- •Series Editor Foreword
- •Preface
- •Contents
- •Contributors
- •Differential Diagnosis
- •Evaluation
- •Treatment
- •Discussion
- •References
- •Background
- •Normal Pubertal Stages
- •Differential Diagnosis of Precocious Puberty
- •Evaluation [1, 3, 4]
- •Treatment [1, 2]
- •Discussion
- •References
- •Background
- •Differential Diagnosis of Delayed Puberty
- •Evaluation
- •History and Physical Examination
- •Laboratory Investigation and Imaging
- •Treatment
- •Discussion
- •Suggested Readings
- •Discussion
- •Differential Diagnosis
- •References
- •Discussion
- •References
- •Differential Diagnosis
- •Evaluation
- •Treatment
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •Interpretation of Thyroid Function Tests (TFTs)
- •Iodine Supplementation for Pregnancy and Lactation
- •Screening for Maternal Hypothyroidism
- •Maternal Subclinical Hypothyroidism
- •Thyroid Autoimmunity
- •Maternal Hyperthyroidism: Diagnosis
- •Maternal Hyperthyroidism: Treatment
- •Postpartum Thyroiditis
- •Summary
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •Intrauterine Pathology
- •Thin Lining
- •Endometrial Receptivity Analysis (ERA)
- •Chronic Endometritis
- •Conclusion
- •References
- •Discussion
- •References
- •Discussion
- •History
- •Physical Exam
- •Semen Analysis
- •Laboratory Testing
- •Genetic Testing
- •Adjunctive Tests
- •Imaging
- •References
- •Discussion
- •Pathophysiology
- •Evaluation
- •Treatment
- •Lifestyle Changes
- •Medications
- •Phosphodiesterase 5 Inhibitors
- •Vacuum Erection Device
- •Intraurethral Alprostadil
- •Intracavernosal Injections
- •Surgery
- •References
- •Discussion
- •History
- •Semen Analysis
- •Physical Examination
- •Proper Varicocele Examination
- •Laboratory Investigations
- •Additional Investigations for the Pain Include
- •Other Investigations for Infertility in the Context of Varicoceles
- •Treatment
- •Indications for Varicocele Treatment Include the Following
- •Numerous Treatments for Varicocele Exist
- •References
- •Discussion
- •Semen Analysis
- •History and Physical Examination
- •Laboratory Investigations
- •Testicular Biopsy
- •Treatment
- •Surgical Techniques for Sperm Retrieval [13]
- •Fresh Vs. Frozen Sperm
- •Counseling
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Background
- •Epidemiology
- •Evaluation
- •Treatment
- •Non-ART Treatment
- •Accelerated Utilization of ART
- •ART Success Rates
- •Recent Trends in ART
- •Discussion
- •Conclusion
- •Suggested Readings
- •Evaluation
- •Differential Diagnosis
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •Suggested Readings
- •Diagnosis
- •Management
- •Discussion
- •References
- •Index
24 Erectile Dysfunction |
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Medications
Phosphodiesterase 5 Inhibitors
Oral PDE5i medications act to inhibit the actions of PDE type 5, the enzyme responsible for cGMP breakdown in the corpora cavernosa. Inhibition of PDE5 results in continued smooth muscle relaxation and engorgement of the cavernosa with blood. There are various PDE5i medications, all with different speed of onset and varying half-lives, allowing the use of different PDE5i for men with differing sexual habits. For example, low-dose (5 mg tablet) tadala l can be taken on a daily basis, allowing men to be more spontaneous in sexual encounters. On the other hand, sildena l can be taken 1 h prior to sexual activity and allow for an 8-h window of opportunity for sex. FDA-approved PDE5i medications include sildena l, vardena l, tadala l, and avana l.
PDE5i are generally well-tolerated; however, relatively common sides effects include headache, fushing, dyspepsia, nasal congestion or rhinitis, and myalgias (mostly with tadala l). Priapism, or erection lasting longer than 4 h, is an extremely rare side effect of PDE5i. There are several absolute and relative contraindications to taking PDE5i. Absolute contraindications include the use of nitrate-containing medications, as the concomitant administration of PDE5i and nitrates can result in life-threatening hypotension. Men with signi cant cardiovascular comorbidities, including recent serious cardiovascular events, uncontrolled hypertension, or unstable angina, should rst be evaluated by a cardiologist prior to initiation of PDE5i for treatment of ED.
Vacuum Erection Device
Vacuum erection or constriction devices (VED/VCD) are non-medicinal, non- surgical means to obtain an erection. A plastic cylinder is placed over a lubricated, faccid penis until the end of the cylinder is tightly t against the abdominal wall. A vacuum is generated within the cylinder using a pump, which engorges the penis with venous blood, and an erection is produced [3]. To maintain the erection, a constriction band is placed at the base of the penis, and can be left in place for a maximum of 30 min. Although reports have described VED/VCD to be an effective means to achieve erection, numerous unfavorable side effects often deter men with ED from using the device. These side effects include coldness or numbness around the penis, bruising, pivoting at the base of the penis, pain or discomfort from the device or constriction band, and decreased ability to orgasm [3]. The use of VED also requires good manual dexterity to use the device appropriately.
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Intraurethral Alprostadil
Alprostadil (prostaglandin E1) can be administered as an intraurethral suppository and has been found to be effective in approximately 40% of men with ED of various etiologies [3]. The medication is absorbed by the cavernosal tissue through vascular communication within the corpus spongiosum. Patients are taught how to insert the suppository in the clinic so that any occurrence of adverse side effects, such as urethral bleeding, vasovagal refex, hypotension, and priapism (rare), can be monitored. Dosing typically starts at 500 μg and can be titrated to 1000 μf depending on the patient’s response. The most common side effect of medication administration is urethral discomfort or pain.
Intracavernosal Injections
ICI can be performed if patients fail other ED medications. The bene t of ICI is that there is generally a high rate of ef cacy and a low rate of side effects. Importantly, nerve function is not required for ICI to be ef cacious; however, the cavernosal smooth muscle must be healthy and intact for ICI to work. Currently, different formulations of ICI available for use include prostaglandin E1 monotherapy (alprostadil), bimix (a combination of papaverine and phentolamine), trimix (a combination of papaverine, phentolamine, and prostaglandin E1), and quadmix (a combination of papaverine, phentolamine, prostaglandin E1, and atropine). There is an approximate 60% ef cacy rate with prostaglandin E1 therapy alone, compared with an approximate 80% ef cacy rate with trimix therapy in the same treatment group [4]. Failure of ICI is typically associated with collagenization of the cavernosal smooth muscle, which then results in venous leak and failure of medications including ICI. The main adverse effect of ICI is the development of ischemic priapism, or an erection lasting longer than 4 h that is not related to sexual stimulation and can occur even after orgasm or ejaculation. Ischemic priapism is a dangerous condition that requires urgent action because although an erection is occurring, no oxygenated blood is reaching the cavernosal smooth muscle, which can lead to irreversible changes and ultimately erectile dysfunction. Men being initiated on ICI should be taught proper injection technique prior to use.
Surgery
Penile implant surgery is typically reserved for patients who fail to achieve adequate erectile function with rstor second-line treatment options for ED. However, after appropriate counseling, patients who do not wish to pursue second-line options can opt for a penile implant. There are various types of penile implants, with 3-piece infatable implants being the most commonly placed. With appropriate preoperative counseling of postoperative expectations, satisfaction rates after penile implant surgery are high (typically greater than 95%) due to the fact that these devices are
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