Erectile Dysfunction Following Radical Retropubic Prostatectomy

Quality of life and sexual health in men with prostate cancer undergoing radical prostatectomy

The aim of this study was to evaluate the relationship between quality of life, erectile function and group psychotherapy in patients with prostate cancer undergoing radical prostatectomy. Sixty patients were evaluated for erectile function (IIEF-5), quality of life (SF-36SF), urinary incontinence (ICQI-SF and ICQI-OAB). Thirty of them had group psychotherapy two weeks before and 12 weeks after surgery. Patients who underwent group psychotherapy had better scores in IIEF-5, satisfaction with life in general, satisfaction with sexual life and in partner relationship; better results of SF-36SF, excepting two domains: bodily pain and role emotional. There were significant correlations between IIEF-5 and perception of discomfort (p = .030), physical functioning (p = .021), physical component (p = .005) and role emotional (p = .009) in patients undergoing group psychotherapy. In patients who didn't have group psychotherapy there were significant correlations between ICQI-OAB and perception of discomfort (p = .025), social functioning (p = .052) and role emotional (p = .034); between ICQI-SF and perception of discomfort (p = .0001). Group psychotherapy has a positive impact in quality of life and erectile function. There was no difference in the urinary function of the two groups. Further studies are necessary to identify the impact of self-perception and self-knowledge in the postoperative management of radical prostatectomy.

Pelvic Floor Muscle Training and Erectile Dysfunction in Radical Prostatectomy: A Randomized Controlled Trial Investigating a Non-Invasive Addition to Penile Rehabilitation

INTRODUCTION

Pelvic floor muscle (PFM) training for postprostatectomy incontinence is considered a first line approach to rehabilitation, but PFM training for erectile dysfunction (ED) after surgery is less well known. With more than 1.4 million new cases diagnosed globally per year, there is a need for non-invasive options to assist sexual dysfunction recovery.

AIM

Commencing preoperatively and using both fast and slow twitch fibre training performed in standing postures, new protocols were developed to address clinical presentations with aims to reduce ED and impact on quality of life (QoL). Comparisons with "usual care" PFM training, prerehabilitation and postrehabilitation were then assessed.

METHODS

A randomised controlled trial of 97 men undergoing radical prostatectomy (RP) were allocated to either a control group (n = 47) performing "usual care" of 3 sets/d PFMT or an intervention group (n = 50), performing 6 sets/d in standing, commencing 5 weeks before RP.

OUTCOME MEASURES

Participants were assessed preoperatively and at 2, 6, and 12 weeks after RP using the Expanded Prostate Cancer Index Composite for Clinical Practice, International Index of Erectile Function-5, and real time ultrasound measurements of PFM function.

RESULTS

At all time points, there was a significant difference (P< 0.05) between groups; however, the only time point where this difference was clinically relevant was at 2 weeks after RP, with the intervention group reporting less distress in the Expanded Prostate Cancer Index Composite for Clinical Practice QoL outcome. Secondary measures of EPIC-EF and real time ultrasound PFM function tests demonstrated improvement over all time points in both groups with lower bothersome scores in the intervention group.

CONCLUSIONS

Early PFM training reduces early QoL impact for postprostatectomy ED, with faster return to continence enabling earlier commencement of penile rehabilitation. While our 12-week protocol and sample size was not powerful enough to demonstrate conclusive benefits of early PFM training for ED, PFM intervention after RP over longer times has been supported by others. Milios JE, Ackland TR, Green DJ. Pelvic Floor Muscle Training and Erectile Dysfunction in Radical Prostatectomy: A Randomized Controlled Trial Investigating a Non-Invasive Addition to Penile Rehabilitation. J Sex Med 2020;8:414-421.

The Prostate Cancer Rehabilitation Clinic: a biopsychosocial clinic for sexual dysfunction after radical prostatectomy

Purpose

The most prevalent intervention for localized prostate cancer (pca) is radical prostatectomy (rp), which has a 10-year relative survival rate of more than 90%. The improved survival rate has led to a focus on reducing the burden of treatment-related morbidity and improving the patient and partner survivorship experience. Post-rp sexual dysfunction (sdf) has received significant attention, given its substantial effect on patient and partner health-related quality of life. Accordingly, there is a need for sdf treatment to be a fundamental component of pca survivorship programming.

Methods

Most research about the treatment of post-rp sdf involves biomedical interventions for erectile dysfunction (ed). Although findings support the effectiveness of pro-erectile agents and devices, most patients discontinue use of such aids within 1 year after their rp. Because side effects of pro-erectile treatment have proved to be inadequate in explaining the gap between efficacy and ongoing use, current research focuses on a biopsychosocial perspective of ed. Unfortunately, there is a dearth of literature describing the components of a biopsychosocial program designed for the post-rp population and their partners.

Results

In this paper, we detail the development of the Prostate Cancer Rehabilitation Clinic (pcrc), which emphasizes multidisciplinary intervention teams, active participation by the partner, and a broad-spectrum medical, psychological, and interpersonal approach.

Conclusions

The goal of the pcrc is to help patients and their partners achieve optimal sexual health and couple intimacy after rp, and to help design cost-effective and beneficial rehabilitation programs.

Development of UK recommendations on treatment for post-surgical erectile dysfunction

AIM

To develop a management strategy (rehabilitation programme) for postsurgical erectile dysfunction (ED) among men experiencing ED associated with treatment of prostate, bladder or rectal cancer that is suitable for use in a UK NHS healthcare context.

METHODS

PubMed literature searches of ED management together with a survey of 13 experts in the management of ED from across the UK were conducted.

RESULTS

Data from 37 articles and completed questionnaires were collated. The results discussed in this study demonstrate improved objective and subjective clinical outcomes for physical parameters, sexual satisfaction, and rates of both spontaneous erections and those associated with ED treatment strategies.

CONCLUSION

Based on the literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for postsurgical ED.

Intraurethral alprostadil for erectile dysfunction: a review of the literature

The global burden of erectile dysfunction (ED) is increasing. It is estimated that 8-19% of men in Europe have ED and that by 2025 the prevalence of ED worldwide will reach 322 million. The gold standard therapy for ED is an oral phosphodiesterase type 5 (PDE5) inhibitor, but they are not suitable for everyone; approximately 25% of patients do not respond to this therapy and it is contraindicated in others, e.g. those with vascular disease. When PDE5 inhibitors are not suitable, available options include intraurethral and intracavernosal alprostadil - a synthetic vasodilator chemically identical to the naturally occurring prostaglandin E(1) indicated for the treatment of ED. Intraurethral alprostadil is delivered by the Medicated System for Erection (MUSE).- a single-use pellet containing alprostadil suspended in polyethylene glycol administered using an applicator. It is recommended that intraurethral alprostadil be initiated at a dose of 500 μg, as it has a higher efficacy than the 250 μg dose, with minimal differences with regard to adverse events. Data from key clinical studies of intraurethral alprostadil show that it has a fast onset of effect and a good safety profile, with no occurrences of priapism, fibrosis (as seen with intracavernosal injection) or the typical systemic effects observed with oral ED pharmacological treatments. Intraurethral alprostadil has been associated with high patient preference, acceptance rates and quality of life versus intracavernosal injection due to its ease of administration. Evidence has shown that combination treatment with sildenafil may be a possible efficient alternative when single oral or local treatment has failed. Intraurethral alprostadil can be administered in all patients irrespective of ED origin and should be the first option in patients with ED for whom therapy with PDE5 inhibitors has failed or is contraindicated.

Should penile rehabilitation become the norm following radical prostatectomy?

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Radical retropubic prostatectomy: a review of outcomes and side-effects

BACKGROUND

Radical prostatectomy (RP) is worldwide probably the most common procedure to treat localized prostate cancer (PC). Due to a more widespread use of Prostate-Specific Antigen (PSA) testing, patients operated today are often younger and have organ confined disease justifying a more preservative surgery. At the same time, surgical technique has improved resulting in lower risk of permanent side-effects. This paper aims to give an overview of results from modern surgery regarding cancer control and side-effects. A brief overview of the history is given.

MATERIAL AND METHODS

A literature research identified recently published papers focusing on outcome and side-effects after RP.

RESULTS

One large randomized study (SPCG-4) compared RP and watchful waiting (WW). The study showed that RP was superior to WW in preventing local progression (RR = 0.36), distant metastasis (RR = 0.65) and death from PC (RR = 0.65). Observational studies also show a better outcome for men treated with RP compared to WW. Peri-operative mortality after RP is low in most material around 0.1%. The risk of stricture of the vesico-urethral anastomosis has decreased with improved technique from historically 10-20% to a low incidence of around 2-9% today. Also the risk of incontinence has declined with improved technique. However, while the rates of severe incontinence is usually very low, as many as 30% still report light incontinence after long-term follow-up. Erectile dysfunction (ED) is still a frequent side-effect after RP. This risk is dependent on age, pre-operative sexual function, surgical technique and other risk factors for ED such as smoking, diabetes, etc. In selected subgroups the risk of ED is low. Inguinal hernia is a more recently described complication after open retropubic RP with a postoperative incidence of 15-20% within three years of surgery.

CONCLUSION

RP is an effective method to achieve cancer control in selected patients. With modern technique it is a safe procedure with a low risk of permanent side-effects except for ED.

Patients' desire to preserve sexual activity and final decision for a nerve-sparing approach: results from the MIRROR (Multicenter Italian Report on Radical Prostatectomy Outcomes and Research) Study

INTRODUCTION

Preservation of sexual function after surgery represents a major issue for patients undergoing radical prostatectomy (RP).

AIM

To investigate determinants of patients' desire to preserve sexual activity before RP and surgeons' final decision to perform a nerve-sparing RP (NSRP).

METHODS

  Overall, 2,408 prostate cancer patients, candidates to RP, from 136 urologic departments across the Italian territory were evaluated in a multicenter prospective observational study. All patients underwent RP, according to single-center indications and procedures.

MAIN OUTCOME MEASURES

Age, body mass index, previous benign prostatic hyperplasia history, preoperative tumor characteristics, quality of life through the Short Form Health Survey (SF-12), and the University of California Los Angeles Prostate Cancer Index (UCLA-PCI), erectile function through the International Index of Erectile Function (IIEF-5), desire to preserve sexual activity, NS operative outcomes, and surgical margins status were recorded.

RESULTS

Overall, 1,667 were interested to preserve sexual activity. Age, physical component summary of SF12 (PCS-12), sexual function score of UCLA-PCI, and IIEF-5 score were the main determinants of such interest. Only 1,246 patients were suitable for a NSRP according to guidelines. Surgeons performed a non-NSRP (NNSRP) in 1,234 patients, a unilateral NSRP in 318 and a bilateral NSRP in 856. Age, bioptical Gleason score, percentage of positive cores, PCS-12, and patient's desire to preserve sexual activity were the main determinants of final decision for a NSRP. Surgeons performed a NSRP in 424 not suitable and in 121 not interested patients. Positive surgical margins in not suitable patients submitted to NSRP were not higher if compared to that obtained after NNSRP in the same subgroup. Limits include lack of oncological and functional follow-up.

CONCLUSIONS

Most patients are interested to preserve sexual activity. Discrepancies exist among patients' preferences, guidelines' indications, and surgeon's final decision.

The excess burden of side-effects from treatment in men allocated to screening for prostate cancer. The Göteborg randomised population-based prostate cancer screening trial

BACKGROUND

The number of men needed to treat to prevent one death is rather high in prostate cancer screening. How this affects the burden of treatment-related side-effects is unclear. The aim of this study was to evaluate the treatment related morbidity following radical prostatectomy in men participating in the Göteborg randomised population-based prostate cancer screening trial.

METHODS

In 1995, 20,000 men aged 50-64 years were randomly allocated (1:1) to biennial PSA-screening or to a control group not invited. A subset of prostate cancer patients undergoing radical prostatectomy between 2001 and 2008 responded to questionnaires preoperatively and at 18 months postoperatively. The primary endpoint was patient-reported frequencies of erectile dysfunction as measured by the validated International Index of Erectile Function-5 questionnaire and urinary incontinence as assessed by use of pads. Analyses were made according to intention to screen.

FINDINGS

After 14 years of follow-up, a total of 1849 men were detected with prostate cancer (1138 screened versus 711 controls, excluding 7 cancers detected at autopsy in the control group). Overall, 1047 received treatment with curative intent and radical prostatectomy was performed in 829 cases (79.2%). In this study, 294 of these men participated (205 screened and 89 controls). Of preoperatively potent men 79.1% (91/115) in the screening-group and 90.7% (49/54) in the control-group became impotent or sexually inactive 18 months postoperatively, whereas 14.3% (29/203) of screened men and 20.5% (18/88) of controls were considered postoperatively incontinent (regular use of pads). Extrapolated data yields that 120/10,000 more men become impotent and 25/10,000 more men will have the need of pads among men invited to regular PSA screening. The 'cost' per life saved at the same follow-up of screening is four men impotent and less than one man incontinent.

INTERPRETATION

Despite the relatively high risk of erectile dysfunction and incontinence following radical prostatectomy for prostate cancer, the excess burden of permanent side-effects after population-based screening can be regarded as relatively low, when related to the number of men saved from prostate cancer death. These data can be useful when calculating the harms and benefits of screening. However, the outcome on a population-level may differ from the benefit for the individual.

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.

Time of decline in sexual function after external beam radiotherapy for prostate cancer

PURPOSE

Erectile dysfunction is one of the most concerning toxicities for patients in the treatment of prostate cancer. The inconsistent evaluation of sexual function (SF) and limited follow-up data have necessitated additional study to clarify the rate and timing of erectile dysfunction after external beam radiotherapy (EBRT) for prostate cancer.

METHODS AND MATERIALS

A total of 143 men completed baseline data on SF before treatment and at the subsequent follow-up visits. A total of 1187 validated SF inventories were analyzed from the study participants. Multiple domains of SF (sex drive, erectile function, ejaculatory function, and overall satisfaction) were analyzed for < or =8 years of follow-up.

RESULTS

The median follow-up was 4.03 years. The strongest predictor of SF after EBRT was SF before treatment. For all domains of SF, the only statistically significant decrease in function occurred in the first 24 months after EBRT. SF stabilized 2 years after treatment completion, with no statistically significant change in any area of SF >2 years after the end of EBRT.

CONCLUSION

These data suggest that SF does not have a continuous decline after EBRT. Instead, SF decreases maximally within the first 24 months after EBRT, with no significant changes thereafter.

A multicenter, randomized, open-labeled, parallel group trial of sildenafil in alcohol-associated erectile dysfunction: the impact on psychosocial outcomes

To examine the effect of sildenafil on erectile dysfunction (ED) and psychosocial outcomes in alcohol-dependent (AD) men, 108 men with these diagnoses were randomly assigned to either take sildenafil (50 mg) as add-on to standard treatment for AD, or the same treatment without sildenafil, for 12 weeks. Only 50 patients in sildenafil group and 51 in control group twice completed the International Index of Erectile Function (IIEF) and a battery of self-report questionnaires. IIEF scores and psychosocial functioning, self-esteem and support from friends improved only for sildenafil-treated patients (P < 0.001). The high effect sizes suggest that the observed benefits are unlikely to be a placebo effect, although their unspecific nature could not be ruled out. In men with ED associated with AD, sildenafil improves both ED and psychosocial outcomes. Further placebo-controlled clinical trial is warranted.

Herranz Fernández L, Garrido P, Jiménez M, Suárez C, Fernández I. [Cavernous tissue rehabilitation whit sildenafil 100 mg in patients after radical prostatectomy]

OBJECTIVES

We try to figure out whether early penile rahabilitation ameliorates erectile dysfunction secondary to radical prostatectomy.

MATERIAL AND METHODS

Retrospective study of 80 cases of patients that were operated between 2005-2008; all of them went under radical prostatectomy and were treated with sildenafil 100 mg every second day (Monday, Wednesday and Friday) plus 100 mg on demand after the surgery. As objective measurements, we used validated questionnaire IIEF-5 and also axil penile rigidity before and after surgery in the third and ninth month.

RESULTS

Patients treated with sildenafil in fixed doses presented a 60% full erection recovery 9 months after radical prostatectomy. In the case where patients underwent bilateral or unilateral nerve sparing, they got a successful rate of almost 90%. Even 20% of those patients who did not have a nerve preservation got satisfactory erections,

CONCLUSIONS

Our experience shows that early penile rehabilitation seems to be a good treatment for erectile dysfunction after radical prostatectomy with IPDE5 in fixed doses. Administration every other day plus on demand looks like also as an appropriate option.

[Prevention and treatment of erectile dysfunction after radical prostatectomy]

Radical prostatectomy is the curative surgical management of organ confined prostate cancer. Erectile dysfunction may follow surgery as the most common complication decreasing the quality of life of the patient. Thanks to spreading PSA screening probability increases to detect prostate cancer in its early stage and so the expected number of surgery is increasing, too. Higher number of operation as well as surgery more frequently performed in younger age calls the attention to the importance of erectile dysfunction and its management. Nowadays the physiology of erectile dysfunction due to radical prostatectomy has been revealed, and as a consequence, the nerve sparing surgery for its prevention is already known. The paper presents the different kind of possible invasive and non-invasive treatments of erectile dysfunction, and surveys their history and effectiveness. The erectile function of patients who underwent radical prostatectomy between 1998 and 2007 at the Department of Urology and Uro-oncological Centre was assessed by IIEF- and MMM questionnaire and letters with questions of habit of medicine taking. The results show that 59% of patients who desire sexual activity are capable of it spontaneously or with medical management.

[Corpus cavernosum rehabilitation after radical urooncological procedures]

Corpus cavernosum rehabilitation is an integral part of modern, quality-of-life-oriented urooncological concepts and therefore a basic task of specific urological rehabilitation. Sexual rehabilitation is based on three different therapeutic options: PDE-5 inhibitors, use of corpus cavernosum injection therapy, and use of a therapeutic vacuum device. The indication depends on the status of nerve protection. Close recovery of erectile function is possible.

Modified technique for neurovascular bundle preservation during radical prostatectomy: association between technique and recovery of erectile function

OBJECTIVES

To prospectively evaluate whether a modified surgical technique for neurovascular bundle (NVB) preservation during radical prostatectomy (RP) is associated with an improvement in erectile function (EF) recovery after RP.

PATIENTS AND METHODS

Data from patients treated before technique modification was used to create a predictive model for EF at 6 months after RP using age, date of surgery, and nerve sparing (none vs unilateral vs bilateral) as predictors for patients who received the modified technique (MT) to estimate the expected outcomes had they received the standard technique (ST), and compared these with actual outcomes. In the MT, the neurovascular bundle (NVB) is completely mobilized off the prostate from the apex to above the seminal vesicles including incision of Denonvilliers' fascia before urethral division and mobilization of the prostate off the rectum.

RESULTS

Of 372 patients with evaluable data, 275 (74%) underwent the ST from 1 January 2001 to 31 December 2004 and 97 (26%) underwent the MT from 1 January 2005 to 30 May 2006. Sixty-five of 97 patients (67%) receiving the MT had EF recovery at 6 months, whereas the expected probability of 6-month recovery of EF, had they received the ST, was 45%. The absolute improvement in EF recovery attributable to the MT was 22% (95% confidence interval 5-40%; P = 0.013).

CONCLUSIONS

Technical modifications to NVB preservation during RP were associated with improved rates of EF recovery.

Chronic daily tadalafil prevents the corporal fibrosis and veno-occlusive dysfunction that occurs after cavernosal nerve resection

OBJECTIVES

To determine whether a long-term single daily oral dose of a longer half-life phosphodiesterase-5 (PDE5) inhibitor, tadalafil, has a similar effect to that of the shorter half-life PDE5 inhibitors sildenafil and vardenafil, and can prevent the fibrosis and resultant corporal veno-occlusive dysfunction (CVOD) occurring after cavernosal nerve (CN) injury.

MATERIALS AND METHODS

Male rats (10 per group) had either a sham operation, unilateral CN resection (CNR) or bilateral CNR, and were left untreated or given retrolingually 5 mg/kg per day of tadalafil. After 45 days, CVOD was assessed via cavernosometry, and the underlying corporal tissue changes were examined by immunohistochemistry and histochemistry (followed by quantitative image analysis), Western blots, and ad hoc methods.

RESULTS

Tadalafil treatment normalized the low response to papaverine and high drop rate in the intracavernosal pressure measured by cavernosometry after CNR compared with sham-operated rats. Tadalafil also normalized the increase in penile shaft collagen content, and the reduction in corporal smooth muscle cell (SMC) content, SMC/collagen, and replication index, and improved the lower collagen III/I ratio and the increase in apoptotic index, caused by CNR, compared with sham operation. There were no effects of tadalafil on increased transforming growth factor beta1, inducible nitric oxide synthase and xanthine oxidoreductase levels.

CONCLUSIONS

A long-term single daily dose of tadalafil prevented CVOD and the underlying corporal fibrosis in the rat caused by CN damage, as effectively as the previously reported continuous treatment with vardenafil or sildenafil, through a cGMP-related mechanism that appears to be independent of inducible nitric oxide synthase induction.

Effect of statin therapy on early return of potency after nerve sparing radical retropubic prostatectomy

PURPOSE

We prospectively investigated whether postoperative statin use would contribute to earlier recovery of erectile function in men who underwent bilateral nerve sparing radical retropubic prostatectomy for clinically localized prostate cancer.

MATERIALS AND METHODS

A total of 50 potent men without hypercholesterolemia undergoing bilateral nerve sparing radical retropubic prostatectomy for clinically localized prostate cancer were prospectively randomized into 2 equal groups. Group 1 patients were instructed to ingest only 50 mg sildenafil per day if needed following hospital discharge after radical retropubic prostatectomy. Group 2 patients were prescribed atorvastatin at a dose of 10 mg daily from postoperative days 1 to 90 and they were also instructed to ingest sildenafil, as in group 1. Patient status regarding potency and adverse events were assessed 6 months after surgery.

RESULTS

The 2 groups demonstrated no significant differences regarding various baseline factors, including International Index of Erectile Function-5 scores. Group 2 had a significantly higher postoperative International Index of Erectile Function-5 score than group 1 at 6 months postoperatively (p = 0.003). Meanwhile, as judged by a preset definition, the incidence of potent patients 6 months after prostatectomy was 26.1% in group 1 and 55% in group 2 (p = 0.068). Also, 17.4% and 40% of the men reported achieving intercourse by vaginal penetration without a phosphodiesterase 5 inhibitor in groups 1 and 2, respectively (p = 0.172). No serious adverse events associated with medication were reported.

CONCLUSIONS

Postoperative treatment with atorvastatin in men who report normal erectile function preoperatively may contribute to earlier recovery of erectile function after nerve sparing radical retropubic prostatectomy.

Phosphodiesterase type 5 inhibitors: the day after

OBJECTIVE

Review the literature on phosphodiesterase type 5 inhibitors (PDE5-Is), addressing critical issues in their current and future use, assessing unanswered questions, and identifying research needs.

METHODS

A MEDLINE search was conducted on PDE5-Is, with emphasis on clinical trials and experience, for interpretation and analysis of their present and future role.

RESULTS

Although approximately 40 million patients with erectile dysfunction have been treated successfully worldwide with the three available PDE5-Is, inappropriate instructions, lack of follow-up, and lack of patient-centered care models are the main reasons for "non-response," leading to drop-out rates of >50%. Patients with severe neurologic damage, diabetes mellitus, or severe vascular disease may be resistant to PDE5-Is. Preservation of corporal smooth muscle with chronic administration of PDE5-Is has been reported and substantial evidence indicates that these drugs have beneficial effects on endothelium and cardiovascular function; sildenafil has been approved for the treatment of idiopathic pulmonary hypertension. Improvement of lower urinary tract symptoms in men with benign prostatic hyperplasia after PDE5-I administration has been also suggested.

CONCLUSIONS

The data indicate the necessity for (1) exploration of the pharmacologic characteristics of the three PDE5-Is; (2) research on their pharmacologic differences because some actions seems to be drug-specific; (3) development of alternative management strategies, such as chronic, low, everyday doses of PDE5-Is, if the monthly cost is affordable; and (4) clinical trials on use of PDE5-Is to treat other chronic conditions. The door for innovative therapeutic approaches will open, specifically for cross-risk factor treatment with PDE5-Is or their use in combination treatments or new multimodal pills that take advantage of drugs that exert pleiotropic vascular actions.