Return of spontaneous erection during long-term intracavernosal alprostadil (Caverject) treatment

Review: Modern treatment of erectile dysfunction

Within the last two decades, major advances have been made in the development of effective treatments for erectile dysfunction. Oral therapy is now established as the mainstay of treatment and new treatments continue to emerge following the launch of sildenafil in 1998. We review here modern treatment strategies for erectile dysfunction.

Is it worth continuing sexual rehabilitation after radical prostatectomy with intracavernous injection of alprostadil for more than 1 year?

Introduction

Intracavernous alprostadil injection (IAI) is a widely used treatment for sexual rehabilitation (SR) after radical prostatectomy (RP). It is unknown whether the continuation of IAI beyond 1 year continues to improve erectile function.

Aims

To assess evolution of sexual function in patients using IAI who are nonresponsive to phosphodiesterase type 5 inhibitors (PDE5i) between 12 (M12) and 24 (M24) months after RP.

Methods

We retrospectively studied 75 men with a nerve-sparing laparoscopic RP, who had normal preoperative erectile function, and who regularly used IAI for SR for at least 24 months. At M12, no patients had responded to PDE5i.

Main Outcome Measures

At 12 and 24 months, sexual function was assessed with the UCLA Prostate Cancer Index (UCLA-PCI), International Index of Erectile Function (IIEF)-15, and erection hardness score (EHS) with and without IAI. We also assessed the satisfaction rate with IAI, injection-related penile pain, and satisfaction of treatment. Statistical analysis was performed by using t-tests for paired data and Spearman's rho correlation coefficients to assess the relationships between scores at M12 and M24.

Results

Improvement of nocturnal erection was noted (UCLA-PCI, question 25); however, no significant difference was found for IIEF-erectile function with (19.60 ± 9.80 vs. 18.07 ± 10.44) and without IAI (4.63 ± 2.93 vs. 4.92 ± 4.15), UCLA-PCI-sexual bother (37.14 ± 21.45 vs. 37.54 ± 19.67), nor the EHS score with (2.97 ± 1.30 vs. 2.57 ± 1.30) and without IAI (0.67 ± 1.11 vs. 0.76 ± 0.10). The rate of satisfaction with treatment decreased over time (66.6% vs. 46.7%, P = 0.013). Improved response to IAI at M12 was not correlated to improvement in spontaneous erections at M24.

Conclusion

The response to IAI remained stable after 2 years of treatment, and no significant improvement of spontaneous erections during intercourse attempts was found between M12 and M24. Patients should be informed of the limited effect of IAI on natural erections after 1 year. Yiou R, Bütow Z, Parisot J, Binhas M, Lingombet O, Augustin D, de la Taille A, and Audureau E. Is it worth continuing sexual rehabilitation after radical prostatectomy with intracavernous injection of alprostadil for more than 1 year? Sex Med 2015;3:42–48.

A study of the possible effects of repeated intracorporeal self-injection of vasoactive drugs in patients with elevated end diastolic velocity during pharmacopenile duplex ultrasonography

Introduction

The aim of the work is to evaluate the effect of repeated intracavernosal self-injection of vasoactive drugs in patients with elevated End Diastolic Velocity (>5 cm/sec) during pharmacopenile duplex ultrasonography (PPDU).

Methods

Duplex evaluation was performed to the patients on self-injection therapy for comparison of end diastolic velocity and resistive index before and after completing the eight doses of IC self-injection.

Results

After the 8 trials of home therapy, 21 (52.5%) patients showed improvement in the duplex parameters regarding the end diastolic velocity, ten of them showed improvement in the EDV to the level of <5 cm/sec. The effect of different factors that may contribute to the improvement in EDV to <5 cm/sec are shown in the table 2. Age was the only predictive factor for successful response to home therapy intracavernous injection (ICI). Improvement in erectile response was assessed before and after the course of the therapy. Erection response to ICI during penile duplex improved in only six patients (E4 & E4-5)) to the point that it was sufficient for satisfactory sexual performance, 3 of them (7.5%) regained spontaneous erection and stopped using ICI (table 3). The IIEF score was 10.6 ±2.8 before the home therapy and it became 14 ±3.9 one month after completing the treatment course (P value <0.001).

Conclusions

Early rehabilitation of the patients with venous leakage ED using ICI may help to regain normal erection and avoid unnecessary penile prosthesis surgeries.

SOP conservative (medical and mechanical) treatment of erectile dysfunction

INTRODUCTION

Erectile dysfunction (ED) is the most frequently treated male sexual dysfunction worldwide. ED is a chronic condition that exerts a negative impact on male self-esteem and nearly all life domains including interpersonal, family, and business relationships.

AIM

The aim of this study is to provide an updated overview on currently used and available conservative treatment options for ED with a special focus on their efficacy, tolerability, safety, merits, and limitations including the role of combination therapies for monotherapy failures.

METHODS

The methods used were PubMed and MEDLINE searches using the following keywords: ED, phosphodiesterase type 5 (PDE5) inhibitors, oral drug therapy, intracavernosal injection therapy, transurethral therapy, topical therapy, and vacuum-erection therapy/constriction devices. Additionally, expert opinions by the authors of this article are included.

RESULTS

Level 1 evidence exists that changes in sedentary lifestyle with weight loss and optimal treatment of concomitant diseases/risk factors (e.g., diabetes, hypertension, and dyslipidemia) can either improve ED or add to the efficacy of ED-specific therapies, e.g., PDE5 inhibitors. Level 1 evidence also exists that treatment of hypogonadism with total testosterone < 300 ng/dL (10.4 nmol/L) can either improve ED or add to the efficacy of PDE5 inhibitors. There is level 1 evidence regarding the efficacy and safety of the following monotherapies in a spectrum-wide range of ED populations: PDE5 inhibitors, intracavernosal injection therapy with prostaglandin E1 (PGE1, synonymous alprostadil) or vasoactive intestinal peptide (VIP)/phentolamine, and transurethral PGE1 therapy. There is level 2 evidence regarding the efficacy and safety of the following ED treatments: vacuum-erection therapy in a wide range of ED populations, oral L-arginine (3-5 g), topical PGE1 in special ED populations, intracavernosal injection therapy with papaverine/phentolamine (bimix), or papaverine/phentolamine/PGE1 (trimix) combination mixtures. There is level 3 evidence regarding the efficacy and safety of oral yohimbine in nonorganic ED. There is level 3 evidence that combination therapies of PDE5 inhibitors + either transurethral or intracavernosal injection therapy generate better efficacy rates than either monotherapy alone. There is level 4 evidence showing enhanced efficacy with the combination of vacuum-erection therapy + either PDE5 inhibitor or transurethral PGE1 or intracavernosal injection therapy. There is level 5 evidence (expert opinion) that combination therapy of PDE5 inhibitors + L-arginine or daily dosing of tadalafil + short-acting PDE5 inhibitors pro re nata may rescue PDE5 inhibitor monotherapy failures. There is level 5 evidence (expert opinion) that adding either PDE5 inhibitors or transurethral PGE1 may improve outcome of penile prosthetic surgery regarding soft (cold) glans syndrome. There is level 5 evidence (expert opinion) that the combination of PDE5 inhibitors and dapoxetine is effective and safe in patients suffering from both ED and premature ejaculation.

Should penile rehabilitation become the norm following radical prostatectomy?

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Sexual dysfunction in uraemic patients undergoing haemodialysis: predisposing and related conditions

Chronic kidney disease and sexual dysfunction are common entities in clinical practice in haemodialysis (HD) units. This article is a review of some articles that focus on sexual dysfunction in patients undergoing HD and its possible relationship in multiple ways.

Intracavernosal pressure characteristics analyzed by power spectral density for identifying the phase of penile erection

Knowledge of the time course of penile erection is very important to understanding erection physiology. The changes in the intracavernosal pressure (ICP) and the different phases of an erection are pivotal to the ability to produce and maintain a rigid penile erection. This study investigated an objective and low-invasiveness method for identifying different erection phases based on an innovative ICP analysis technique. Blood infuses into the corpora cavernosa and causes the ICP to increase. The ICP usually exhibits tiny oscillations at the frequency of the heartbeat when it increases from diastole to systole. The characteristic oscillation amplitudes corresponding to the period when the full and rigid erection phases begin can be extracted by power spectral density analysis. The reliability and accuracy of the proposed method was verified by the Bland-Altman graphs indicating a good agreement with the existing method that compares the ICP with the arterial pressure. Moreover, all of the intraclass correlation coefficient values were close to 1.00, with the lower limit of the 95% confidence interval exceeding 0.75. The described novel objective and low-invasiveness method can therefore be used for identifying the full and rigid erection phases of the penis in urological investigations during different erection phases.

How urologists manage erectile dysfunction after radical prostatectomy: a national survey (REPAIR) by the French urological association

INTRODUCTION

There is little sound information on how urologists manage erectile dysfunction (ED) arising after radical prostatectomy (RP) in a real-world situation.

AIM

To perform a national survey of how French urologists manage ED after RP in routine practice.

MAIN OUTCOME MEASURES

Choice of first-line treatment, type of treatment (rehabilitation of erectile function vs. treatment on demand for intercourse), and timing and duration of treatment.

METHODS

All French urologists were invited to take part in a survey; 59.7% accepted provisionally (760/1,272). They received the survey questionnaire and 10 patient data forms to be completed during the visits of the first 10 patients with fewer than 12 months follow-up post-RP. These were returned to an independent third party for analysis.

RESULTS

The final response rate was 535/1,272 (42%). Before performing RP, 80% of the urologists assessed sexual activity and 76% erectile function; 9% did neither. Thirty-eight percent reported that they systematically proposed ED treatment to their patients post-RP ("routine prescribers"). The remainder was treated on occasion, either at the patients' request (49%) or at their own discretion (13%). Routine prescribers tended to be younger and had performed more RPs in the preceding year. Most urologists (88%) always used the same first-line treatment: regular intracavernosal injections (ICIs) for rehabilitation, 39%; ICI on demand for intercourse, 30%; phosphodiesterase type 5 (PDE5) inhibitors on demand, 16%, or regular PDE5 inhibitors for rehabilitation, 8%; alternating ICI and PDE5 inhibitors, 7%; vacuum device, <1%. ED treatment was initiated within 3 months of RP by 72% of the urologists (92% of routine prescribers). The percentage of urologists recommending ED treatment for 6 months was 20%, 38% for 1 year, and 33% for 2 years.

CONCLUSION

ED was commonplace after RP. French urologists reported a proactive attitude to ED treatment, many favoring pharmacologic rehabilitation therapy. ICI was their first-line treatment of choice.

Sexual rehabilitation with intracavernous PGE1 injections and oral drug administration in diabetic patients non-responder to oral therapy alone

Diabetes is an important risk factor in erectile dysfunction (ED), acting via several mechanisms. We assessed the efficacy of intracavernous injections (ICI) rehabilitation and oral systematic therapy in diabetic patients, as well as the response of controls to oral therapy ‘on demand’.

Materials and Methods

Sixteen diabetic patients with ED were treated with vasoactive drugs orally when needed, without satisfactory erections. The patients underwent then ICI rehabilitation with PGE1 20 mcg twice weekly for 4 weeks, followed by the administration of oral drugs twice weekly for 4 weeks. Before and after rehabilitation, the patients completed a detailed anamnestic protocol to study their libido (always present); they answered questions Q3 and Q4 of the IIEF questionnaire. During ICI, a study with dynamic echocolordoppler (ECCD) was carried out. All patients had Type 2 diabetes: 10 were treated with oral antidiabetics, 4 were treated with insulin, and in the other 2 patients, treated with insulin, a sensitive neuropathy of the lower limbs was diagnosed. Fourteen patients were treated with antihypertensive drugs.

Results

Before rehabilitation, the mean responses to questions 3 and 4 of the IIEF (International Index of Erectile Function) questionnaire were 1.6 and 1.5 respectively; after rehabilitation, the mean responses were 2.68 and 2.5, respectively. The ECCD test showed an arterial component in 4 cases and a high end-diastolic velocity (EDV) in 14 cases. Four patients (25%), 2 of which had neuropathy, and 2 were in advanced age, did not respond to PGE1 or to oral therapy, 4 patients (25%) (2 treated with insulin and 2 by oral therapy) responded to ICI but not to oral therapy, while 8 patients (50%) showed a good response to both injectable and oral therapy, with good Q3 and Q4 scores.

Conclusions

Good endothelial function appears to be essential for the maintenance of acceptable erectile function. Diabetes has a negative effect on this function, as does hypoxia and low perfusion. Based on the principle that a good erection improves endothelial function, we tried to determine if oral systematic and intracavernous rehabilitation would improve erectile function in diabetic patients. The results indicate that diabetes interferes with erectile function, compromising the effects of the vasoactive drugs. However, integrated systematic rehabilitation appears to allow a good erectile response to both intracavernous and oral therapy in a large number of cases. Therefore, we support this kind of rehabilitative protocol in the treatment of ED in diabetic patients.

Management of erectile dysfunction after radical prostatectomy in 2007

As radical prostatectomy (RP) remains a commonly used procedure in the treatment of clinically localized prostate cancer, we critically analyzed the evidence suggesting the role of pharmacological prophylaxis and treatment of erectile dysfunction (ED) after surgery. Systematic literature review using Medline and Cancerlit from January 1997 to December 2006. Abstracts published in the journals European Urology, The Journal of Urology, The International Journal of Impotence Research and The Journal of Sexual Medicine as official proceedings of internationally known scientific Societies held in the same time period were also assessed. Patient selection and surgical technique (i.e., preservation of neurovascular bundles) are the major determinants of post-operative erectile function. Pharmacological treatment of post-operative ED, using either oral or local approaches, is effective and safe. Moreover, recent studies have shown that pharmacological prophylaxis early after RP can significantly improve the rate of erectile function recovery after surgery. Use of on-demand treatments for treatment of ED in patients subjected to RP has been shown to be highly effective, especially in case of properly selected young patients treated with a bilateral nerve-sparing approach by experienced surgeons. In this context, pharmacological prophylaxis may potentially have a significant expanding role in future strategies aimed at preserving post-operative erectile function.

Update on erectile dysfunction in prostate cancer patients

PURPOSE OF REVIEW

Evolution in the management of prostate cancer includes increased attention being paid to patient quality of life after treatment, specifically with issues related to sexual function. Erectile dysfunction is one of the major concerns of patients undergoing treatment for prostate cancer. There are several recognized factors that determine the postoperative incidence of erectile difficulties, including patient age, degree of cavernosal nerve sparing during surgery, cancer stage, and associated vascular comorbidities. Early initiation of rehabilitation protocols after radical prostatectomy has been advocated to promote the speed and degree of recovery of erectile function. The aim of this communication is to review recent initiatives in erectile dysfunction restoration after prostate cancer therapy.

RECENT FINDINGS

In recognition of the neurogenic basis of erectile dysfunction after radical prostatectomy, new strategies have been devised to initiate the rehabilitation process. Type 5 phosphodiesterase inhibitors, vacuum erection devices, and intracavernosal and intraurethral application of vasoactive agents have all been reported in a positive light in recent studies. Developments in cavernous nerve graft interposition procedures, perioperative neuroprotection measures, and postoperative neurotrophic treatments aim to preserve prostate cancer patients' qualities of life.

SUMMARY

Data generated from a number of clinical investigations document that pharmacologic rehabilitation programs provide a higher rate of recovery of erectile function following radical prostatectomy. Both intracavernosal and intraurethral applications of vasoactive agents and vacuum devices can speed the recovery period for return of erectile function. Various neuroprotective and neurotrophic approaches are thought to provide integral roles for the maintenance of sexual function in men undergoing prostate cancer therapy.

Erectile dysfunction and treatment of carcinoma of the prostate

Prostate cancer is the leading malignancy in men in the United States and causes more than 60,000 deaths annually. Treatment of prostate cancer, whether it be with surgery, radiation therapy, cryotherapy, or medical treatment, is associated with significant life-altering morbidity. Incontinence and erectile dysfunction (ED) too often are sequelae of these treatment alternatives. ED can be a significant complication and can alter the life of the patient with prostate cancer and his partner. Newer modifications of the radical prostatectomy with nerve-sparing techniques are the cornerstone of erection preservation. Time following radical prostatectomy has been shown to increase erectile function such that more patients have functional erections at 3 years than 1 year after surgery. With the advent of phosphodiesterase-5 (PDE-5) inhibitors, many men can have improved functional erections and return to active coitus. Prevention of ED also is an important management technique. Evidence is gathering that prophylaxis with regular vasoactive injection or daily PDE-5 agents may be an integral part of preservation of corpus cavernosum smooth muscle function. Combination medical therapy and surgical penile prosthesis implantation also are options for patients who do not respond to oral PDE-5 inhibitors.

Pathophysiologie und Rehabilitation der erektilen Dysfunktion nach nerverhaltender radikaler Prostatektomie

Radical prostatectomy is the current standard procedure for locally confined prostate cancer and accounts for the largest portion of invasive therapies. However, a major drawback of this approach remains the frequently ensuing postoperative erectile dysfunction. This aspect represents a frequent cause of fear and concern both for the patients and their partners and has a significant impact on the choice of therapy.After bilateral sparing of the neurovascular bundles, an average of 50% of the patients is likely to complain of erectile dysfunction. It is only in the course of the first 2 years after prostatectomy that rehabilitation of erectile dysfunction can be expected. It is all the more crucial to begin with rehabilitation therapy of the erectile tissue at an early postoperative stage to the prevent an irretrievable loss of erectile function. Application of PDE-5 inhibitors as well as prostaglandins, phentolamine, or papaverine can help to induce and to support penile blood perfusion and oxygenation, thus preserving structure and function of the corpora cavernosa. All efforts must be directed towards keeping the erectile function at the level ascertained prior to the intervention.

Current concepts in the management of erectile dysfunction in men with prostate cancer

Development in the management of prostate cancer has placed increased attention on patient quality of life after treatment, particularly sexual function. The incidence of erectile dysfunction (ED) in men following radical prostatectomy has been estimated to range from 16% to 82%. Several factors determine the postoperative incidence of erectile difficulties; these include patient age, degree of cavernosal nerve sparing during surgery, cancer stage, and associated comorbidities. Early initiation of available treatments after radical prostatectomy, such as phosphodiesterase-5 (PDE-5) inhibitors and intracavernosal alprostadil, may improve the speed and degree of recovery of erectile function. Oral PDE-5 inhibitors are recognized as the first line of therapy for men with ED after radical prostatectomy, with reasonable success rates reported for all commercially available PDE-5 inhibitors. In recognition of the neurogenic basis for erectile dysfunction after radical prostatectomy, new strategies have been devised, such as cavernous nerve graft interposition procedures, perioperative neuroprotection measures, and postoperative neurotrophic treatments. Hopefully, these efforts will improve quality of life for patients with prostate cancer. The aim of this article is to review the current modalities of ED management for men with prostate cancer.

Erectile dysfunction: evaluation and new treatment options

OBJECTIVE

Erectile dysfunction (ED) is a common condition of aging men. Indeed as many as 50% of men over age 40 will suffer some degree of ED. This erectile dysfunction has substantial impact on interaction with their partners, families, and employment. ED may be a harbinger of more serious vascular events and is commonly associated with depression.

METHODS

Evaluation of ED begins with a careful history, asking the patient about his sexual function during clinical visits. Once identified, ED must be carefully considered with full history, careful physical examination, and laboratory studies to include markers of vascular risk factors, diabetes, and hypogonadism.

RESULTS

The treatment of ED was revolutionized by the introduction of phosphodiesterase type 5 (PDE5) inhibitors in 1998. Currently, 3 PDE5 inhibitors are available internationally with excellent expected results and somewhat unique profiles. Although these agents are safe in all patients who do not have severe cardiac disease or who are taking nitrate medications, they require some patient instruction and counseling to optimize results. In that small group of patients who do not respond to these oral medications, additional alternatives are available for patients motivated to pursue treatment of their ED.

CONCLUSION

Currently available safe and effective alternatives for the treatment of ED can improve the lives of patients and partners and increase their quality of life.

Current and Future Strategies for Preventing and Managing Erectile Dysfunction Following Radical Prostatectomy

INTRODUCTION AND OBJECTIVES

As radical prostatectomy remains a commonly used procedure in the treatment of clinically localized prostate cancer, we critically analyzed current and future strategies for preventing and managing postoperative erectile dysfunction.

METHODS

Systematic literature review using Medline and CancerLit from January 1997 to June 2003. Abstracts published in the journals European Urology, The Journal of Urology and the International Journal of Impotence Research as official proceedings of internationally known scientific societies held in the same time period were also assessed.

RESULTS

Patient selection and surgical technique are the major determinants of postoperative erectile function. Apoptosis of corporeal smooth muscle cells plays a role in the development of cavernous veno-occlusive dysfunction following radical prostatectomy. Pharmacological prophylaxis and treatment of postoperative erectile dysfunction is effective and safe. The concepts of cavernous nerve reconstruction and neuroprotection have been associated to promising results.

CONCLUSIONS

In the hands of experienced surgeons, properly selected patients undergoing a nerve sparing radical prostatectomy should achieve unassisted or medically assisted erections postoperatively.

New achievements and pharmacotherapeutic approaches to impotence in the elderly

Erectile dysfunction (ED) has a negative impact on the quality of life of elderly men, but impotence is not an absolute concomitant of aging. Aging changes influencing sexual function in men consist of a decreased capacity to reach arousal by imagination or view, fragility of erection, and an increase in the refractory period. These events may be part of the andropause syndrome, which includes a decrease in intellectual activity, fatigue, depression, decreases in body hair, lean body mass and bone mineral density, accompanied by an increase in weight. As a consequence, the overlap of aging processes, concurrent diseases and social situations to which elderly men are subject, results in the great variability reported in epidemiological studies. In the same way, the complex physiology of erection depends on the social, environmental, or physical context in which it occurs. New achievements in research on intracellular mechanisms of erection and on the neuroendocrinology of aging contribute to better understanding the pathophysiology of ED in the elderly. For example, testosterone declines with age with great interindividual variability, since other hormonal changes are also involved. What currently can be easily identified is the alteration of LH-testosterone feedback alterations, although hormone levels fall in the normal range. Nevertheless, the extent to which age-dependent decline in hormones leads to health problems that may affect the quality of life remains to be clarified. Several concepts on aging-related processes have been challenged, and conditions that were once accepted as physiologically age-related are now thought to lead to medical problems, but until now erectile dysfunction remains underreported, underdiagnosed, and undertreated, especially in the elderly. Nowadays, we are witnessing a rapid growth in available pharmacotherapies, from intracavernous injections of vasoactive drugs, to powerful new oral agents, with differing pharmacological dynamic and kinetic properties. New options for treatment are therefore possible, taking into account both the possibility of changing ineffective drugs and augmenting efficacy by means of synergistic associations. This rich generation of progress is certainly contributing to a better medical approach to sexuality in aging people.

Comparison of a needle-free high-pressure injection system with needle-tipped injection of intracavernosal alprostadil for erectile dysfunction

Patients identified from hospital records as using alprostadil injections for erectile dysfunction were invited to take part in this open crossover study. On alternate weeks eight patients were given intracavernosal needle injections and transdermal needle-free injection of alprostadil in a randomized order. Efficacy of injection and associated pain were assessed and compared for the two methods. Pain produced during injection was significantly greater with the needle-free system than with the needle-tipped injection whilst efficacy was significantly less. Bruising was reported in all except one patient following needle-free injection only. Patient ratings of the needle-free injector were significantly lower than ratings for needle-tipped alprostadil delivery and when asked to express a preference, every patient chose the needle-tipped injection over the needle-free device.

Intracavernous injections for erectile dysfunction in patients with cardiovascular diseases and failure or contraindications for sildenafil citrate

The aim of this study was to evaluate the effectiveness of a progressive program for the treatment of erectile dysfunction in patients with cardiovascular disease in whom sildenafil citrate (Viagra) was not an option. The study population included 106 patients selected from 267 with cardiovascular disease. The intracavernous injection program consisted of three protocols of increasingly complex combinations of vasoactive drugs, papaverine, phentolamine, prostaglandin E1 and atropine sulfate. Patients who failed the first protocol were switched to the second, and those who failed the second were switched to the third. A positive response was defined as an erection sufficient for vaginal penetration. A positive response was achieved on protocol I in 61 of the 106 patients (57.5%); protocol II in 32 of the remaining 45 patients (71.1%); and protocol III in seven of the remaining 13 patients (53.8%); the total success rate was 94.3%. These 100 patients were included in the 1-year follow-up, and 90 reported successful coitus at the end of that period: 79 patients (87.8%) with intracavernous injection and 11 (12.2%) without injection. The remaining 10 patients (10%) dropped out of the program, seven (7.0%) for health or marital reasons and three (3.0%) because of treatment failure. We conclude that a progressive program of intracavernous injections of vasoactive drugs may be a good alternative for the treatment of erectile dysfunction in patients with cardiovascular disease.