinicians and especially urologists to be facile in interpreting data from drug trials investigating such medications. MATERIALS AND METHODS: A comprehensive review of the literature addressing novel Food and Drug Administration approved erectogenic drugs was conducted using MEDLINE to highlight the key points in the analysis of data arising from these trials. RESULTS: The major points for analysis include trial design, patient population studied, end points used and adverse event profile. The patients enrolled in erectile dysfunction drug trials should be representative of the general erectile dysfunction population. Assessment of the population includes defining baseline erectile dysfunction severity, co-morbidity profiles and concomitant medication use. Defining clinically meaningful end points is difficult. Several validated questionnaire instruments are available, the most commonly used being the International Index of Erectile Function. Much of the data gathered are based on this self-report inventory. Factors relating to adverse events include frequency of events--per patient and per administration rates--and severity and duration of side effects. CONCLUSIONS: Several key factors in trial design, patient enrollment and outcome analysis need to be assessed to interpret accurately the data generated from erectile dysfunction drug trials.

Adult↗

PubMed1998

Management of male erectile dysfunction: a review.

Male erectile dysfunction is common although some patients are embarrassed and delay seeking medical advice. Recent improvements in the understanding of the anatomy, physiology and pharmacotherapy of penile erections, and the introduction of intracavernosal pharmacotherapy has resolved most of the controversies regarding the aetiology of erectile dysfunction. Impotence is equally divided into organic and psychogenic causes. Arterial insufficiency, alcoholism, venosinusoidal, neurological and endocrine disorders are known to cause organic erectile dysfunction. Two most popular options in the management of erectile dysfunction are intracavernosal injections with vasoactive drugs like papavarine, phentolamine, and prostaglandin EI with discontinuation rates of 40-50%, and the use of external vacuum devices whose limitations include failure to achieve and maintain full erection. The use of inflatable penile prostheses is successful but limited with periprosthetic infection and cylinder erosion through the skin or urethra. Surgical procedures have included revascularisation of penile vessels without good results. Surgical ligation of penile veins for venosinusoidal incompetence has been successful compared to excision and embolisation which has disappointing results. Currently the role of oral medications in the treatment of erectile dysfunction is limited. However, there are now several new agents including sildenafil, a phosphodiasterase inhibitor, which is undergoing clinical trials that appear to be effective.

Dopamine Agonists↗

PubMedDate not supplied

Partners' perspective of erectile dysfunction: literature review.

Erectile dysfunction is a problem which men may or may not share with their partners for a variety of reasons. This literature review of 26 articles revealed the partners' perspective of men with erectile dysfunction. Partners fell into four groups: supportive partner/acceptable to patient (the optimum category); supportive partner/unacceptable to patient; non-supportive partner/acceptable to patient; and non-supportive partner/unacceptable to patient. With comprehensive education and counselling by urology nurses, the couples could move into the optimal category. There is increasing recognition that the partner should be involved in the assessment, diagnosis, patient education, counselling and choice of treatment for long-term treatment to be successful, unless the informed patient is unwilling.

Adaptation, Psychological↗

PubMedDate not supplied

[Diagnosis and treatment of erectile dysfunction].

Pathogenesis of erectile dysfunction is well studied now. So another problem arises: how to choose individual methods of diagnosis and treatment as well as sequence of diagnostic and therapeutic measures. Our method of purposeful approach to diagnosis and treatment of erectile dysfunction is based on the choice of the patient who decides himself the scope and invasiveness of the diagnosis and treatment. The patient makes his choice after he is informed about all available diagnostic techniques and treatment methods.

Adrenergic alpha-Antagonists↗

PubMed2004

Update on oral treatments for male erectile dysfunction.

Impairment of erectile function compromises quality of life in millions of men and their partners, many of whom prefer to suffer in silence. It is important to maintain an elevated index of clinical suspicion in patients with erectile dysfunction (ED) risk factors (e.g. hypertension, diabetes, coronary heart disease). There remains a high rate of voluntary discontinuation of therapy associated with most treatment modalities. Since the introduction of sildenafil, a greater awareness and openness regarding the epidemiology and treatment of male erectile dysfunction has emerged. The development of newer and potentially more efficacious phosphodiesterase type 5 (PDE5) inhibitors will serve to treat an even greater number of patients, allowing once daily and more convenient dosing. An increased understanding of the physiological principles of penile erection has allowed the development of novel oral pharmacological therapies. The new agents offer a potential benefit in a broader range of patients and clinical situations. They may provide a more acceptable alternative than other more invasive options (intracavernosal/urethral injection, implant surgery). The dopamine agonist apomorphine acts on the central control of penile erection to allow a sublingual preparation to produce a prompt response. It is not contraindicated in patients on nitrate medication for coronary artery disease, or in patients with depression or on antidepressants. As with any other treatment, the clinician's responsibility in the care of ED patients does not end with the writing of a prescription. Adequate education and follow-up are needed to optimize the efficacy and safety of oral ED therapy. Furthermore, patients and their partners need to be advised that the agents are not effective in the absence of sexual stimulation. Communicating with both the patient and his partner in a discreet, non-judgmental manner that fosters the physician-patient alliance can facilitate the recognition and treatment of ED.

Administration, Oral↗

PubMed2006

The role of endothelial dysfunction in the pathophysiology of erectile dysfunction in diabetes and in determining response to treatment.

BACKGROUND: Erectile dysfunction (ED) in diabetes is related to autonomic neuropathy and endothelial dysfunction. We studied the relative importance of these factors in diabetic and non-diabetic men with ED and determined if they predict responses to treatment with sildenafil. METHODS: Thirty-three men, aged 35-65 years, with ED (20 diabetic, 13 non-diabetic), 15 of whom were sildenafil responders and 18 non-responders, were compared with 30 age and risk-matched control subjects (15 diabetic, 15 non-diabetic). Subjects with ED completed the International Index of Erectile Function (IIEF) questionnaire. Endothelial function was assessed by changes in brachio-radial and femoro-tibial arterial pulse-wave velocity (pulse-wave velocity) during reactive hyperaemia, expressed as percentage endothelium-dependent dilatation. Autonomic function was assessed by heart rate variation during expiration and inspiration (E/I ratio) and during the valsalva manoeuvre. RESULTS: The respective changes in pulse-wave velocity, in the arm and leg [mean (sd)] were 0.71 (6.5)% and 3.5 (6.4)% in the impotent diabetic men, 0.7 (7.6)% and 2.4 (5.9)% in the non-diabetic impotent men, -0.68 (5.7)% and -1.31 (7.2)% in the non-impotent diabetic men and 7.7 (3.7)% and 7.6 (3.4)% in the control subjects. There was a significant interaction between ED and diabetic status such that there was significantly impaired vascular response in the diabetic group (both with and without ED) and in the non-diabetic group with ED compared with the non-diabetic control group (P = 0.01 and P = 0.001 for brachio-radial and femoro-tibial measures, respectively). The E/I ratios of the diabetic men were significantly lower than those of the control subjects [1.17 (0.14) vs. 1.33 (0.16), P < 0.02), but there were no differences in the measures of autonomic neuropathy between the groups with ED and those with normal erectile function. Amongst diabetic men, the initial IIEF scores (maximum score 30, low score indicates more severe ED) were significantly higher in sildenafil-responders than non-responders [16.3 (8.4), vs. 6.8 (7 1), P < 0.02]. The rate of sildenafil response was not significantly affected by the measures of endothelial or autonomic function. CONCLUSIONS: ED in both diabetic and non-diabetic men is characterized by marked endothelial dysfunction in comparison with non-diabetic control subjects. Response to sildenafil is not predicted by either endothelial function or autonomic function, but in diabetic men appears to be related to the initial degree of erectile dysfunction.

Adult↗

PubMed2002

Erectile dysfunction practice guidelines.

Erectile dysfunction has undergone dramatic advances in diagnosis and therapeutics over the past decade. Increasing numbers of men are currently seeking medical help for their sexual concerns, often from primary health care providers. The Canadian Urological Association (CUA), Guidelines Committee is charged with the responsibility of creating practice guidelines for urologic conditions with the goal of improving physician knowledge and enhancing patient care. These Erectile Dysfunction Guidelines highlight the evolving use of a minimally invasive patient self-directed goal oriented approach to evaluation and treatment using oral agents as first-line therapy based on efficacy, side effect profile and ease of use. Second-line therapies include vacuum devices, injectable agents and intraurethral vasoactive devices. Surgical treatments are reserved for men who cannot use or fail to respond to first and second line treatments.

Algorithms↗

PubMed2000

Oral and injectable medications for the treatment of erectile dysfunction.

The treatment of erectile dysfunction has changed dramatically over the past two decades. The introduction of the oral agent sildenafil 2 years ago has revolutionized the treatment of men with compromised erections and has met with expected success and low morbidity. Sildenafil is effective in most men with erectile dysfunction in the general population and in select populations, such as men with spinal cord injury, diabetes mellitus, and patients who have had nerve-sparing radical prostatectomy. It is safe in the general population as well as in many men with cardiac disease. Other newer medications are in trial and may soon be available to supplement treatment with sildenafil. Oral phentolamine, apomorphine, newer phosphodiesterase type-5 inhibitors, and topical agents are currently in phase 3 trials. These agents, in addition to newer intraurethral and indictable agents, may assist men with erectile dysfunction and rescue those in whom sildenafil is ineffective or in whom untoward side effects of sildenafil reduce its effectiveness. The 21st century will witness many additional agents designed for specific patients with specific conditions causing erectile dysfunction. We can expect these oral agents, assisted by topical and injectable agents, to successfully restore erectile function in the majority of men suffering from erectile dysfunction.

Administration, Oral↗

PubMed2002

Combination therapy for erectile dysfunction: a randomized, double blind, unblinded active-controlled, cross-over study of the pharmacodynamics and safety of combined oral formulations of apomorphine hydrochloride, phentolamine mesylate and papaverine hydrochloride in men with moderate to severe erectile dysfunction.

Oral therapy has become first line treatment for patients with mild to moderate erectile dysfunction (ED). Studies have shown that sildenafil may not be effective in all patients, and has been associated with a variety of adverse effects and an adverse interaction with nitrates and inhibitors of cytochrome P450 enzymes. The objective was to compare the efficacy and safety of three different oral combinations with the highest dose of sildenafil in men with moderate to severe ED. Randomized, double blind, unblinded active-controlled, Phase II study was carried out at three sites in Mexico. After a 4-week placebo run-in period, patients received all four of the following treatments using a 4-way cross-over design: 40 mg phentolamine (PM) +6 mg apomorphine (Apo); 40 mg PM +150 mg papaverine (Pap); 40 mg PM +6 mg Apo +150 mg Pap (Tricombo); 100 mg sildenafil (SC). With the exception of sildenafil tablets, all study medication was blinded. Moderate to severe ED was defined as a less than 50% vaginal penetration success rate during the placebo run-in period. A total of 44 patients were enrolled, of whom 36 completed all four treatment periods. All treatments produced a significant effect in primary efficacy variable (Sexual Encounter Profile) compared to baseline, however, no statistically significant differences were found between treatments. A significant period effect was observed. Also, the four treatments were found not to differ significantly in five out of six secondary efficacy variables. The lowest incidence of treatment-related adverse events (AE) occurred in the 40 mg PM +6 mg Apo group (9.8%), followed by 100 mg SC (15%), and the other two combinations (16.7 and 17.5%, respectively). Nasocongestion and headache were the most frequently reported AE. An oral combination of vasoactive agents may provide an alternative approach to sildenafil. Based on these results a combination of phentolamine and apomorphine warrants further clinical investigation.

Adrenergic alpha-Antagonists↗

PubMedDate not supplied

Is smoking a cause of erectile dysfunction? A literature review.

Erectile dysfunction is common, and its prevalence increases with age owing to age-related diseases of vascular, hormonal, neurogenic and psychogenic factors. A literature review was undertaken to explore the impact of smoking on erectile dysfunction. The literature review of 18 studies revealed the detrimental effect of smoking on erectile function. Smokers were 1.5 times more likely to suffer erectile dysfunction than non-smokers. Men may be unaware of the effect of tobacco on erectile function. This literature review presents strong reasons for stopping smoking, and highlights the need for education within a comprehensive smoking cessation programme. All men should be offered smoking cessation treatment which includes nicotine replacement therapy and continued support. Randomized controlled trials are needed to explore the effect of smoking and smoking cessation on erectile dysfunction.

Age Distribution↗

PubMed2001

Prevalence and independent risk factors for erectile dysfunction in Spain: results of the Epidemiologia de la Disfuncion Erectil Masculina Study.

PURPOSE: We determined the prevalence of and risks factors for erectile dysfunction in Spain in a cross-sectional study. MATERIALS AND METHODS: A total of 2,476 noninstitutionalized Spanish men 25 to 70 years old were interviewed at home and answered a self-administered questionnaire of 71 items, including 2 instruments to define erectile dysfunction, a simple self-assessment question to estimate erectile function and the International Index of Erectile Function. Data on disease, medication and toxic habits were also obtained. RESULTS: With an overall participation rate of 75% the prevalence of erectile dysfunction according to the simple question was 12.1%. According to the erectile function domain of the International Index of Erectile Function the overall prevalence was 18.9%. Several independent risk factors were significantly associated with the probability of erectile dysfunction. Some differences arose according to the tool used to define the condition. However, there was a strong relationship of patient age with frequency or severity no matter which instrument was used to define erectile dysfunction. Diabetes (age adjusted odds ratio 4), high blood pressure (odds ratio 1.58), high cholesterol (1.63), peripheral vascular disorder (2.63), lung disease (3.11), prostate disease (2.93), cardiac problems (1.79), rheumatism (2.37) and allergy (3.08) were significantly associated with erectile dysfunction. Drug intake, which respondents called medication for nerves and sleeping pills, correlated strongly (odds ratio 2.78 and 4.27, respectively), as did tobacco use (2.5) and alcohol consumption (1.53). CONCLUSIONS: This study provides data on the prevalence of and risks factors for erectile dysfunction in Spain. The relationship of erectile dysfunction with certain risk factors, such as cardiovascular risk factors and drugs intake, are well known and our study corroborates these associations. Other associations with erectile dysfunction, such as prostate disease, allergy and rheumatism, support findings in previous reports, although to our knowledge the pathophysiological mechanisms remain unclear. Estimating the strength of the association of erectile dysfunction with distinct risk factors in terms of odds ratios enabled us to identify the factors to pursue when seeking to prevent erectile dysfunction. Furthermore, the relationship of tobacco with erectile dysfunction, which has been controversial in previous series, was well characterized in our study.

Adult↗

PubMed1995

Pharmacological management of erectile dysfunction.

Pharmacological treatment of erectile dysfunction includes all therapeutic modalities based on the use of erectogenic drugs, regardless of the route of administration. Intracavernous vasoactive injection therapy is the most commonly used treatment for erectile dysfunction. Most patients respond to intracavernous injection of either single or multiple vasoactive drugs. Major adverse effects related to this treatment include priapism, corporeal pain and the formation of nodules or plaques in the corpora cavernosa. Oral administration of drugs aimed at improving erectile function has not produced results comparable with those obtained with intracavernous injection therapy. However, in patients with psychogenic or mild organic impotence, oral treatment with drugs that influence either central or peripheral pathways controlling erection may improve erectile function. Topical administration of vasoactive drugs in the form of gels, liquid solutions or plasters is another attractive alternative for the treatment of psychogenic and mild organic erectile dysfunction. Although the ideal drug for the treatment of erectile dysfunction has not yet been identified, extensive laboratory and clinical research is ongoing and successful results are expected in the near future.

Administration, Oral↗

PubMed1985

[Selective arteriography of the internal pudendal artery in posttraumatic erectile dysfunction].

102 patients with erectile dysfunction were evaluated by a multidisciplinary approach including measurement of the bulbocavernous reflex (BCR)-latency, cystometry, dynamic cavernosography and bilateral selective arteriography of the pudendal arteries. Seven patients had a posttraumatic source of their erectile failure. Three patients showed a mixed neurogenic-arteriogenic aetiology of erectile dysfunction, two patients had evidence of isolated arterial damage, one patient had a venous and one an isolated neurogenic cause of erectile dysfunction. The passage of pudendal-penile vessels and nerves through the urogenital diaphragm is the most vulnerable portion of its way through the pelvis. Ruptures of the prostatomembranous urethra are frequently accompanied by injury to the pudendal-penile vessels and nerves, thus causing erectile dysfunction.

Accidents, Traffic↗

PubMed2005

[Erectile dysfunction: a sentinel symptom?].

Erectile dysfunction (ED) is a frequent disorder affecting the man's sexual and relational quality of life. French epidemiological studies estimate that the prevalence of ED is between 11% and 44% and prevalence surveys show a correlation between ED and age: the relative risk of erectile dysfunction increases by a factor of 2 to 4 between the ages of 40 and 70 years. Few patients consult their doctor and only a small proportion of them receive treatment and few doctors take the initiative to discuss the question of their patients' sex life. Doctors should now have a good understanding of erectile dysfunction and must be aware of the importance of detecting or at least investigating any erectile dysfunction, which can be the first symptom of an underlying disease such as cardiovascular disease, diabetes, depression, benign prostatic hyperplasia, prostate cancer, androgen deficiency or a drug-induced effect. Demonstration of erectile disorders therefore represents an excellent opportunity to conduct a general work-up, as more than one-third of patients with ED ignore their underlying health problem and management of ED is therefore an integral part of preventive medicine.

Erectile Dysfunction↗

PubMed2003

Erectile dysfunction in diabetes mellitus.

Erectile dysfunction (ED) is 2-3 times more frequent in men with diabetes mellitus than in men without such a history and might be an early marker of endothelial dysfunction. We studied a group of 310 unselected male patients within the Clinical Center of Diabetes and Metabolic Diseases of Dolj County, with ages ranging between 20-78 years (57.43 + 0.835) and a positive history of diabetes mellitus for 1-47 years (10.09 +/- 8.715). Erectile dysfunction, quantified using SHIM (Sexual Health Inventory for Men), was present in 196 patients (63.2%); severe in 52 patients (16.8%), moderate in 42 patients (13.5%) and mild in 102 patients (32.9%). Erectile dysfunction showed a positive correlation with age after 65 years, history of diabetes of more than 10 years, obesity, stroke, arteriopathy, retinopathy, neuropathy and the smoking habit and was not correlated to the type of diabetes mellitus, history of diabetes less than 10 years, diabetes therapy, hypertension, ischemic heart disease, nephropathy, dyslipidemia and alcohol consumption. Our results plead for a holistic approach of the diabetic patient, irrespective of age, in order to detect and to treat all the risk factors, keeping in mind that the appearance of erectile dysfunction might indicate the presence of occult chronic diabetes complications.

Adult↗

PubMed2002

Global perspectives and controversies in the epidemiology of male erectile dysfunction.

PURPOSE OF REVIEW: Erectile dysfunction is a neurovascular phenomenon that requires an intact psychological, neural, and vascular component. The advent of Food and Drug Administration approval of sildenafil citrate (Viagra) in 1998 has resulted in increased awareness and a large population of patients seeking treatment. Unfortunately, the estimated number of patients seeking medical therapy still persists at approximately 10%. The predominant reasons suggested here are the complexity of sexuality, taboos, cultural restrictions, lack of satisfactory treatment, and acceptance of the situation as a normal sequence of aging. This perspective discusses the global prevalence and the differences in prevalence on a worldwide basis. RECENT FINDINGS: Recent epidemiologic studies from Spain and Germany have suggested lower rates of erectile dysfunction. This, however, may actually reflect population or cultural differences in the perceptions and attitudes towards the condition. Aging, diabetes, coronary artery disease, and cigarette smoking as epidemiologic factors are reviewed extensively, including some of the controversies with the prevalence rates on a global scale. Chronic renal failure, pelvic surgery, and lifestyle determinants similarly suggest there may be subtle differences, requiring further education from the medical care provider in order to have patient acceptance on a relatively earlier scale. SUMMARY: Erectile dysfunction is a worldwide health issue that affects nearly half the men over the age of 40. As the world population ages, the number of patients affected by this disorder will certainly be increased. With the identification of risk factors, it may be possible to identify patients at risk of erectile dysfunction.

Adult↗