Intracavernosal therapy: when oral agents fail

The effect of topical synthetic prostaglandin E1 (misoprostol) on clitoral hemodynamics

INTRODUCTION

Genital blood flow plays an important role on female sexual function. Measures that increase genital blood flow may be a therapeutic approach for female sexual dysfunction.

AIM

This study aims to show the effect of topical misoprostol, a synthetic prostaglandin, on clitoral blood flow.

METHODS

Seventeen volunteers with female sexual dysfunction on the basis of female sexual function index scores were included in the study. All women were premenopausal and within their sexually active ages. Hormonal profiles were also normal. Those with suspected pregnancy, history of pelvic or vaginal surgery or radiotherapy, and diabetes or hypertension were excluded. Female sexual function index scores were determined. Clitoral peak systolic velocity (PSV) and clitoral artery diameter of all women were measured by using Doppler ultrasound. The measurements were done on two occasions as before and after placebo in one session and before and after 100 µg of misoprostol in another. This is a double-blind study where the patient and the ultrasonographist were unaware of either placebo or active drug has been applied before measurements.

MAIN OUTCOME MEASURES

Clitoral artery diameter and peak systolic velocity.

RESULTS

Misoprostol caused a significant increase in clitoral artery PSV compared to basal level (P = 0.0001), while changes in clitoral artery PSV with placebo remained insignificant. Remarkably, misoprostol caused 118.3% increase in clitoral artery PSV and 47.5% increase in clitoral artery diameter when compared to basal levels. No side effects were observed.

CONCLUSION

Topical misoprostol can significantly increase clitoral blood flow without any unwanted effects and this finding may be promising for future investigations with relevance to female sexual dysfunction.

Erectile dysfunction and cardiovascular disease

Cardiovascular disease and erectile dysfunction (ED) are closely interrelated disease processes. Erectile dysfunction reportedly affects 10 million to 20 million men in the United States and more than 100 million men worldwide. Each year, about 500,000 persons in the United States survive a myocardial infarction, and an estimated 11 million have existing cardiovascular disease, making the issue of sexual function and cardiac disease relevant to many patients. We explore the relationship between ED and the presence of cardiovascular disease in the general population. We also review the prevalence and pathophysiological associations of ED and cardiovascular disease. The risks of sexual activity for patients with cardiovascular disease are discussed, as are prevention and treatment strategies for ED in this patient population.

Long-term intracavernous therapy responders can potentially switch to sildenafil citrate after radical prostatectomy

OBJECTIVES

To assess whether long-term users of intracavernous (IC) injections after radical prostatectomy can switch to oral therapy with sildenafil citrate.

METHODS

Forty-nine patients (mean age 60.9 years) with erectile dysfunction after radical prostatectomy were identified as long-term users of IC injections (3.7 +/- 1.9 years). These patients received open-label treatment with sildenafil citrate (50 to 100 mg) for a minimum of 4 weeks or five attempts. The primary outcome measure of our study was assessed by the Sexual Health Inventory of Men (SHIM) questionnaire (International Index of Erectile Function-5 [IIEF]). A successful switch was prospectively defined as erection sufficient for vaginal penetration after sildenafil use and compliance to therapy. Patients were designated as responders or nonresponders on the basis of their ability to achieve vaginal penetration.

RESULTS

Of 49 patients, only 36 agreed to receive oral open-label sildenafil (50 to 100 mg) for a minimum of 4 weeks or five attempts. Prostaglandin E1 (PGE1) was used in 70% and triple therapy (PGE1, papaverine, and phentolamine) in the remaining 30%. Of the 36 patients, 15 (41%) successfully switched to sildenafil and discontinued IC injections. When the results were stratified by the type of IC solution, patients with high-dose triple therapy had a poor success rate of switch (7%) compared with patients using PGE1 treatment (67%). Of the 36 patients, 14 (38%) found sildenafil ineffective and continued using IC injections. Patients who switched to oral therapy had had a greater (P <0.001) total mean SHIM (IIEF-5) score with IC injections than those who did not switch (12.3 +/- 7.8 versus 20.0 +/- 4.9). Of the 36 patients, 7 (19%) found sildenafil alone to be suboptimal but continued using it, enhancing the efficacy of IC injections alone. The three predictive factors for a successful switch were high preoperative SHIM (IIEF-5) score, high post-IC injection SHIM score, and type of IC medication used (PGE1 alone versus high-dose triple therapy).

CONCLUSIONS

Long-term users of IC injection therapy can potentially switch to sildenafil citrate with acceptable sexual satisfaction. Patients will accept a lower degree of sexual satisfaction as measured by the IIEF-5 (SHIM) score if oral therapy is effective.

Long-term efficacy and compliance of intracorporeal (IC) injection for erectile dysfunction following radical prostatectomy: SHIM (IIEF-5) analysis

Baseline and follow-up data from 102 patients using intracorporeal (IC) injection for erectile dysfunction (ED) following RP were retrospectively collected. We compared baseline International Index for Erectile Function (IIEF) questionnaires with the abridged IIEF-5 questionnaires, referred to as the Sexual Health Inventory of Men (SHIM) to determine drug efficacy. The mean presurgery SHIM score was 21.75+/-5.23, which decreased to 4.23+/-3.48 after surgery and increased to 19.46+/-8.78 post-treatment. Overall, 68% (69/102) of patients achieved and maintained erections sufficient for sexual intercourse and 48% (49/102) of patients continued long-term therapy with a mean use of 3.7+/-1.9 y. In all, 52% (53/102) patients discontinued IC therapy. However when excluding patients who switched to oral therapy, had loss of partner or return of normal erections; the compliance to IC injections was 70.6% (71/102). There was no difference in the SHIM analysis between the nerve sparing (NS) and the non-NS or between the types of medications used. IC injections can provide excellent long-term efficacy and compliance in up to 70% of the patients. This study suggests that IC injections are an excellent salvage option in NS patients who fail oral therapy and a first option in patients with non-NS procedures.