Nonpharmacologic treatment of erectile dysfunction

Nonpharmacologic treatment for erectile dysfunction (ED) includes sex therapy, the use of vacuum erection devices, penile prosthesis implantation, and penile vascular surgery. Sex therapy is indicated for psychogenic ED and is at times a useful adjunct for other treatments in men with mixed psychogenic and organic ED. Vacuum erection devices produce usable erections in over 90% of patients; however, patient and partner acceptability is an issue. Three-piece inflatable penile prostheses create flaccidity and an erection that comes close to that which occurs naturally. Penile vascular surgery has shown greatest efficacy in young men with vasculogenic ED resulting from pelvic or perineal trauma.     

Macrostructural alterations of subcortical grey matter in psychogenic erectile dysfunction

Psychogenic erectile dysfunction (ED) has been defined as the persistent inability to attain and maintain an erection sufficient to permit sexual performance. It shows a high incidence and prevalence among men, with a significant impact on the quality of life. Few neuroimaging studies have investigated the cerebral basis of erectile dysfunctions observing the role played by prefrontal, cingulate, and parietal cortices during erotic stimulation. In spite of the well-known involvement of subcortical regions such as hypothalamus and caudate nucleus in male sexual response, and the key role of nucleus accumbens in pleasure and reward, poor attention was paid to their role in male sexual dysfunction. In this study, we determined the presence of grey matter (GM) atrophy patterns in subcortical structures such as amygdala, hippocampus, nucleus accumbens, caudate nucleus, putamen, pallidum, thalamus, and hypothalamus in patients with psychogenic ED and healthy men. After Rigiscan evaluation, urological, general medical, metabolic and hormonal, psychological and psychiatric assessment, 17 outpatients with psychogenic ED and 25 healthy controls were recruited for structural MRI session. Significant GM atrophy of nucleus accumbens was observed bilaterally in patients with respect to controls. Shape analysis showed that this atrophy was located in the left medial-anterior and posterior portion of accumbens. Left nucleus accumbens volumes in patients correlated with low erectile functioning as measured by IIEF-5 (International Index of Erectile Function). In addition, a GM atrophy of left hypothalamus was also observed. Our results suggest that atrophy of nucleus accumbens plays an important role in psychogenic erectile dysfunction. We believe that this change can influence the motivation-related component of sexual behavior. Our findings help to elucidate a neural basis of psychogenic erectile dysfunction.     

Erectile dysfunction in patients with cardiovascular disease

Erectile dysfunction is a highly prevalent disease, especially in cardiovascular-compromised men. Many of the well-established risk factors for cardiovascular disease are also risk factors for erectile dysfunction. A correlation between erectile dysfunction and endothelial dysfunction is well established. It is postulated that erectile dysfunction with an arteriovascular aetiology can predate and be an indicator of potential coronary artery disease. In this paper we will attempt to increase awareness among cardiologists for the predictive value of erectile dysfunction for future cardiovascular disease in order to optimise cardiovascular risk management. The treatment of erectile dysfunction and cardiovascular interactions is also discussed in detail.     

Hypothèse de parcours diagnostique du déficit érectile à la lumière de connaissances récentes sur l’anatomo-physiologie de l’érection et sur la thérapie des troubles érectiles

Nowadays the diagnosis of erectile disfunction is based on a wide range of clinical and instrumental investigations in order to obtain specific and detailed information on the pathogenesis of this syndrome, but at same time these investigations are useless to know much about the aetiology. Therefore the erectile failure must be related to organic and psychological causes always detected in each patient. Sixty-six men complaining of erectile failure were evaluated with nocturnal penile activity registration (NPT), echo-color-doppler (ECD) and dynamic infusion cavernosometry (FCM) and the reports were, even empirically, compared. This study pointed-out that the nocturnal rigidity is not reliable either to differentiate between erection trouble having a psychogenic or organic origin, or in anticipating the therapeutic response. Furthermore, the records of instrumental investigations (NPT, ECD, FMC) failed to point-out the aetiology of erectile failure. Therefore, in our opinion, the main goal of the andrologist should be the prompt control of the symptom and we propose an early assessment of the patient by means of medical history, physical examination, hormonal assays, intracavernous injection of vasoactive drug, and nocturnal activity monitoring. Further investigations, including ECD and FCM, should be performed in non respondent patients or when surgical therapy is indicated.     

Topical treatment of erectile dysfunction: randomised double blind placebo controlled trial of cream containing aminophylline,isosorbide dinitrate,and co-dergocrine mesylate.

OBJECTIVE--To examine the effectiveness in treating impotence to topically applied cream containing three vasodilators--aminophylline, isosorbide dinitrate, and co-dergocrine mesylate--which act by different mechanisms. DESIGN--Randomised double blinded placebo controlled crossover trial over two weeks. SUBJECTS--36 men with erectile dysfunction randomly allocated to two equal groups. INTERVENTIONS--Active cream containing aminophylline 3%, isosorbide dinitrate 0.25%, and co-dergocrine mesylate 0.05% for one week and placebo for another. MAIN OUTCOME MEASURES--Patients'' reported experience of penile responses and side effects of treatment in questionnaires. Penile tumescence and arterial flow in the laboratory. RESULTS--21 patients reported full erection and satisfactory intercourse with the active cream. Three men reported full erection and satisfactory intercourse with either cream. The active cream was more effective in psychogenic than organic impotence (eight out of nine men with psychogenic impotence achieved a full erection upsilon four out of eight with neurogenic impotence and two out of seven with arterial insufficiency). No major side effects were reported. In the laboratory the active cream increased penile arterial flow (0.19 (SD 0.08) m/s upsilon 0.02 (0.15) m/s with placebo) and induced tumescence in 24 patients. CONCLUSIONS--Topical treatment with a cream containing three different vasodilators might be considered before intracavernous injection of vasoactive agents, particularly in psychogenic impotence.     

Epidémiologie de la dysfonction érectile (2ème partie). Facteurs de risque

Epidemiological studies in the general population or target populations in several countries in the world have revealed a large number of risk factors for erectile dysfunction: diabetes mellitus, hypertension, smoking, dyslipidaemia, cardiovascular diseases, psychological disorders, certain medications, chronic renal failure, socioeconomic factors and lifestyle, obesity, lower urinary tract symptoms, poor health and bicycling. Cardiovascular risk factors are predictors of erectile dysfunction and erectile dysfunction is now considered to be a manifestation of vascular disease. Further studies are necessary to establish the pathophysiological mechanisms of certain risk factors and the possible value of preventive measures.     

Pharmaco-écho-doppler pénien: méthodologie, critères diagnostiques et indications actuelles dans l’exploration d’une dysfonction érectile

Erectile dysfunction (ED) is a common multifactorial disease, whose organic or mixed origin is currently considered as dominant in men aged 50 years and older. Most ED classified as arterial are linked to endothelial dysfunction in relation to the key factors of cardiovascular risk. ED is an indicator of vascular health in general. It is also a predictor of cardiovascular events, including coronary heart disease. It has also been associated with lower peripheral arterial disease and stroke. The penile doppler ultrasound examination is actually used relatively infrequently in the management of ED, the etiologic factors being considered most often not necessary for the therapeutic management, but also because of the absence of standardization. Nonetheless, large recent studies have shown that the vascular nature of ED, basis on doppler parameters recorded after intracavernous injection of vasoactive drugs, strengthened the predictive value of ED on events and cardiovascular mortality, justifying a highest interest in this test.     

Blessé médullaire: prise en charge en andrologie

Sexual reactions are under neurological control. Spinal cord trauma alters neurological structure and induces sexual dysfunction. Pharmacological drugs used currently allow erectile function to be recovered in spinal cord-injured men, an essential step towards the resumption of a sex life. Triggering of ejaculation is often difficult. Perineal stimulation techniques, used either in isolation or in association with pharmacological treatment, promote ejaculation and allow sperm collection and freezing. The possibility of achieving ejaculation during sexual intercourse in spinal cord-injured men remains rare and there is as yet no real therapy available. Despite poor semen quality, spinal cord-injured men maintain reproductive possibilities in 40 to 60% of couples. The use of assisted reproductive technologies is often required. Management of sexual dysfunction in spinal cord-injured men must be integrated into a rehabilitation and re-insertion programme.     

Les problemes d'erection: une souffrance encore trop souvent cachee

Many epidemiological studies have demonstrated the high prevalence of erectile dysfunction, particularly among aging males and patients with chronic diseases. Many of these studies, using an objective methodology, showed that this problem induces major suffering for the patient and his partner. This suffering results less from loss of sexual pleasure than from loss of self-esteem, humiliation or guilt of being “impotent”, and from the consequences on the relationship of the patient's modified personality and attitudes (introversion, irritability, avoidance of tenderness and intimacy). These problems are also worsened by the female partner, who questions her own femininity, related, to confusion between loss of erection and lack of desire. The impact of erectile dysfunction extends well beyond sexual function, as it constitutes a real identity problem for the man, affecting his relational and work life (loss of dynamism and self-confidence). Many objective studies have demonstrated significant improvement of various quality of life parameters after effective treatment of erectile problems with intracavernosal injections or tablets They also have shown significant improvement of global quality of life (and not only sexual quality of life) and many psychological parameters (anxiety, depression, self-confidence in sexual and marital relationships and social and work life, hostility and interrelational sensitivity). Global health indices are also improved. Despite the suffering due to erectile problems, and the fact these problems can be effectively treated, few men mention these problems to their general practitioner. Many surveys, estimate between 5 and 30% the percentage of men with erectile dysfunction seeking medical attention, although they also reveal that a higher proportion would like to be helped. Because of religious and sociocultural taboos and their shame and fear of being judged or that their problem will be revealed, men are embarrassed to raise this question. Other causes are also involved in this phenomenon: fear that their request will be rejected by the doctor, or the belief that no treatments are available for this type of problem, or that they have to accept this problem as an inevitable part of physiological aging. Surveys confirm that patients would like their doctor to question them about their sexual functioning. This appears to be all the more desirable in that erectile problems are often due to endothelial dysfunction with may also affect other vessels such as coronary arteries. The diagnosis of these disorders could help to identify and correct the risks factors responsible for both types of this disease.     

Erectile Dysfunction and Essential Hypertension: The Same Aging-related Disorder?

An erection is a mechanical event dependent primarily on corporeal vascular dynamics wherein arterial inflow and storage of blood within the corpora is greater than the egress of blood from the corpora. The most common cause of erectile dysfunction (ED) is the inability of the corporal tissue to store the blood within the corporal sinusoids once inflow into the corpora begins. This failure to store is primarily due to a corporal smooth muscle dysfunction and, in most men, is most likely an aging-related occurrence. Because the corporal smooth muscle is embryologically and physiologically indistinguishable from the smooth muscle within our arterial system, the authors hypothesize that the aging-related dysfunction that occurs within the penis also occurs within the arterial system, and that this smooth muscle dysfunction within the arterial media is most likely the cause of what is called essential hypertension. This panvascular smooth muscle myopathy could explain why hypertension is the most common comorbidity associated with ED and appears to indicate that both ED and essential hypertension are the same disorder, albeit in two different organ systems.Key words: Erection, Endothelium, Smooth muscle, HypertensionAlmost all men recognize at some time in their lives that their erectile function begins to change. For most men, the ability to attain and maintain an erection during the teenage years is second nature. However, by the time men hit the fourth and fifth decade of life, many have recognized that their erectile function has changed, and the ability to maintain an erection during sex has diminished; the refractory period, the time in between erectile events, begins to increase. Although men in their teenage years and young adult lives are able to have multiple erectile events at will, this ability begins to fade as aging sets in. Because the ability to maintain an erection is directly related to the function of the corporal smooth muscle, this increase in the refractory period is a clinical sign that the smooth muscle of the corpora is likely becoming dysfunctional. This review highlights what we know about the corporal smooth muscle cell and demonstrates that what occurs to the corporal smooth muscle cell also occurs to its embryologic sibling, the smooth muscle cell within the media of the peripheral vascular system. As a result of this relationship, changes in the function of the penis can reflect changes in the vascular system.     

Future strategies for treating erectile dysfunction

Erectile dysfunction affects over half of all men between 50 and 70 years of age, and by the age of 40, about 40% of men may suffer from some form of erectile dysfunction. Many disease states, such as diabetes, hypertension, depression, and vascular disease, are associated with the condition, which may occur many years prior to the onset of these disorders. The phenomenal success of sildenafil in improving erections in men with erectile dysfunction is due to the fact that the drug, as a phosphodiesterase inhibitor, improves the relaxation of smooth muscle cells, which become dysfunctional with the aging process. However, not everyone responds to this medication, mainly because the efficacy of the drug is directly dependent on the release of nitric oxide from the nerve terminals of the cavernosal nerve, and this may become defective with aging/certain disease states. The goal of gene therapy for organic impotence is to allow the patient to sustain physiologically elicited erections without resorting to pharmacological treatment immediately prior to the sexual act. Experimental efforts in gene therapy for erectile dysfunction are likely to continue intensively in a series of directions, some specific to the nature of the selected gene to be manipulated or the physiology of the corpora cavernosa itself, and others extrapolatable from the advancement of gene therapy in general.     

Fonction sexuelle et bilan sexologique de i’homme paraplégique et tétraplégique

This paper describes the sexological examination of spinal cord injured men. The complete exam includes a clinical interview, neurological examination, an EMG of the pelvic floor, a urodynamic examination and ano-rectal exploration, and the objective recording of the man’s sexual response to reflex and psychogenic professionals or psychologists and sextherapists can proceed with a more thorough interview which evaluates number of the elements of the physical examination. The results of the investigation give rise to a number of clinical entities described in terms of lesion levels with respect to the innervation of the reproductive system. Lesions can therefore be classified as being located above the two pathways of erection, or extended to the cauda equina. Each lesion type is associated with a given pronostic of erectile and ejaculatory function. The accompanying physiological recording of penile responses further helps to establish a differential diagnosis between an exclusively organic dysfunction or a primarily psychogenic dysfunction in spinal cord injured men.     

Ischaemia with no obstructive coronary arteries

Ischaemia with no obstructive coronary arteries (INOCA) is a common ischaemic heart disease with a female preponderance, mostly due to underlying coronary vascular dysfunction comprising coronary microvascular dysfunction and/or epicardial coronary vasospasm. Since standard ischaemia detection tests and coronary angiograms are not suitable to diagnose coronary vascular dysfunction, INOCA is often overlooked in current cardiology practice. Future research, including large outcome trials, is much awaited. Yet, adequate diagnosis is possible and treatment options are available and vital to reduce symptoms and most probably improve cardiovascular prognosis. This review intends to give a brief overview of the clinical presentation, underlying pathophysiology, and the diagnostic and treatment options in patients with suspected INOCA.

     

Role of duplex scanning in the diagnosis of erectile dysfunction

A total of 110 patients aged 34-74 years who complained of erectile dysfunction (ED) were examined. A control group of 9 patients without complaints of ED was formed to determine the normal condition. Baseline ultrasonography was followed by scanning after intracavernous administration of a vasoactive drug to whose use 59 individuals contended to. In the control group, the variation of PSV values was in the range of 23-59 cm/sec. Among the patients with complaints of ED, the baseline study has indicated normal PSV values in both cavernous arteries in 21 cases of the 110 patients; in the other patients, the baseline cavernous arterial blood flow, such as that in the great arteries, was less than 30 cm/sec. Summing up the data of observations of 59 patients undergone erectile stimulation has ascertained that that 20, 34, and 4 patients were diagnosed as having the isolated arterial form of ED, the arteriovenous form, and venous form, respectively; there was no evidence for the form of vascular genesis in 1 patient. Ultrasonography, including color duplex scanning with Doppler energy flow mapping, and B-mode before and after erectile stimulation with intracavernous administration of an E1-prostaglandin drug, makes it possible to assess the contribution of the vascular component to the pathogenesis of erectile dysfunction.     

The molecular basis of erectile dysfunction: from bench to bedside

Erectile dysfunction is a common problem affecting many men across all age groups. Its etiology is multifactorial. Hormonal, vascular, neurogenic, lifestyle, and psychological entities have all been implicated as causative agents. The molecular basis underlying its etiology and progression is complex and still challenges researchers in the field. Nonetheless, newly discovered common pathways and targets of its pathogenesis have opened a new era for both prevention and active treatment of the disease. This review describes some of the known molecular mechanisms contributing to erectile dysfunction and discusses the future of gene therapy for the disease.     

Clinical evaluation of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is the most common neoplastic condition afflicting men and constitutes a major factor impacting male health. Clinical evaluation to assess the presence and degree of voiding dysfunction and/or the role of BPH in its presence has an increasingly broad spectrum of treatment goals. The goals of the evaluation of such men are to identify the patient's voiding or, more appropriately, urinary tract problems, both symptomatic and physiologic; to establish the etiologic role of BPH in these problems; to evaluate the necessity for and probability of success and risks of various therapeutic approaches; and to present the results of these assessments to the patient so he can make an informed decision about management recommendations and available alternatives.     

Epidémiologie de la dysfonction érectile (1ère partie). Prévalence et incidence mondiales

Many studies have provided epidemiological data on erectile dysfunction over the last ten years. Surveys performed in several countries in the world include a single question and a detailed questionnaire, usually the IIEF (International index of erectile function). However, the results are difficult to compare because of methodological differences. Prevalence estimates of moderate or severe erectile dysfunction range between 11 and 19% in France, 3 and 11% in Europe (Germany, Italy, Netherlands, Spain and Sweden) and in USA, according to the MMAS (Massachusetts male aging study), this prevalence is 35%. Prevalence estimates increase with age and the threshold is situated between 50 and 60 years. Incidence data are lacking, but data have recently become available from the MMAS. According to this study, the annual incidence rate for erectile dysfunction is 25.9 cases per 1,000 men. This rate increases with each decade of age.     

Les traitements pharmacologiques de l'insuffisance érectile

About 10 to 20% of men are affected by erectile dysfunction in France. The prevalence of erectile dysfunction increases with age and has a multifactorial etiology in the great majority of cases. The recent availability of oral treatments has improved the medical approach to erectile dysfunction. After a clinical presentation of erectile dysfunction and its causes, this article deals with the general principle of medical therapy for erectile dysfunction. Oral therapy with sildenafil and other compounds and local therapy by intracavernous injections (papaverine, moxisylyte, prostaglandin E1) or intraurethral administration of PGE1 are reviewed.     

Multidisciplinary survey of erectile impotence.

A study was done of 220 men referred principally by family physicians to a multidisciplinary erectile dysfunction study group to determine the factors causing or contributing to impotence that had persisted for more than 2 months and for which no cause was apparent. The men were aged 21 to 79 (mean 50.3) years, and the duration of impotence was a few months to 15 years (mean 2.65 years). The men were to be assessed from general medical, endocrinologic/metabolic, psychiatric and urogenital viewpoints. The significance of the causal or contributory factors detected was scored by application of defined criteria and a four-point scale. The degree of loss of potency and of libido as well as level of concern were also scored by each specialist. Impotence was complete in 60%, and an associated decline in libido was reported by 38%. The level of concern was high--that is, normal--in 81% and slightly reduced in 9%. Full investigation by all the specialists was precluded by the severity of other conditions in 16 patients, by the return of potency following relief of anxiety/depression or genitourinary tract infection in 16 and for logistic or other reasons in 34. Although the cause of the impotence could be attributed in 186 of the patients, only 154 were fully assessed. Among these patients general medical factors were contributory in 46%, endocrinologic/metabolic factors in 44%, psychogenic factors (primary or secondary) in 60% and urogenital factors in 49%. Multiple contributing factors were identified in 65%, which underscores the importance of a multidisciplinary approach to assessing many cases of impotence.