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PubMed2006

[Erectile dysfunction, physiologic approach, diagnosis and therapy].

Erectile dysfunction is defined as the consistent or recurrent inability to obtain and/or maintain a penile erection sufficient for sexual activity. Erection is a vascular phenomenon under a psychoneurological control and situated in an hormonal environment. A variety of treatment options are available to the clinician including medical, psychological and surgical treatments. The choice of therapy should be based on careful matching of the patient's needs and preferences with the available treatment options.

Algorithms↗

PubMed1998

Prospective comparative study with intracavernous sodium nitroprusside and prostaglandin E1 in patients with erectile dysfunction.

PURPOSE: To compare the effectiveness of intracavernous administration of sodium nitroprusside and prostaglandin E1 to induce penile erection in men with erectile dysfunction. MATERIAL AND METHODS: 100 patients with erectile dysfunction entered the study prospectively. As part of the diagnostic workup, each patient received an intracavernous injection of 20 microg prostaglandin E1 and a second injection of 600 microg sodium nitroprusside 1-7 days later. A tourniquet was placed at the base of the penis before each injection. The data recorded included time required to initiate tumescence, local and systemic side effects, objective and subjective quality of erections, duration of tumescence and patient satisfaction by means of a personal questionnaire. RESULTS: Prostaglandin E1 induced better overall responses than sodium nitroprusside, the difference being almost significant (p = 0.055). The overall duration of erections was also significantly longer with prostaglandin E1 (mean 81.3 min) than with sodium nitroprusside (mean 65.4 min; p < 0.04). 67% of the patients considered the erections induced with prostaglandin E1 to be of better quality than those with sodium nitroprusside, and only 11% stated that sodium nitroprusside was superior. Side effects were minimal with both drugs, the most frequent side effect being systemic hypotension, which was induced by sodium nitroprusside in 7% of the patients. CONCLUSIONS: The moderate risk of systemic hypotension and the lower potency of sodium nitroprusside to induce erections compared to prostaglandin E1 rules out sodium nitroprusside as a routine alternative intracavernous drug in men with erectile dysfunction at the doses employed. Sodium nitroprusside, however, could be used in patients who have intolerance or penile pain with intracavernous prostaglandin E1.

Adult↗

PubMed2006

Combination of phosphodiesterase-5 inhibitors and alpha-blockers in patients with benign prostatic hyperplasia: treatments of lower urinary tract symptoms, erectile dysfunction, or both?

As the prevalence of both erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) increases with age, physicians could be in the position to manage these two conditions simultaneously. Moreover, medical therapies for either one of these conditions can affect the other and this should be carefully considered when making treatment decisions. Pharmacotherapy for benign prostatic hyperplasia (BPH)/LUTS can cause side-effects affecting sexual function. Hence, 5alpha-reductase inhibitors such as finasteride and dutasteride are associated with a greater risk of ED, ejaculatory disorders (EjD) and decreased libido than is placebo. Among alpha1-adrenergic blockers, tamsulosin is associated with an increased risk of EjD. However, some alpha1-adrenergic blockers can also have a positive impact on erection. This is the case for alfuzosin, which has been shown to enhance erectile function in experimental models, probably by reducing the sympathetic tone and thus relaxing corpus cavernosum smooth muscle cells. Phosphodiesterase 5 (PDE-5) inhibitors are commonly used to treat ED. There is increasing evidence that they might also have a beneficial effect on LUTS, probably through the nitric-oxide pathway. Nitric oxide is an important mediator of the relaxation of isolated bladder and urethral smooth muscle, and could modulate prostatic smooth muscle tone. Alpha1-adrenergic blockers and PDE-5 inhibitors can therefore have a positive impact on both ED and LUTS. Although placebo-controlled studies are needed to confirm the impact of these drugs, alone or combined, on both ED and LUTS, this reinforces the need for a common approach to managing these two highly prevalent and bothersome conditions.

3',5'-Cyclic-GMP Phosphodiesterases↗

PubMed1998

Efficacy and safety of transurethral alprostadil therapy in men with erectile dysfunction. MUSE Study Group.

OBJECTIVE: To examine the safety and efficacy of transurethral pharmacotherapy for erectile dysfunction, involving the use of a novel therapeutic system to administer alprostadil (prostaglandin E1) to the urethral mucosa in a double-blind, randomized, parallel, placebo-controlled study conducted in five countries in Europe. PATIENTS AND METHODS: In an outpatient setting, patients with primarily organic erectile dysfunction of at least 3 months' duration were treated with transurethral alprostadil, in an open-label, dose-escalating study. Testing stopped when the dose provided an erection sufficient for intercourse, as assessed by the patient and the investigator. Patients who achieved a sufficient response were then randomized to either active medication at the selected dose or to placebo for use at home for 3 months. After each home administration, patients recorded in diaries whether or not sexual intercourse occurred and any adverse reactions to the drug. RESULTS: A total of 249 patients were treated in an outpatient setting; of these patients, 159 (64%) achieved an erection sufficient for intercourse and were randomized (1:1) to either active medication or placebo for home treatment. Of the patients randomized to alprostadil for home treatment, 69% reported intercourse at least once, compared with 11% of patients randomized to placebo (P < 0.001). The most common adverse reaction, urethral pain/burning, was reported by 7% of patients in the clinic. Most patients (83%) graded transurethral alprostadil as causing minimal or no discomfort in the clinic. No patient reported priapism or developed penile fibrosis. CONCLUSION: Alprostadil delivered transurethrally by this system was well tolerated and effective in treating erectile dysfunction.

Adult↗

PubMed2006

Reactive oxygen species and erectile dysfunction: possible role of NADPH oxidase.

Erectile dysfunction (ED) is a widespread condition, the incidence of which is increasing globally. ED is also indicative of underlying vasculopathy and represents a predictor of more serious cardiovascular disorders. Understanding the aetiology of ED may therefore provide invaluable pointers to the pathobiology of other cardiovascular diseases (CVDs) and syndromes. It follows, too, that therapeutic interventions that are successful in treating ED may, ipso facto, be effective in treating the early stages of conditions that include atherosclerosis, angina, plaque rupture and diabetic angiopathy. One common pathological denominator in both CVD and ED is oxidative stress, that is, the overproduction of reactive oxygen species (ROS), in particular, superoxide (O(2)(*-)) and hydrogen peroxide (H(2)O(2)). In this review, therefore, we consider the aetiology and pathobiology of O(2)(*-) in promoting ED and focus on NADPH oxidase as an inducible source of O(2)(*-) and H(2)O(2). Therapeutic strategies aimed at reducing oxidative stress to improve erectile function are also discussed.

Animals↗

PubMed1988

Mid-term results of autoinjection therapy for erectile dysfunction.

Of over 300 patients with erectile dysfunction, 186 were selected for intracavernosal autoinjection therapy with a standardized papaverine-phentolamine mixture. A total of 156 patients performed 4,813 protocol autoinjections with a minimum of 10 and a maximum of 230 per patient. The dose that induced a full erection at the hospital could be reduced under home conditions by a mean of 35 per cent. Systemic side effects were not observed. The most inconvenient local side effects were prolonged erections in 24 patients in diagnostic use and in 3 patients in therapeutic use. There were treated easily without further consequences.

Dose-Response Relationship, Drug↗

PubMed2006

Penile prosthetic surgery and its role in the treatment of end-stage erectile dysfunction - an update.

The treatment of erectile dysfunction has been revolutionised with the introduction of orally active phosphodiesterase inhibitors which are successful in 70-80% of men. However, there remain a group of men in whom conservative treatment fails and surgical insertion of a penile prosthesis is required. This type of surgery has in the past been associated with technical difficulties and a high complication rate. This has spurred numerous developments in prosthesis design and surgical technique with the field changing at a rapid pace. Perhaps the most significant is the use of antimicrobial coatings on prostheses that have been shown to reduce the infection rate significantly. This review highlights those developments reported in the last 5 years.

Erectile Dysfunction↗

PubMed2004

Specific aspects of erectile dysfunction in sexology.

The sexology of erectile dysfunction (ED) is approached from a perspective that integrates medical, psychological, and social aspects. This article reviews the clinical intervention in sexology beginning with the diagnostic evaluation, where the organic and psychological factors (predisposing, precipitating, and perpetuating) contributing to ED are determined. A description of the differential diagnosis process follows, which establishes the relevance of organic factors in order to organize therapeutic strategies. There are three possible treatment processes: psychological intervention with the patient, intervention on the partner relationship, or intervention with the partner. Referral criteria are also described, such as when patients with ED should be referred to a sexologist, and to whom sexologists should refer patients with ED.

Diagnosis, Differential↗

PubMed2000

Diagnosis and treatment of erectile dysfunction: the process of care model.

The new era of erectile dysfunction (ED) medicine ushered in by the availability of an effective and safe oral medication paves the way toward managing ED in a primary care setting. The Process of Care Model for the Evaluation and Treatment of Erectile Dysfunction was developed to advance new guidelines for the diagnosis and management of ED. This paper discusses these guidelines.

Erectile Dysfunction↗

PubMed2006

Doppler evaluation of erectile dysfunction - part 2.

Doppler evaluation in erectile dysfunction (ED) has a significant role in determining the cause of ED. The advantages of penile Doppler and pharmacologic duplex ultrasonography include objective, minimally invasive evaluation of penile hemodynamics at a relatively low cost. Arteriogenic ED may be secondary to peripheral vascular disease and diabetes, or may be seen in association with coronary artery disease. Various parameters, such as diameter of the cavernosal artery, peak systolic flow velocity, degree of arterial dilatation and acceleration time, have been suggested for the diagnosis of arteriogenic ED, but peak systolic flow velocity is the most accurate indicator of arterial disease. This second part of the review article describes the various causes of ED and the interpretation and evaluation of color flow Doppler examination in ED.

Erectile Dysfunction↗

PubMedDate not supplied

[Sildenafil and alprostadil in the combined drug therapy of erectile dysfunction].

Forty-four patients with erectile dysfunction (ED) aged 21-72 years aged 21-72 years (mean age 61 years) were examined and treated with sildenafil and alprostadil monotherapy or combined therapy. ED was psychogenic in 9(20.5%), arterial in 12(27.2%), vein occlusive in 9(20.5%) and neurogenic in 14(31.8%) patients. Monotherapy was most effective in psychogenic ED (alprostadil--100%, sildenafil--88.9%), least effective in vein occlusive ED (alprostadil--33.3%, sildenafil--22.2%). Alprostadil was more effective in arterial and neurogenic ED (83.3 vs 66.7 and 78.6 vs 57.1%, respectively). Combination of the two drugs produced much high response: 100, 85.7 and 55.5% in arterial, neurogenic and vein occlusive ED, respectively. Thus, combined treatment with sildenafil and alprostadil is a method of choice in the treatment of ED in failure of monotherapy with these drugs or in vein occlusive ED. In the combined treatment dose of the drugs, number of side effects and cost of therapy are lower.

Adult↗

PubMed1992

Noninvasive treatment for erectile dysfunction in the neurogenically disabled population.

Erectile dysfunction is the most prevalent sexual dysfunction in neurogenically disabled men. Studies of rehabilitation patients indicate that the restoration of sexual functioning is considered an important priority. This article reports on a pilot study of vacuum tumescence constriction therapy as a noninvasive method for use by a population with traumatic or nontraumatic neurologic disorders such as spinal cord injury, stroke, multiple sclerosis, and diabetes mellitus. Of the 30 patients who participated in the study, 17 purchased the device and over 50% of them reported using the device on a long-term basis. Frequency of coitus increased from 0.3/wk to 1.5/wk. Included in the study are methods used by patients to integrate the device into their sex life, the role of the patient's partner in the decision to purchase the device, and the rate of partner satisfaction. There were no reports of substantial morbidity. Thus, this method shows promise as a noninvasive treatment for men who are moderately to severely neurogenically disabled.

Equipment and Supplies↗

PubMed2003

Viability and safety of combination drug therapies for erectile dysfunction.

PURPOSE: In some patients with erectile dysfunction (ED) oral, topical or intracavernous drug therapy fails. However, several classes of drugs demonstrate efficacy for ED, creating the potential for pharmacological combinations preferable to implantation of a penile prosthesis. MATERIALS AND METHODS: Preliminary reports suggest that combining oral, topical or intracavernous drugs may salvage patients in whom monotherapy fails. RESULTS: Agents that lead to activation or increases in cyclic nucleotides (cyclic adenosine monophosphate and guanosine monophosphate) with or without nitric oxide donors or nitrates, or alpha-adrenergic antagonists have been used to treat ED. The phosphodiesterase-5 inhibitor sildenafil has been combined with alprostadil (prostaglandin E1) and administered by either the intraurethral or intracavernous route. Successful intercourse following this combination varies from 47% to 100% when monotherapy with each has failed. The introduction of apomorphine has led to its unapproved use in combination with sildenafil in Europe. Combination strategies may allow lower drug doses and reduced adverse effects. CONCLUSIONS: The encouraging preliminary observations combined with the potential for adverse events provide a scientific rationale for prospective, randomized clinical trials with adequate numbers of subjects.

Alprostadil↗

PubMed1994

Communication patterns in patients with erectile dysfunction and their partners.

Patients with erectile dysfunction (ED) and their partners (n = 18) were compared on perceived distress caused by the ED, attribution of responsibility for the ED and marital communication. Comparisons were also made between couples in whom the ED was organically based versus those in whom it was psychogenically based. No differences were found between organic versus psychogenic ED couples on perceived distress, attributions, or marital communication skills. Patients and partners differed on communication (P < 0.001), attributions (P < 0.001) and perceptions of distress experienced by their spouse (P < 0.001). However, both members of the couple found the ED equally distressing. Partners tended to attribute more responsibility for the ED to themselves when they believed it was psychogenic (P < 0.001), while patients claimed sole responsibility regardless of their perceptions of its etiology. Patients had clinically problematic communication scores (P < 0.001), while partners did not. Contrary to initial hypotheses, communication scores did not predict agreement/disagreement between patients and partners on perceived etiology, attributions or distress. Discussion is focused on the need for therapy to address couples' communication specific to sexual activity and the effects of the ED.

Communication↗

PubMed2000

The treatment of hypertension in patients with erectile dysfunction.

Hypertension is another predictor of erectile dysfunction (ED). This is further evidence supporting a link between the pathogenesis of atherosclerotic disease and ED. In one study (TOMHS) involving hypertensive patients, the incidence of ED was 14.4%. The drugs used to treat hypertension may cause ED. However, there is little trial-based evidence to indicate which drugs are more likely to cause this side effect. In general, thiazide diuretics and beta-blockers seem to cause ED more often. In contrast, the alpha-blocker, doxazosin, has not been associated with an increased incidence of ED as a side effect. Doxazosin also improves urinary flow in patients with benign prostatic hyperplasia (BPH). This condition is common in elderly men as is hypertension and ED. Therefore, doxazosin may present a special advantage among this group of patients. This alpha-blocker would also be a good choice in patients with impaired glucose tolerance/diabetes because it improves insulin sensitivity. Moreover, ED and hypertension are more prevalent among diabetics. On a more speculative note, doxazosin may potentiate the therapeutic impact of specific treatments for ED.

Antihypertensive Agents↗

PubMed1996

Erectile dysfunction in hypertensive subjects. Assessment of potential determinants.

Hypertension is often cited as a risk factor for erectile dysfunction. To clarify the relation between hypertension and erectile dysfunction, we evaluated 32 consecutive hypertensive and 78 normotensive impotent men with respect to multiple potential determinants and parameters of erectile function, including medical and sexual history, depression, hormonal profile, penile nocturnal tumescence, penile vascular supply, and pudendal nerve conduction. The hypertensive men were older, had higher body mass index, and used more medications than the normotensive men. The groups were not different with respect to the prevalence of smoking and peripheral vascular disease, but the hypertensive men had a marginally higher rate of ischemic heart disease (P = .06). The prevalence of depression, abnormal nocturnal penile tumescence, anomalous pudendal nerve conduction, and impairment in arterial supply as determined by penile brachial index were similar in the two groups. Testosterone and bioavailable testosterone levels were lower in the hypertensive men. After stratification by age and body mass index, hypertensive men younger than 50 years with body mass index less than 30 kg/m2 had significantly lower testosterone levels (12.0 +/- 1.7 versus 21.3 +/- 1.4 nmol/L, P < .02) but not bioavailable testosterone levels (3.9 +/- 0.7 versus 6.4 +/- 0.7 nmol/L, P < .17) than the corresponding normotensive group. Prolactin, follicle-stimulating hormone, and luteinizing hormone levels of the two groups were not significantly different. Contrary to common belief and with the exception of lower circulating testosterone levels, the overall analysis showed little difference between hypertensive and normotensive men with respect to a wide range of classic determinants of erectile function. Direct study of the local vascular erectile apparatus appears necessary for further elucidation of the mechanisms underlying erectile dysfunction in hypertensive men.

Adult↗

PubMed2001

Relaxation degree: a new concept in erectile dysfunction.

PURPOSE: To investigate the clinical application of the new parameter' Relaxation Degree. PATIENTS AND METHODS: Chart reviews of 150 patients were evaluated retrospectively of whom 96 had been diagnosed as pure cavernoocclusive dysfunction (COD) by using corpus cavernosum electromyography (CC-EMG) and cavernosometry and of whom 54 had been diagnosed as psychogenic erectile dysfunction by normal CC-EMG; cavernosometry and pulse doppler scanning. Relaxation degree was defined as the percent decrease in the amplitudes of the electrical activity of corpus cavernosum (EACC). RESULTS: Mean relaxation degree measurements were found as 66.5%, 66.28% and 16% in minimal, moderate and severe COD groups respectively. This value was 80% in psychogenic erectile dysfunction group. Statistical comparisons were found significant between minimal and severe and moderate and severe COD groups. All three organic erectile dysfunction groups were also compared with psychogenic erectile dysfunction group where differences were found significant. If the normal relaxation degree was accepted as more than 80%, COD could be diagnosed with 93% specificity and 98% sensitivity without performing cavernosometry. CONCLUSION: Relaxation degree parameter could be used in diagnosis of COD showing the percent relaxation ability of the cavernous smooth muscle as a non invasive method when compared with cavernosometry.

Adult↗

PubMed2000

Integrating erectile dysfunction treatment into primary care practice.

Erectile dysfunction (ED) is a highly prevalent medical disorder. Nearly 1 of 3 men in the United States between the ages of 18 and 59 years report dissatisfaction with some aspect of their sexual function. These problems contribute to anxiety, depression, loss of self-esteem, and diminished quality of life. The availability of sildenafil, the first safe and effective oral agent for ED, has greatly increased the number of men seeking treatment and shifted much of the management of ED to primary care physicians. As a result, primary care physicians now need to add questions about sexual functioning and satisfaction with sex to their initial patient workups. Patients with ED can be treated by the primary care physician or referred to mental health professionals, endocrinologists, urologists, or sex therapists, depending on the problem presented. First-line treatments that can be easily prescribed and recommended by primary care clinicians include sildenafil, counseling, lifestyle changes, medication changes, and vacuum-constriction devices. The responsibilities of treating patients with ED include educating the patient about sexually transmitted diseases, providing general sex education and counseling to the patient and his partner, and providing a treatment that is appropriate for the cause of the problem. The rewards of treatment will be a happier and more functional patient, an enhanced physician-patient relationship, and great professional satisfaction.

Erectile Dysfunction↗