Vacuum constriction and external erection devices in erectile dysfunction

Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology

BACKGROUND AND OBJECTIVE

Most patients with neurourological disorders require lifelong medical care. The European Association of Urology (EAU) regularly updates guidelines for diagnosis and treatment of these patients. The objective of this review is to provide a summary of the 2024 updated EAU guidelines on neurourology.

METHODS

A structured literature review covering the timeframe 2021-2023 was conducted for the guideline update. A level of evidence and a strength rating were assigned for each recommendation on the basis of the literature data.

KEY FINDINGS AND LIMITATIONS

Neurological conditions significantly affect urinary, sexual, and bowel function, and lifelong management is required for neurourological patients to maintain their quality of life and prevent urinary tract deterioration. Early diagnosis and effective treatment are key, and comprehensive clinical assessments, including urodynamics, are crucial. Management should be customised to individual needs and should involve a multidisciplinary approach and address sexuality and fertility. Lifelong monitoring and follow-up highlight the importance of continuous care for neurourological patients.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The 2024 EAU guidelines on neurourology provide an up-to-date overview of available evidence on diagnosis, treatment, and follow-up for neurourological patients.

PATIENT SUMMARY

Neurological disorders very frequently affect the lower urinary tract and sexual and bowel function and patients need lifelong management. We summarise the updated European Association of Urology guidelines on neurourology to provide patients and caregivers with the latest insights for optimal health care support.

High prevalence of erectile dysfunction in men with hyperthyroidism: a meta-analysis

OBJECTIVE

The objective of this study was to evaluate the association between hyperthyroidism and the risk of developing erectile dysfunction (ED).

METHODS

A comprehensive search of multiple databases, including PubMed, Embase, Cochrane, and Web of Science, was conducted to identify relevant studies investigating the relationship between hyperthyroidism and ED in men. The quality of the included studies was assessed using the Newcastle‒Ottawa Quality Rating Scale, and a meta-analysis was performed using Stata 16.0 and RevMan 5.3 software.

RESULTS

A total of four papers encompassing 25,519 study subjects were included in the analysis. Among these, 6,429 individuals had hyperthyroidism, while 19,090 served as controls. The overall prevalence of ED in patients with hyperthyroidism was determined to be 31.1% (95% CI 0.06-0.56). In patients with uncomplicated hyperthyroidism, the incidence of ED was 21.9% (95% CI 0.05-0.38). The combined odds ratio (OR) for the four studies was 1.73 (OR: 1.73; 95% CI [1.46-2.04]; p < .00001).

CONCLUSION

Our findings demonstrate a higher incidence of ED in patients with hyperthyroidism. These results provide valuable information for healthcare professionals and can facilitate discussions surrounding appropriate treatment options for ED in patients with hyperthyroidism.

Considerations for prescribing pharmacotherapy for the treatment of erectile dysfunction

Introduction: The effectiveness of phosphodiesterase type 5 inhibitors (PDE5i) in treating erectile dysfunction (ED) creates a new field of both medical practice and pharmaceutical manufacturing. Both paved the way for emerging minimally invasive therapies to restore male sexual function. However, what is the best drug to achieve the optimum outcome is still a challenging question to be answered.Areas covered: The general viewpoint of matching the pharmacotherapeutic characteristics with the patient's medical, social, and psychological variables, in order to balance between efficacy and safety. Several studies had investigated considerations for preference and long-term adherence for PDE5i. However, a thorough investigation of considerations for prescribing ED pharmacotherapy is still lacking in the literature. This is the aim of this manuscript.Expert opinion: Several issues should be considered in the planning of ED management such as the patient's and partner's expectations, etiologic considerations, performance status, safety, adverse effects, ease of administration, compliance, bad experiences with previous treatment, availability, cost, social factors, satisfaction, and finally, regimen considerations. Addressing the patient's and partner's individual needs help to tailoring treatment in order to minimize compromises and optimize gains.

Novel Emerging Therapies for Erectile Dysfunction

Currently, several treatments exist for the improvement of erectile dysfunction (ED). These include medical therapies such as phosphodiesterase type 5 inhibitors (PDE5-Is), invasive methods such as intracavernosal injection therapy of vaso-active substances, vacuum erection devices, and penile prosthesis implants. However, the percentage of patients that are unresponsive to available treatments and who drop out from treatments remains high. Current evidence reveals that the pathogenesis of ED is related to multiple factors including underlying comorbidities, previous surgery, and psychological factors. Diverse approaches using novel molecular pathways or new technologies have been tested as potential therapeutic options for difficultto-treat ED populations. Melanocortin receptor agonist, a centrally acting agent, showed promising results by initiating erection without sexual stimulation in non-responders to PDE5-Is. Recent clinical and pre-clinical studies using human tissues suggested that new peripherally acting agents including the Max-K channel activator, guanylate cyclase activator, and nitric oxide donor could be potential therapies either as a monotherapy or in combination with PDE5-Is in ED patients. According to several clinical trials, regeneration therapy using stem cells showed favorable data in men with diabetic or post-prostatectomy ED. Low-intensity shock wave therapy also demonstrated promising results in patients with vasculogenic ED. There are growing evidences which suggest the efficacy of these emerging therapies, though most of the therapies still need to be validated by well-designed clinical trials. It is expected that, should their long-term safety and efficacy be proven, the emerging treatments can meet the needs of patients hitherto unresponsive to or unsatisfied by current therapies for ED.

Urogenital Symptoms in Neurologic Patients

PURPOSE OF REVIEW

Lower urinary tract and sexual dysfunction are commonly reported sequelae of neurologic disease and have a significant impact on quality of life. This article presents an up-to-date summary of the clinical presentation, investigations, and treatment options for urogenital dysfunction in patients with neurologic disease.

RECENT FINDINGS

The pattern of lower urinary tract dysfunction is influenced by the site of the neurologic lesion. The risk for developing upper urinary tract damage is considerably less in patients with slowly progressive nontraumatic neurologic disorders, as compared to those with spinal cord injury or spina bifida. Investigations such as urinalysis, ultrasonography, and urodynamics provide further information about the cause and nature of lower urinary tract dysfunction. Antimuscarinic agents are the first-line management of urinary incontinence; however, side effect profile and anticholinergic burden should be considered when prescribing medications. β3-Adrenergic receptor agonists are a promising alternative oral medication. Tibial and sacral neuromodulation have been shown to be effective for managing incontinence, as well as urinary retention due to Fowler syndrome. Intradetrusor injections of onabotulinumtoxinA have revolutionized the management of neurogenic detrusor overactivity.

SUMMARY

Neurologic patients reporting urogenital symptoms require a comprehensive evaluation for planning a patient-tailored approach to management. Neurologists are increasingly inquiring about lower urinary tract and sexual functions and becoming involved in the management of these disorders.

Vacuum erection device in treatment of organic erectile dysfunction and penile vascular differences between patients with DM type I and DM type II

The aim of this study is to investigate changes in the vascular system and hemodynamics between patients with organic erectile dysfunction (ED) (DM type I and II), as well as to compare the quality of sexual life between those two groups after the treatment with vacuum erection device (VED). Study enrolled 50 males with DM, aged from 35 to 67 years, who have attended the urologic clinic due to inability to attain and maintain an erection of the penis sufficient to permit satisfactory sexual intercourse. Patients were using VED and six months later were assessed for therapy results. The International Index of Erectile Function (IIEF) was used to quantify erectile dysfunction. Alprostadil injection test was also used, with Doppler color flow imaging system, to evaluate the peak systolic velocity (PSV) and diameter of cavernosal artery (DCA). Significantly higher values of PSV were obtained in patients with DM type II. Also, DCA showed significant difference between two groups of patients. There was significant improvement in three items of IIEF after six months of treatment among both groups of examinees. Patients with DM type I had more serious risk for development of arteriogenic ED. VED could be a good alternative therapy for patients who denied peroral therapy.

Erectile dysfunction

Erectile dysfunction is a multidimensional but common male sexual dysfunction that involves an alteration in any of the components of the erectile response, including organic, relational and psychological. Roles for nonendocrine (neurogenic, vasculogenic and iatrogenic) and endocrine pathways have been proposed. Owing to its strong association with metabolic syndrome and cardiovascular disease, cardiac assessment may be warranted in men with symptoms of erectile dysfunction. Minimally invasive interventions to relieve the symptoms of erectile dysfunction include lifestyle modifications, oral drugs, injected vasodilator agents and vacuum erection devices. Surgical therapies are reserved for the subset of patients who have contraindications to these nonsurgical interventions, those who experience adverse effects from (or are refractory to) medical therapy and those who also have penile fibrosis or penile vascular insufficiency. Erectile dysfunction can have deleterious effects on a man's quality of life; most patients have symptoms of depression and anxiety related to sexual performance. These symptoms, in turn, affect his partner's sexual experience and the couple's quality of life. This Primer highlights numerous aspects of erectile dysfunction, summarizes new treatment targets and ongoing preclinical studies that evaluate new pharmacotherapies, and covers the topic of regenerative medicine, which represents the future of sexual medicine.

Minimally invasive infrapubic inflatable penile prosthesis implant for erectile dysfunction: evaluation of efficacy, satisfaction profile and complications

Erectile dysfunction (ED), the second most common male sexual disorder, has an important impact on man sexuality and quality of life affecting also female partner's sexual life. ED is usually related to cardiovascular disease or is an iatrogenic cause of pelvic surgery. Many non-surgical treatments have been developed with results that are controversial, while surgical treatment has reached high levels of satisfaction. The aim is to evaluate outcomes and complications related to prosthesis implant in patients suffering from ED not responding to conventional medical therapy or reporting side effects with such a therapy. One hundred eighty Caucasian male suffering from ED were selected. The patient population were divided into two groups: 84 patients with diabetes and metabolic syndrome (group A) and 96 patients with dysfunction following laparoscopic radical prostatectomy for prostate cancer (group B). All subjects underwent primary inflatable penile prosthesis implant with an infrapubic minimally invasive approach. During 12 months of follow-up, we reported 3 (1.67%) explants for infection, 1 (0.56%) urethral erosion, 1 (0.56%) prosthesis extrusion while no intraoperative complications were reported. Mean International Index of Erectile Function-5 (IIEF-5) was 8.2 ± 4.0 and after the surgery (12 months later) was 20.6 ± 2.7. The improvement after the implant is significant in both groups without a statistically significant difference between the two groups (P-value 0.65). Mean Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score 1 year after the implant is 72.2 ± 20.7, and there was no statistically significant difference between groups A and B (P-value 0.55). Implantation of an inflatable prosthesis, for treatment of ED, is a safe and efficacious approach; and the patient and partner satisfaction is very high. Surgical technique should be minimally invasive and latest technology equipment should be implanted in order to decrease after surgery common complications (infection and mechanical failure).

[Surgical treatment of erectile dysfunction]

During the past decades several efforts had been undertaken to treat erectile dysfunction by vascular surgery. Today one option survived: Implantation of Penile Prostheses. A lot of improvements of the material and the process quality lead to very good long term results. Patients with severe erectile dysfunction can be recommended in good conscience for implant surgery.

A comprehensive review of urologic complications in patients with diabetes

Diabetes Mellitus (DM) is a chronic disease characterized by hyperglycemia, as a result of abnormal insulin production, insulin function, or both. DM is associated with systemic complications, such as infections, neuropathy and angiopathy, which involve the genitourinary tract. The three most significant urologic complications include: bladder cystopathy, sexual dysfunction and urinary tract infections. Almost half of the patients with DM have bladder dysfunction or cystopathy, which can be manifested in women as hypersensitivity (in 39-61% of the diabetic women) or neurogenic bladder. In males it can be experienced as lower urinary tract symptoms (in 25% of diabetic males with a nearly twofold increased risk when seen by age groups). Additionally, an increased prostate volume affects their micturition as well as their urinary tract. Involving sexual dysfunction in women, it includes reduced libido, decreased arousal, clitoral erectile dysfunction and painful or non-sensitive intercourse; and in diabetic males it varies from low libido, ejaculatory abnormalities and erectile dysfunction. Globally, sexual disorders have a prevalence of 18-42%. Erectile dysfunction is ranked as the third most important complication of DM. Urinary tract infections are observed frequently in diabetic patients, and vary from emphysematous infections, Fournier gangrene, staghorn infected lithiasis to repetitive bacterial cystitis. The most frequent finding in diabetic women has been lower urinary tract infections. Because of the high incidence of obesity worldwide and its association with diabetes, it is very important to keep in mind the urologic complication associated with DM in patients, in order to better diagnose and treat this population.

Korean Society for Sexual Medicine and Andrology (KSSMA) Guideline on Erectile Dysfunction

In February 2011, the Korean Society for Sexual Medicine and Andrology (KSSMA) realized the necessity of developing a guideline on erectile dysfunction (ED) appropriate for the local context, and established a committee for the development of a guideline on ED. As many international guidelines based on objective evidence are available, the committee decided to adapt these guidelines for local needs instead of developing a new guideline. Considering the extensive research activities on ED in Korea, data with a high level of evidence among those reported by Korean researchers have been collected and included in the guideline development process. The latest KSSMA guideline on ED has been developed for urologists. The KSSMA hopes that this guideline will help urologists in clinical practice.

Erectile dysfunction and diabetes: a review of the current evidence-based medicine and a synthesis of the main available therapies

AIM

This review aimed to provide an update of the epidemiology, pathophysiology and management of erectile dysfunction (ED) in diabetes patients.

METHODS

Data on the management of ED in diabetes patients in the literature were analyzed using Medline, and by matching the following keywords: diabetes; erectile dysfunction; endothelial dysfunction; cardiovascular disease; phosphodiesterase inhibitors; intracavernous injection; and penile prosthesis.

RESULTS

ED has a higher incidence in diabetic patients. The pathophysiology is multifactorial, involving endothelial dysfunction, specific complications of diabetes and psychological factors. Recent studies have shown that ED is able to predict future cardiovascular events not only in non-diabetics, but also in patients with diabetes. ED could also be a potential marker to screen for silent coronary artery disease. The management of ED has been revolutionized by the discovery of phosphodiesterase type-5 (PDE5) inhibitors, the first-line therapeutic options for diabetic men with ED that are efficient and safe. As a second line, intracavernous injections remain a gold-standard treatment, although a vacuum device can be used as well. In cases of failure, penile prosthesis may be considered. Hypogonadism, commonly found in diabetics, may require identification and treatment. Optimalized glycaemic control, management of associated co-morbidities and lifestyle modifications are essential in all patients. As ED and diabetes negatively impact male self-esteem, and generate depression and anxiety, the psychological treatment of patients is also likely to be beneficial.

CONCLUSION

The aetiology of diabetic ED is multifactorial. Endothelial dysfunction is the link between diabetes-induced ED and coronary artery disease. A global approach is needed for the successful management of diabetic ED.

Vacuum erection devices revisited: its emerging role in the treatment of erectile dysfunction and early penile rehabilitation following prostate cancer therapy

INTRODUCTION

Vacuum erection devices (VEDs) are becoming first-line therapies for the treatment of erectile dysfunction and preservation (rehabilitation) of erectile function following treatment for prostate cancer. Currently, there is limited efficacy of the use of phosphodiesterase type 5 inhibitors in elderly patients, or patients with moderate to severe diabetes, hypertension, and coronary artery disease.

AIM

The article aims to study the role of VED in patients following prostate cancer therapy.

RESULTS

Alternative therapies such as VED have emerged as one of the primary options for patients refractory to oral therapy. VED has also been successfully used in combination treatment with oral therapy and penile injections. More recently, there has been interest in the use of VED in early intervention protocols to encourage corporeal rehabilitation and prevention of postradical prostatectomy veno-occlusive dysfunction. This is evident by the preservation of penile length and girth that is seen with early use of the VED following radical prostatectomy. There are ongoing studies to help preserve penile length and girth with early use of VED following prostate brachytherapy and external beam radiation for prostate cancer. Recently, there has also been interest in the use of VED to help maintain penile length following surgical correction of Peyronie's disease and to increase penile size prior to implantation of the penile prosthesis.

CONCLUSION

VEDs can be one of the options for penile rehabilitation after prostate cancer therapy.

Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation

CONTEXT

Erectile dysfunction (ED) and premature ejaculation (PE) are the two most prevalent male sexual dysfunctions.

OBJECTIVE

To present the updated version of 2009 European Association of Urology (EAU) guidelines on ED and PE.

EVIDENCE ACQUISITION

A systematic review of the recent literature on the epidemiology, diagnosis, and treatment of ED and PE was performed. Levels of evidence and grades of recommendation were assigned.

EVIDENCE SYNTHESIS

ED is highly prevalent, and 5-20% of men have moderate to severe ED. ED shares common risk factors with cardiovascular disease. Diagnosis is based on medical and sexual history, including validated questionnaires. Physical examination and laboratory testing must be tailored to the patient's complaints and risk factors. Treatment is based on phosphodiesterase type 5 inhibitors (PDE5-Is), including sildenafil, tadalafil, and vardenafil. PDE5-Is have high efficacy and safety rates, even in difficult-to-treat populations such as patients with diabetes mellitus. Treatment options for patients who do not respond to PDE5-Is or for whom PDE5-Is are contraindicated include intracavernous injections, intraurethral alprostadil, vacuum constriction devices, or implantation of a penile prosthesis. PE has prevalence rates of 20-30%. PE may be classified as lifelong (primary) or acquired (secondary). Diagnosis is based on medical and sexual history assessing intravaginal ejaculatory latency time, perceived control, distress, and interpersonal difficulty related to the ejaculatory dysfunction. Physical examination and laboratory testing may be needed in selected patients only. Pharmacotherapy is the basis of treatment in lifelong PE, including daily dosing of selective serotonin reuptake inhibitors and topical anaesthetics. Dapoxetine is the only drug approved for the on-demand treatment of PE in Europe. Behavioural techniques may be efficacious as a monotherapy or in combination with pharmacotherapy. Recurrence is likely to occur after treatment withdrawal.

CONCLUSIONS

These EAU guidelines summarise the present information on ED and PE. The extended version of the guidelines is available at the EAU Web site (http://www.uroweb.org/nc/professional-resources/guidelines/online/).

Sexual dysfunction in multiple sclerosis

Multiple sclerosis is a chronic disease that commonly affects young adults who may be sexually active. Sexual dysfunction is a significant, but often underestimated, symptom of multiple sclerosis, affecting 50-90% of men and 40-80% of women. The types of sexual dysfunction can be categorized in terms of the normal sexual response cycle: sexual interest/desire dysfunction (reduced libido), sexual arousal dysfunction (including erectile dysfunction) and ejaculatory and orgasmic dysfunction. Sexual dysfunction may not only be due to lesions affecting the neural pathways involved in physiological function (primary dysfunction), but also result from general physical disabilities (secondary dysfunction) or psychological and emotional issues (tertiary dysfunction). Comprehensive management should address all these possible contributing problems. Specific pharmacotherapy is only currently available for erectile dysfunction. This review summarizes the available information about sexual dysfunction in men and women with multiple sclerosis.

British Society for Sexual Medicine guidelines on the management of erectile dysfunction

INTRODUCTION

UK primary care physicians are required to follow authoritative endorsed guidelines as part of their terms of service. The major influence on the management of erectile dysfunction in primary and secondary care between 1999 and 2007 has been Department of Health "guidance on good practice," a non-evidence-based document, essentially defining patients who qualify for government-funded treatment.

AIM

To provide clinically based guidelines relevant to UK primary and secondary healthcare professionals in their daily practice.

METHODS

A multidisciplinary panel of seven UK experts including two primary care physicians from the British Society for Sexual Medicine met for two full day meetings between September 2006 and April 2007, with each member allocated to disease areas related to their specialty. Feedback and approval of all sections between panel members was facilitated by the chairman. Source information was obtained from peer reviewed articles, meetings and presentations. Articles were chosen from electronically searching the Cochrane Library, Medline and Embase for randomized controlled clinical trials and graded according to level of evidence.

RESULTS

Patient-reported sexual activity, satisfaction with sexual activity (Male Sexual Health Questionnaire), and treatment expectations; urologists' subjective assessment of the importance given by their patients to ED; the timing they propose for starting ED treatment.

RESULTS

After the second full day meeting in January 2007, the final version was approved by panel members and made available for healthcare professions by download from http://www.bssm.org and from http://www.eguidelines.co.uk

CONCLUSIONS

A comprehensive evidence-based guideline has been developed that is highly relevant for primary and secondary care professionals enabling them to work within the unique requirements of the UK healthcare system.

Treatment options for erectile dysfunction

A wide variety of medications, devices, and surgical interventions are available to patients who have ED. These range from first-line oral agents to second-line therapy with injections or vacuum devices to third-line options, such as penile prosthesis implantation. In this article, we cover available treatments for erectile dysfunction, ranging from first-line to third-line therapies.

Early use of vacuum constriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function

To assess the efficacy of vacuum constriction devices (VCD) following radical prostatectomy (RP) and determine whether early use of VCD facilitates early sexual activity and potentially earlier return of erectile function. This prospective study consisted of 109 patients who underwent nerve-sparing (NS) or non-nerve-sparing (NNS) RP between August 1999 and October 2001 and developed erectile dysfunction following surgery. The patients were randomized to VCD use daily for 9 months (Group 1, N=74) or observation without any erectogenic treatment (Group 2, N=35). Treatment efficacy was analyzed by responses to the Sexual Health Inventory of Men (SHIM) (abridged 5-item International Index of Erectile Function (IIEF-5)), which were stratified by the NS status. Patient outcome regarding compliance, change in penile length, return of natural erection, and ability for vaginal intercourse were also assessed. The mean patient age was 58.2 years, and the minimum follow-up was 9 months. Use of VCD began at an average of 3.9 weeks after RP. In Group 1, 80% (60/74) successfully used their VCD with a constriction ring for vaginal intercourse at a frequency of twice/week with an overall spousal satisfaction rate of 55% (33/60). In all, 19 of these 60 patients (32%) reported return of natural erections at 9 months, with 10/60 (17%) having erections sufficient for vaginal intercourse. The abridged IIEF-5 score significantly increased after VCD use in both the NS and NNS groups. After a mean use of 3 months, 14/74 (18%) discontinued treatment. In Group 2, 37% (13/35) of patients regained spontaneous erections at a minimum follow-up of 9 months after surgery. However, only four of these patients (29%) had erections sufficient for successful vaginal intercourse and rest of patients (71%) sought adjuvant treatment. Of the 60 successful users, 14 (23%) reported a decrease in penile length and circumference at 9 months (range, 4-8 months) compared to 12/14 (85%) among the nonresponders. However, in control group 22/35 reported decrease in penile length and circumference. Early use of VCD following RP facilitates early sexual intercourse, early patient/spousal sexual satisfaction, and potentially an earlier return of natural erections sufficient for vaginal penetration.

Evaluation of a progressive treatment program for erectile dysfunction in patients with diabetes mellitus

The aim was to evaluate the effectiveness of a progressive program, starting with simple methods and, when not effective, moving to more complex methods, to treat erectile dysfunction (ED) in patients with diabetes mellitus. A total of 284 diabetic patients with ED entered into a 6-phase program starting with sildenafil citrate (Viagra). Those with contraindications, side effects, or negative response (erection insufficient for vaginal penetration) were switched to the vacuum erection device (VED), and then progressively (for failures) to intracavernous injection (ICI), sildenafil citrate+ICI, ICI+VED, and penile prosthesis. Patients were followed for 2 y. Of the 284 patients 276 patients were eligible for sildenafil citrate and 147 (53.3%) responded positively, but 25 (9.1%) patients stopped it soon due to adverse effects. Of 162 patients (129 nonresponders, eight noneligible for the sildenafil and 25 patients who dropped out due to adverse effects), treated with VED, 114 (70.4%) responded well, however, only 19 (11.7%) patients agreed to continue its use. Of the remaining 143 patients (nonresponders, noneligible for the previously mentioned treatments and patients who dropped out due to adverse effects), 103/143 (72%) responded to ICI, 27/40 (67.5%) to sildenafil+ICI, and 9/13 (69.2%) to ICI+VED. Four patients received a penile implant. At the 2 y follow-up, 81 of 284 patients who entered the study (28.5%) were still responding to sildenafil, seven (2.5%) to VED, 113 (39.8%) to ICI, 24 (8.5%) to sildenafil+ICI, two (0.7%) to ICI+VED; 15 (5.3%) had a penile implant. In all 17 (6%) patients reported spontaneous erections, 11 (3.9%) stopped the treatment due to family reasons and 14 (4.9%) failed the treatment. In conclusion, the progressive treatment program for ED seems to be very effective for diabetic patients, yielded a complete response for short-term and 91.2% rate of success at the end of 2 y follow-up.

Male infertility in spinal cord trauma

Every year there are 10 thousand new cases of patients victimized by spinal cord trauma (SCT) in the United States and it is estimated that there are 7 thousand new cases in Brazil. Eighty percent of patients are fertile males. Infertility in this patient group is due to 3 main factors resulting from spinal cord lesions: erectile dysfunction, ejaculatory disorder and low sperm counts. Erectile dysfunction has been successfully treated with oral and injectable medications, use of vacuum devices and penile prosthesis implants. The technological improvement in penile vibratory stimulation devices (PVS) and rectal probe electro-ejaculation (RPE) has made such procedures safer and accessible to patients with ejaculatory dysfunction. Despite the normal number of spermatozoa found in semen of spinal cord-injured patients, their motility is abnormal. This change does not seem to be related to changes in scrotal thermal regulation, frequency of ejaculation or duration of spinal cord damage but to factors related to the seminal plasma. Despite the poor seminal quality, increasingly more men with SCT have become fathers through techniques ranging from simple homologous insemination to sophisticated assisted reproduction techniques such as intracytoplasmic sperm injection (ICSI).

Specific aspects of erectile function in urology/andrology

The urologist/andrologist is the specialist responsible for diagnosis and treatment of health problems related to the genitourinary tract, and his or her participation in comprehensive care for a patient with erectile dysfunction (ED) is fundamental and often indispensable. The urologists/andrologists should characterize the origin of ED because of their knowledge and familiarity of all diagnostic tests and second- and third-line therapy. The origin of ED is important to determine for various reasons, such as young people suitable for etiologic treatment, medicolegal reasons, or patients' wishes for a better understanding of their condition. A review of the diagnostic tests available as well as indications for second- and third-line therapy is presented. The close relationship between ED and urological disorders, such as benign prostatic hyperplasia, prostate cancer and their treatments, and renal failure, in association with penile conditions like Peyronie's disease, priapism, and possible androgen deficiency in men older than 50 years, places the urologist at the center of integrated treatment of male ED.

Sexual dysfunction and diabetes

Erectile Dysfunction (ED) is common in men with diabetes. Diabetic men are three times as likely to develop ED as non-diabetic men. The cause is multifactorial, but most commonly reflects endothelial dysfunction and autonomic neuropathy. Diabetes and vascular disease often coexist and ED may be a marker for silent occlusive arterial disease, for which the patient should be screened. Many men still do not volunteer their problem, hence, routine questioning by health care professionals is an important part of the overall management because of the deleterious effect of ED on relationships, self-esteem and quality of life. Treatment is effective in the majority and all options should be considered, beginning with the much preferred oral phosphodiesterase type 5 inhibitors (sildenafil, tadalafil, vardenafil). Female Sexual Dysfunction or Disorder (FSD) is more difficult to define and specific studies in diabetics are limited. Problems with arousal, lubrication and orgasmic dysfunction occur, but the fatigue of diabetes may be influencing these complaints, and in general, psychological issues appear to predominate.

Inflatable penile prosthesis: site-specific malfunction analysis

The purpose of this study was to analyze retrospectively the exact site(s) of device failure of a large series of Mentor Alpha I inflatable penile prostheses. The study consisted of 442 patients implanted over a 12-year period. Only those patients who developed a device malfunction and returned for re-evaluation by the author were included. The exact site(s) of device malfunction were obtained from a review of operative reports. The average length of follow-up in this series was 63 months, ranging from 1 to 138 months. In all, 22 (4.98%) patients developed device malfunction and returned for evaluation, including six (3.9%) of the 154 infrapubic devices and 16 (5.6%) of the 288 scrotal devices. Of these 22 patients, three declined revision and 19 were reoperated on by the author. The exact site of malfunction differed in the infrapubic vs scrotal implants. Most malfunctions of the scrotal device involved tubing fractures at the pump strain reliefs, whereas infrapubic device malfunctions typically involved the cylinders or the reservoir. A review of these malfunction patterns may assist the manufacturer in further improving the reliability of this prosthesis, and may assist implanting surgeons in planning operative procedures.

[Erectile dysfunction]

In Spain, based on the IIEF, 19% of males between 25 and 70 years old present some degree of erectile dysfunction (ED). Therefore, around 2,000,000 Spanish men present this condition and could require medical attention for it. Here, we present an up-date of the most important aspects of erectile dysfunction (pathophysiology, diagnosis and treatment). We review, in detail, the oral treatments and future drugs that are presently in the premarketing experimental phase. Diagnostic and therapeutic management of the patient with erectile dysfunction should be individualized, taking into account the goals of each patient. It is highly recommendable to carry out a basic assessment (comprehensive clinical history, physical examination, recommended lab testing). If previously undiagnosed diseases are discovered (diabetes, arteriosclerosis, etc.) these should be treated and modifiable risk factors should be corrected. There are numerous therapeutic options for the treatment of erectile dysfunction. Replacement therapy with testosterone should only be used in males with ED and low levels of this hormone, under medical supervision. At present, first line treatment consists of the administration of oral drugs (sildenafil, apomorphine). There are two new PDE 5 inhibitors (tadalafil and vardenafil) that will be released on the market 2003, which will provide better selectivity. Moreover, several drugs for oral administration are in the initial phases of research that will facilitate erection via a direct penile action. When oral drugs are contraindicated, are not effective or when they are unpopular with the patient, the second line of treatment is intracavernous injection. Prostaglandin E1 is the initial drug of choice in patients using intracavernous autoinjection for the first time and has a high efficacy. Implantation of a penis prosthesis and penile revascularisation are appropriate for highly selected patients. Psychotherapy can be an option for men with ED of psychogenic origin, either as a monotherapy or combined with sildenafil or apomorphine.

Erectile dysfunction and diabetes

Erectile dysfunction (ED) has been the most neglected complication of diabetes. It is a common abnormality that affects more than 20 million American men. The prevalence of ED in the general population between the ages of 40 to 70 years is 52%. In men with diabetes, it ranges from 35% to 75%, and occurs at an earlier age. There have been several advances in the understanding of the physiologic and biochemical mechanisms controlling penile erections. Improved techniques in diagnoses and treatment of impotence have given the male with diabetes some hope in the management of this prevalent and emotionally disturbing complication.