Practical Guidelines for the Treatment of Erectile Dysfunction and Peyronie´s Disease

Erectile Dysfunction

Introduction

Erectile dysfunction (ED) is defined as persistent inability to attain and/or maintain an erection sufficient for sexual performance.1,2 It is assumed that 5–20% of men complain of moderate to severe ED3; common risk factors are very similar to risk factors of cardiovascular disease and include smoking, hypertension, diabetes, lipidemia, atherosclerosis, and pelvic surgery.2,4 The introduction of oral drugs has revolutionized the medical treatment of ED; successful intercourse can be achieved with inhibitors of phosphodiesterase 5 (PDE-5) such as sildenafil, tadalafil, and vardenafil in about 75% of patients suffering from ED.5 However, a considerable amount of men does not respond to PDE-5 inhibitors, particularly patients with diabetes mellitus (DM) or patients having undergone radical prostatectomy. This chapter aims to present a pragmatic approach for the clinical diagnosis and therapy of ED, based on available literature, particularly the guidelines of the European Association of Urology,6 the American Urological Association7 as well as the British Society for Sexual Medicine,5 and on current research and clinical practice.

Diagnosis

Diagnostic steps of patients presenting with ED contain basic tests, which are recommended in all patients, optional and specialized evaluations that should be tailored to the individual patient´s profile.

Basic Evaluation

It is crucial to obtain a thorough medical, sexual and psychosocial history, physical examination, and focused laboratory tests.A detailed patient´s history evaluates the presence of risk factors such as hypertension, diabetes mellitus, myocardial disease,lipidemia,hypercholesterolemia, renal insufficiency, hypogonadism, and neurologic and psychiatric disorders.8 If possible, the partner should be included. Predisposing, precipitating, and maintaining factors should be obtained (Table 28.1) as well as a detailed description of the quality of morning and erotic or masturbation-induced erections, in terms of rigidity and duration, as well as arousal, ejaculation, and orgasmic problems. Lower urinary tract symptoms and genitourinary (mainly radical prostatectomy) and rectal surgery, as well as many drugs, particularly antihypertensive and psychotropic drugs may cause ED.9-11 The chronic use of alcohol, marijuana, codeine,

lack of sexual knowledge Poor past sexual experience relationship problems religious or cultural beliefs restrictive upbringing

Unclear sexual or gender preference Previous sexual abuse

other sexual problems in the man or his partner

drugs

new relationship

acute relationship problems

Family or social pressures

Pregnancy and childbirth

other major life events

Partner’s menopause

acute physical or mental health problems

lack of knowledge about normal changes of aging

other sexual problems in the man or his partner

drugs

relationship problems

Poor communication between partners

lack of knowledge about treatment options

ongoing physical or mental health problems

other sexual problems in the man or his partner

drugs

meperidine, methadone, and heroin is also associated with a high percentage of ED.12

The use of validated questionnaires, such as the International Index for Erectile Function (IIEF), may be helpful to assess all sexual function domains (erectile function, orgasmic function, sexual desire, ejaculation, intercourse, and overall satisfaction) and also the impact of a specific treatment modality (Grade C – level IV).13

A focused physical examination must be performed on every patient,with particular emphasis on the genitourinary, endocrine, vascular, and neurologic systems. All patients should have a focused physical examination. A genital examination is recommended to detect a history of rapid onset of pain, deviation of the penis during tumescence, the symptoms of hypogonadism, or other urological symptoms (past or present). A digital rectal examination of the prostate is not mandatory in ED but should be conducted in the presence of genitourinary or protracted secondary ejaculatory symptoms. Blood pressure, heart rate, waist circumference, and weight should be measured14 (Grade C – level IV).

Laboratory testing must be tailored to the patient’s complaints and risk factors.All patients must undergo a fasting glucose and lipid profile if not assessed in the previous 12 months to rule out diabetes and hyperlipidemia. Hormonal

testing must include a morning sample of total testosterone (bioavailable or calculated-free testosterone is more reliable to establish the presence of hypogonadism, i.e., these tests are preferable to total testosterone if available). Additional hormonal tests (e.g., prolactin, folli- cle-stimulating hormone [FSH], luteinizing hormone [LH]) must be carried out when low testosterone levels are detected (Grade B – level IIa). If any abnormality is observed, further investigation by referral to another specialist may be necessary.10 Minimal diagnostic evaluation (basic workup) in patients with ED is presented in Fig. 28.1. Serum prostate-specific antigen should be considered if clinically indicated. It should certainly be measured before commencing testosterone and at regular intervals during testosterone therapy (Grade C – level IV).

Cardiovascular System and Sexual Activity

Coronary heart disease (CHD) shares many risk factors with ED15 since endothelial dysfunction and atherosclerosis affect both coronary arteries and penile vasculature. ED often precedes coronary artery disease.16 Guidelines for the management of ED in patients with cardiovascular disease have been developed by the Princeton Consensus Panel.17 Patients with ED

Figure 28.1. minimal diagnostic evaluation for patients with erectile dysfunction (ED). IIEF international index for Erectile Function, CV cardiovascular (reprinted from 6. copyright 2006, with permission from Elsevier).

Patient with erectile dysfunction (self-reported)

Medical and psychosexual history (use of validated instruments, e.g., IIEF)

Glucose - Lipid profile (if not assessed in the last 12 months)

Total testosterone (morning sample) If available: bio-available or free testosterone (instead of total)

requiring initiating or resuming sexual activity are stratified into three risk categories based on their cardiovascular risk factors. High-risk patients are defined as those with unstable or refractory angina; uncontrolled hypertension; left ventricular dysfunction/congestive heart failure (CHF; New York Heart Association class II); MI or a cardiovascular accident within the previous 2 weeks; high-risk arrhythmias; hypertrophic obstructive and other cardiomyopathies; or moderate-to-severe valvular disease. It is recommended that patients at high risk should not receive treatment for sexual dysfunction until their cardiac condition has stabilized. Patients at low risk may be considered for all first-line therapies. The majority of patients treated for ED are in the low-risk category defined as those who have asymptomatic coronary artery disease and less than three risk factors for coronary artery disease (excluding gender); controlled hypertension; mild, stable angina; a successful coronary revascularization; uncomplicated past MI; mild valvular disease; or CHF (left ventricular dysfunction and/or New York Heart Association class I). Patients whose risk is indeterminate should undergo further evaluation by a cardiologist before receiving therapies for sexual dysfunction. The vast majority of men with CHD can safely

resume sexual activity and use ED therapies.18 Education and appropriate counseling about sex should be given to all men with CHD. There is currently no proof that licensed treatments for ED increase the cardiovascular risk in patients with or without previously diagnosed cardiovascular disease (Grade A – level Ia5) (Fig. 28.2).

Optional Tests

Even though most patients do not require further investigations, in certain circumstances, specific test may be required.In order to analyze the etiology of erectile dysfunction, appropriate assessments have to be conducted (Grade C – level IV). Other indications for special investigations include: young patients who have always had difficulty in obtaining and/or sustaining an erection, patients with a history of trauma, if an abnormality of the testes or penis is found on examination, and nonresponders to medical therapy potentially needing surgical treatment.5-7

Nocturnal penile tumescence and rigidity assessments measure natural nocturnal and early awakening erections, which are normal physiological events. With the Intracavernous Injection (ICI) test, penile rigidity is evaluated 10 min after injection of prostaglandin E1 into