Intracavernous injections: still the gold standard for treatment of erectile dysfunction in elderly men

Management of male erectile dysfunction: From the past to the future

Erectile dysfunction is a common disease of the male reproductive system, which seriously affects the life quality of patients and their partners. At present, erectile dysfunction is considered as a social-psychological-physiological disease with complex etiology and various treatment methods. Oral PDE5I is the first-line treatment for erectile dysfunction with the advantages of high safety, good effect and non-invasiveness. But intracavernosal injection, hormonal replacement therapy, vacuum erection device, penile prosthesis implantation can also be alternative treatments for patients have organic erectile dysfunction or tolerance to PDE5I. With the rapid development of technologies, some new methods, such as low-intensity extracorporeal shock wave and stem cell injection therapy can even repair the organic damage of the corpora cavernosa. These are important directions for the treatment of male erectile dysfunction in the future. In this mini-review, we will introduce these therapies in detail.

Sexual dysfunction in the older man

Age is strongly associated with risk of sexual dysfunction in both men and women. For many years it was assumed that such a loss of sexuality was natural and inevitable, and therefore little attention was given to sexual behaviour and treatment in this population. However, more recent data have suggested that sexuality remains important into later life for many individuals. Although appreciation of sexuality persists, a decline in sexual activity is typical with advancing age, which is in part attributable to both general health problems and specific sexual dysfunctions, both becoming more prevalent with ageing. The principle sexual health issues in older men include erectile dysfunction and late onset hypogonadism. Although premature ejaculation is prevalent in older men, the bother from this disorder is generally lower in older men. This manuscript consists of a review of the contemporary peer-reviewed literature and attempts to provide insights for the physician treating the geriatric population. We discuss sexual behaviour at older age, and address erectile and androgen biology in older men and the prevalence and aetiology of sexual dysfunction in this population. Furthermore, an overview of contemporary pharmacological treatments for older men's sexual problems is provided.

Repeated intracorporeal self-injection: effect on peak systolic velocity and cavernosal artery diameter

This work is aimed at evaluating the effect of repeated intracavernosal injection (ICI) self-injection on the peak systolic velocity (PSV) and the diameter of cavernosal arteries. Sixty erectile dysfunction (ED) patients who were positive responders for ICI therapy were studied. Pharmacopenile duplex ultrasonography (PPDU) was carried out before starting ICI and after 10 doses of home therapy in an open-label uncontrolled study. There was significant increase in the cavernosal artery diameter and their PSV before and after injection. Cavernosal arteries diameter before injection in both right and left sides was 0.64+/-0.13 and 0.63+/-0.12 mm at the start and became 0.81+/-0.22 and 0.79+/-0.22 mm respectively at the end with significant differences (P<0.001). Cavernosal arteries diameter after injection in both right and left sides was 1.10+/-0.18 and 1.09+/-0.19 mm at the start and became 1.34+/-0.39 and 1.27+/-0.33 mm respectively at the end with significant differences (P<0.001). PSV at the start was 33.77+/-13.26 and 32.33+/-8.09 cm/s on both right and left sides and became 44.4+/-1.19 and 46.1+/-5.86 cm/s respectively at the end with significant differences (P<0.001). It is concluded that repeated ICI improves arterial erectile response with associated increase in PSV and cavernosal artery diameters.

Erectile dysfunction:

The treatment of male sexual dysfunction in the elderly offers special challenges. Commonly, these men have other conditions requiring medical treatment and the possibility of adverse drug interactions is common. Similarly, the severity of dysfunction is frequently increased by alteration in various organ systems. For instance, ED is commonly associated with significant cardiovascular problems and hormonal alterations. The treatment of these men requires familiarity with the various options available and good clinical judgment to determine when and how modification of therapeutic regimens and combinations of specific drugs may provide the best responses. Frequently one hears the embarrassed older man coming for a consultation and stating that, "At my age, I should not be thinking of this." It is imperative to remember that advancing age does not preclude sexual interest and desire for performance. A well-informed, understanding physician can provide sound advice, institute appropriate therapies, and organize intelligent referrals.

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.

Topical alprostadil cream for the treatment of erectile dysfunction: a combined analysis of the phase II program

OBJECTIVES

To present a meta-analysis of the efficacy and safety data of two recently completed Phase II studies examining a novel alprostadil topical cream for the treatment of erectile dysfunction (ED).

METHODS

Patients (n = 303) with ED of at least 3 months' duration were randomized to receive placebo or 50, 100, 200, or 300 microg alprostadil in two nearly identical 11-dose, multicenter, at-home studies of a novel topical cream containing alprostadil and a proprietary skin permeation enhancer. The primary efficacy endpoint was the change in erectile function domain score from baseline to the final visit. Secondary endpoints included changes in scores for questions 3 and 4 of the International Index of Erectile Function and standard diary analyses. Safety was assessed by analysis of adverse events, changes in laboratory test results, and physical examination findings.

RESULTS

The mean baseline parameters for the erectile function score, ED history, and secondary diagnoses suggested no significant differences among the treatment groups. The changes from baseline to the final visit erectile function scores were 0.98 +/- 0.84, 3.4 +/- 1.3, 3.4 +/- 0.88 (P <0.05), 5.3 +/- 0.92 (P <0.001), and 9.4 +/- 1.43 (P <0.001) for the ascending dose groups. Most secondary efficacy endpoints were significant for the 200 and 300-microg dose groups. Dose-related trends in efficacy were observed. Adverse events were localized to the application site, were of mild or moderate intensity, and were of short duration.

CONCLUSIONS

These results suggest topical alprostadil cream, when combined with a novel dermal permeation-enhancer, to be a potentially useful agent for the treatment of ED.