Intracavernosal injection and intraurethral therapy for erectile dysfunction

Prostaglandins as a Topical Therapy for Erectile Dysfunction: A Comprehensive Review

INTRODUCTION

Erectile dysfunction (ED) is a substantial cause of dissatisfaction among many men. This discontentment has led to the emergence of various drug treatment options for this problem.

OBJECTIVES

Unfortunately, due to various interactions, contraindications, and side effects, systemic therapies such as phosphodiesterase-5 inhibitors (including sildenafil, tadalafil, vardenafil, avanafil, etc.) are not welcomed in many patients. These problems have led researchers to look for other ways to reduce these complications.

METHODS

This article holistically reviews the efficacy of topical prostaglandins and their role in treating ED. We sought to provide a comprehensive overview of recent findings on the current topic by using the extensive literature search to identify the latest scientific reports on the topic.

RESULTS

In this regard, topical and transdermal treatments can be suitable alternatives. In diverse studies, prostaglandins, remarkably PGE1 (also known as alprostadil), have been suggested to be an acceptable candidate for topical treatment.

CONCLUSION

Numerous formulations of PGE1 have been used to treat patients so far. Still, in general, with the evolution of classical formulation methods toward modern techniques (such as using nanocarriers and skin permeability enhancers), the probability of treatment success also increases.

Evaluation of the sexual function of female partners of men with erectile dysfunction receiving different treatment modalities: An observational study

Objective:

To evaluate sexual functions of patients with erectile dysfunction (ED) and their female partners.

Methods:

A total of 90 consecutive ED patients who received different ED therapies and their partners and 90 consecutive controls and their partners were divided into four groups. All participants were evaluated by the 15-item international index of erectile function and the Arabic version of female sexual function index (Ar-FSFI).

Results:

All ED patients who received sildenafil demonstrated significant improvements of their erectile function compared to baseline. Their partners did not demonstrate improvements in frequency of pain during vaginal penetration (3.86 ± 0.58, 3.93 ± 0.45, p = 0.477), confidence of becoming aroused (3.86 ± 0.58, 3.93 ± 0.45, p 0.477), frequency of satisfaction with arousal (3.07 ± 0.37, 3.03 ± 0.49, p 0.712), and maintenance of lubrication (4.37 ± 0.49, 4.23 ± 0.73, p 0.354). All ED patients who received quadmix demonstrated significant improvements of their erectile function compared to baseline. Their partners did not demonstrate improvements in desire level (2.6 ± 0.67, 2.63 ± 0.85, p = 0.869) and lubrication maintenance (3.53 ± 0.82, 3.47 ± 0.82, p = 0.423). Finally, All ED patients who underwent semi rigid penile implant demonstrated significant improvements of their erectile function compared to baseline. Their female partners demonstrated significant improvements in all items of FSFI-19 compared to baseline except the frequency of pain during vaginal penetration (3.86 ± 0.58, 3.93 ± 0.45, p = 0.477), confidence of becoming aroused (3.86 ± 0.58, 3.93 ± 0.45, p = 0.477), frequency of satisfaction with arousal (3.07 ± 0.37, 3.03 ± 0.49, p = 0.712), and maintenance of lubrication (4.37 ± 0.49, 4.23 ± 0.73, p = 0.354).

Conclusions:

Sexual functions of ED males significantly improved after ED therapies. Nevertheless, some sexual functions of their partners were not positively impacted.

Lipid-based nanoparticles in the treatment of erectile dysfunction

Erectile dysfunction (ED) is a common disorder among men, with significant public health implications. Current therapies have certain limitations including efficacy and safety issues, necessitating the development of novel therapeutic strategies for ED. Nanotechnology-based drug delivery systems are being explored to overcome these limitations with promising in vitro and in vivo efficacies. In particular, lipid-based nanoparticles have generated considerable interest owing to their potential to enhance drug bioavailability, and decrease side effects and drug susceptibility to metabolism. This review summarizes the recent findings using lipid-based nanoparticles in ED therapy.

Efficacy and safety of an herbal formula (KBMSI-2) in the treatment of erectile dysfunction: A preliminary clinical study

Purpose

To investigate the efficacy and safety of KBMSI-2, an herbal formula consisting of Ginseng Radix Rubra, Dioscorea tenuipes, Cornus officinalis Sieb. et Zucc., Lycium chinense Mill, and Curcuma longa Linn, for the treatment of erectile dysfunction (ED).

Materials and Methods

Patients were instructed to take placebo or 6 g of KBMSI-2 twice per day for 8 weeks, at least 1 hour after food intake. The primary outcome was a change from baseline in erectile function (EF) domain scores of the International Index of Erectile Function (IIEF) questionnaire. Secondary outcome included changes from baseline in all domain scores of the IIEF, scores on the Aging Males' Symptoms scale, and serum total testosterone levels, as well as changes in questions 2 and 3 of the Sexual Encounter Profile, responses to the Global Assessment Question, and changes in the number of ‘yes’ responses on the Androgen Deficiency in Aging Males questionnaire.

Results

Patients receiving KBMSI-2 had a statistically significant improvement in baseline IIEF-EF domain scores at 8 weeks compared to the placebo group. Intercourse satisfaction domain and the total IIEF scores also increased in the KBMSI-2 group. However, we could not find any significant differences in other efficacy variables between the groups. Only one patient had an adverse event, which was mild in severity.

Conclusions

This preliminary clinical study of KBMSI-2 shows significant improvements in EF and intercourse satisfaction, as measured by the IIEF in patients with ED. Further studies using a larger number of patients in the long term should follow.

A Randomized, Placebo-Controlled, Double-Blind, Multi-Center Therapeutic Confirmatory Study to Evaluate the Safety and Efficacy of Avanafil in Korean Patients with Erectile Dysfunction

A multi-center, randomized, double-blind, placebo-controlled study was conducted with 158 subjects who were randomized to placebo or avanafil 50, 100, and 200 mg on demand for 8 weeks to evaluate the safety, tolerability, and efficacy of avanafil in the treatment of erectile dysfunction (ED) in Korean men. The primary outcome was the erectile function (EF) domain score of the International Index of Erectile Function (IIEF) questionnaire. Secondary outcomes included changes in the scores of IIEF questions 3 and 4 (IIEF Q3, Q4) from baseline, changes in all domain scores in the IIEF from baseline, Sexual Encounter Profile questions 2-5 (SEP2-5), the Global Efficacy Assessment Question (GEAQ), and the number of subjects whose EF domain score at the 8th week visit was ≥ 26. After 8 weeks of treatment, the dose groups except avanafil 50 mg scored significantly higher on the IIEF-EF domain from baseline than the placebo group. The changes from baseline in the avanafil group in IIEF Q3 (all doses) and Q4 (200 mg alone) were higher than the placebo group. The differences between avanafil and placebo groups were significant in SEP2 (100 and 200 mg) and SEP3-5 (200 mg). The differences in the GEAQ "Yes" response were also significant in the avanafil 100 and 200 mg groups. Regarding the ratio of normal EF at the end of the study, avanafil 200 mg differed significantly from the placebo. Most treatment-associated adverse events were mild and resolved spontaneously. This is a clinical trial study and was registered at www.ClinicalTrials.gov (Identifier: NCT02477436).

Pathophysiological role of the renin-angiotensin system on erectile dysfunction

BACKGROUND

The renin-angiotensin system (RAS) has been shown to play an active role within the erectile tissues. The aim of this narrative review is to summarize the literature addressing the pathophysiological role of RAS on erectile function. Additionally, we update evidence on recent findings on the role of the Ang-(1-7) and Mas receptor on the erectile function and its therapeutic potential for treating erectile dysfunction (ED).

MATERIALS AND METHODS

This narrative review is based on the material searched and obtained via MEDLINE and PubMed up to November 2012. The search terms we used are 'angiotensin, erectile dysfunction, renin, Mas receptor' in combination with 'pathophysiology, fibrosis, pathways'.

RESULTS

The levels of angiotensin (Ang) II, the main component of this system, are increased in the corpus cavernosum as compared to those found in the systemic circulation. Moreover, emerging evidence indicates that an increased activity of Ang II via AT1 receptor might contribute to the development of ED, whereas the pharmacological blockage of Ang II/AT1 actions has beneficial effects on the erection. On the other hand, the heptapeptide Ang-(1-7), known as a major endogenous counter-regulator of Ang II actions, favours penile erection via the activation of Mas receptor.

CONCLUSIONS

Ang-(1-7) and Mas receptor pathway might be considered as a promising therapeutic target for the treatment of ED.

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.

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.

Erectile Dysfunction Following Radical Retropubic Prostatectomy

Radical prostatectomy has been the time-honoured and standard treatment option for prostate cancer. Erectile dysfunction (ED) is one of the common quality-of-life issues following radical prostatectomy. The recovery of potency following radical prostatectomy varies from 16% to 86%. Although major modifications in surgical technique appear to be promising, the reported ED rates are still high. The time period required for the recovery of erectile function after surgery varies from 6 to 24 months. During this period of neuropraxia lack of natural erections produces cavernosal hypoxia. This cavernosal hypoxia has been implicated as one of the most important factors in the pathophysiology of ED. Cavernosal hypoxia predisposes to cavernosal fibrosis, ultimately producing venous leak and long-term ED. Interruption of this cascade of events has been the major challenge for physicians. Physicians have several options available for the treatment of ED. However, oral treatment options have quickly become established as first-line treatment options. Sildenafil has been most extensively studied in the radical prostatectomy population. In patients who do not respond to oral therapy alone, standard treatment options (intracavernosal injections, vacuum constriction devices and intraurethral alprostadil) are useful. Use of penile prostheses is one of the oldest treatment options available for the treatment of ED but is used only as a last resort. Initial attempts to promote the earlier recovery of erectile function appear to be promising. However, further confirmatory studies are essential. The roles of gene transfer and growth factors are still in experimental stages. In this review we discuss the epidemiology, pathophysiology and treatment options available for ED following radical prostatectomy.

Isolated endogenous endophthalmitis due to a sporodochial-formingPhialemonium curvatumacquired through intracavernous autoinjections

We report a case of endogenous endophthalmitis due to a sporodochial-forming species of Phialemonium curvatum. The infection led to the enucleation of the affected eye, but there was no evidence of systemic dissemination. The isolated P. curvatum produced aggregates of phialides, many occurring on coils or in verticils, which eventually develop into sporodochia. The initial and post-enucleation isolates revealed they were identical to strains of P. curvatum from Israel causing disseminated disease in patients practicing intracavernous autoinjections for the treatment of erectile dysfunction. The reported case had unusual clinical and microbiological features. Despite the route of acquisition and the lack of systemic antifungal therapy, the infection did not spread beyond the eye. The morphology of the phialides aggregates was also unique, and the distinction between Volutella and Acremonium is discussed. This case expands the spectrum of infections due to Phialemonium species, and reveals a novel way of developing fungal endophthalmitis.

Erectile dysfunction: management update

Dramatic advances in the management of erectile dysfunction have occurred over the past decade. Oral therapy with vasoactive agents has emerged as first-line treatment and has transformed both the manner in which the public views erectile dysfunction and the way health care providers deliver care. Whereas an extensive investigation was previously common in the management of erectile dysfunction, recent treatment guidelines promote a more minimalist, goal-oriented approach. In this article, we review the physiology of erection, and the pathophysiology, diagnosis and clinical management of erectile dysfunction. We also present the existing evidence for the efficacy of 3 phosphodiesterase inhibitors, the most widely used class of agents for erectile dysfunction.

Erectile dysfunction

Erectile dysfunction (ED) is a highly prevalent and often undertreated condition. It may be a symptom of underlying, chronic illness and can have a negative impact on quality of life, psychosocial health, and relationships. The aging of the population, as well as the introduction of new treatment options, such as sildenafil, has led to increased public awareness of this disorder. New oral therapeutic agents are on the horizon. This article provides an overview of the physiology of erection, the pathophysiology of ED, and modern patient evaluation. Management options, including traditional therapeutic approaches as well as the new generation of oral agents, are also presented.

Pharmacological management of erectile dysfunction

Erectile dysfunction (ED) is a common medical condition that affects the sexual life of millions of men worldwide. Many drugs are now available for treating ED; oral pharmacotherapy represents the first-line option for most patients with ED. Sildenafil, an inhibitor of the enzyme phosphodiesterase type 5, is currently the most widely prescribed oral agent and has a very satisfactory efficacy-safety profile in all patient categories. Apomorphine SL is a dopamine D1- and D2-receptor agonist which has recently been approved for marketing in Europe. It is best selected for treating patients with mild to moderate ED. Vardenafil and tadalafil are new phosphodiesterase type 5 inhibitors which are expected to be approved this year. Both of them have significant positive efficacy-safety profiles. Patients who do not respond to oral pharmacotherapy or who cannot use it are good candidates for intracavernosal and intraurethral therapy. Alprostadil is the most widely used drug, both for injection therapy and for the intraurethral route. The efficacy of second-line treatment is high but the attrition rate remains significant.

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.

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.

[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.

Vasoactive agents induce cytotoxicity in cultured human penile smooth muscle cells

OBJECTIVES

To evaluate the direct in vitro cytotoxicity of vasoactive agents (papaverine, phentolamine, and prostaglandin E(1) [PGE(1)]) to human penile cavernosal smooth muscle cells. Intracavernous pharmacotherapy with vasoactive agents for male erectile dysfunction has been associated with long-term complications such as a reduction in penile smooth muscle content and fibrosis.

METHODS

Human penile cavernosal tissue explants (1 to 2 mm(3) size) were obtained with proper institutional review board approval from patients undergoing penile prosthesis implantation. Primary culture was initiated in Dulbecco's modified Eagles medium containing 10% fetal bovine serum, and monolayer cavernosal cells were grown in 48-well tissue culture dishes. At 60% to 80% confluence, cells were labeled overnight with (51)Na(2)CrO(4) (1.5 microCi) and then incubated with therapeutic concentrations of papaverine (1.5 to 30 mg/mL), phentolamine (0.5 mg/mL), and PGE(1) (5 microg/mL) alone, as well as in combination, for 30 minutes at 37 degrees C. At the end of incubation, an aliquot of supernatant was collected in scintillation vials. The release of cell-free chromium in supernatants was determined in a liquid scintillation counter, and results were expressed as the percentage of cytotoxicity.

RESULTS

Papaverine induced a significant dose-dependent increase in chromium release from the cavernosal cells. At therapeutic concentrations, papaverine (30 mg/mL) produced up to 60% cytotoxicity; PGE(1) (5 microg/mL) resulted in 40% toxicity. The combination of papaverine with either PGE(1) or phentolamine had a cumulative toxic effect, and maximal toxicity (70%) was observed with the triple combination.

CONCLUSIONS

Papaverine-induced cytotoxicity to cavernosal smooth muscle cells may contribute to the fibrosis and loss of smooth muscle content associated with the intracavernous pharmacotherapy. Quantitative evaluation of in vitro cytotoxicity in human cavernosal smooth muscle cell culture may be important in the development of new intracavernosal vasoactive agents.