Intracavernous Alprostadil Research Articles

(268) Intracavernous Prostaglandin Injection as a Predictor and Effectiveness Measure for LISWT Sessions in ED Patients: A Single Urologist's Experience

Abstract Introduction In recent years, therapeutic approaches for treating vasculogenic Erectile Dysfunction (ED) have evolved, with Low Intensity Shock Wave Therapy (LISWT) emerging as a promising modality. Objective To objectively evaluate the efficacy of LISWT for ED patients and to predict the required number of sessions, we examined the effects of administering up to 10 mcg of intracavernous alprostadil injections both before and after treatment Methods 85 vasculogenic ED patients (Average age: 57); 33 with mild to moderate ED and 52 with moderate or severe ED. Intracavernous injection (ICI) of ≤10 mcg of alprostadil was given before LISWT and one month post-treatment. Depending on ICI response, patients underwent either six (Erection Hardness Score (EHS) ≤3) or four (EHS=4) weekly LISWT sessions using PiezoWave2 from Richard WOLF. LISWT Parameters: 0.16mj/mm2 energy flux density, 8 Hz frequency, 10mm wave focus penetration depth, and 6000 shocks per session distributed among the two crura of the penis (2000 shocks), dorsum penis (2000 shocks), and lateral penis (2000 shocks). Results 33 patients showed a robust response to the 10mcg ICI and were treated with four LISWT sessions. 52 patients exhibited a partial response to the 10mcg ICI, necessitating six LISWT sessions. 78.6% (26 out of 33) of the patients who initially responded well to 10 mcg ICI had a consistent response to 8 mcg ICI; 63.6% (33 out of 52) of those with a partial initial response to 10 mcg ICI demonstrated an improved reaction to the same dosage post-treatment (table 1) (fig. 1). No complications were reported from the ICI. Conclusions Intracavernous prostaglandin injection can serve as a predictor for the required number of LISWT sessions and can objectively gauge the treatment's effectiveness in ED patients. Further randomized studies, incorporating parameters such as EHS, IIEF, and the ICI dosage, are recommended to validate this method's feasibility Disclosure No.

Erection hardness score or penile Doppler ultrasound: which is a better predictor of failure of nonsurgical treatment of erectile dysfunction?

In the evaluation of men presenting for erectile dysfunction (ED), specific diagnostic tests, such as an intracavernous injection test (IIT) with Erection Hardness Score (EHS) assessment or penile Doppler ultrasound (PDU), may be necessary. The study sought to compare the prognostic value of PDU parameters with erection rigidity with EHS during IIT in predicting refractory ED after 5 years. Patients referred for ED were evaluated and had a PDU with at least 15 μg of intracavernous alprostadil and without any sexual stimulation. At 5 years of follow-up, current and past ED treatments were noted. Refractory ED was defined as having a penile prosthesis (PP) implanted, having failed nonsurgical treatments but having refused PP implantation, or having discontinuation of nonsurgical treatments due to loss of efficacy. Patients with hypogonadism and pelvic surgery were excluded. Receiver-operating characteristic curves were drawn and the area under the curve (AUC) was calculated. The outcome was the AUC for predicting refractory ED. At 5years, 69 men were still in follow-up with a mean age of 58.47 ± 10.39years, and 13 (18.8%) were classified as having refractory ED. The AUC for the EHS, peak systolic velocity, end-diastolic flow, and resistive index to discriminate refractory ED were 0.820, 0.613, 0.730, and 0.714, respectively. EHS can be a good predictor of response to nonsurgical treatments in ED. This was a prospective study to compare IIT with PDU, and validated disease-specific questionnaires were used to assess both clinical efficacy and satisfaction. PDU was performed by a blinded third party. However, resulting from a single-center study, our sample size can be considered small, and the number of events observed was also low. Our data suggest that an abnormal EHS during an IIT is, at least, noninferior than an abnormal PDU in predicting those patients that will not respond to nonsurgical treatments and that will need a PP in long-term.

Sexual rehabilitation with intracavernous alprostadil after radical prostatectomy: outcomes from a nursing program

Sexual rehabilitation with intracavernous alprostadil after radical prostatectomy: outcomes from a nursing program

Sexual rehabilitation with intracavernous alprostadil after radical prostatectomy: outcomes from a nursing program

Sexual rehabilitation with intracavernous alprostadil after radical prostatectomy: outcomes from a nursing program

The Role of NGF and Its Receptor TrKA in Patients With Erectile Dysfunction

The aim of our study was to investigate the plasma NGF concentration and TrkA/p75NTR receptor expression on white blood cells (WBCs), in peripheral and corpus cavernosum blood isolated from patients with erectile dysfunction and metabolic syndrome (ED/MetS). This was a pilot case–control study. Inclusion criteria were as follows: men 18–65 years with ED and MetS and healthy subjects. The first sampling was performed at the level of the cubital vein (VC). Subsequently, 20 μg of intracavernous alprostadil was administered, and a second blood draw from the corpora cavernosa (CC) was performed once erection was achieved. Subsequently, the third blood sample was repeated at the level of the VC. We enrolled 8 cases with ED/MetS and 8 controls. There was no significant difference between the case and control group in terms of mean age (49.3 ± 5.9 and 53.13 ± 8.9, respectively). The case group had a lower IIEF score compared to the control group (14 ± 3.2 versus 27.3 ± 2.1; p < 0.05). Decreased NGF and TrKA expression on WBC and thiols were found in the plasma of ED/MetS patients compared to control. The study showed that patients with ED/MetS had a decrease in plasma NGF and thiol concentration, and they had a decrease in TrKA expression on WBCs.

Sexual rehabilitation with intracavernous alprostadil after radical prostatectomy: Outcomes from a nursing program.

Erectile dysfunction (ED) is a common complication after radical prostatectomy that affects quality of life. There are several therapeutic options, including intracavernous alprostadil injections (IAI). However, no specific recommendations have been made on the optimal rehabilitation strategy. In this study we evaluated a sexual rehabilitation program (SRP) with IAI for patients with ED after radical prostatectomy, assessing the rate of compliance and reasons for dropout. The sexual rehabilitation program (SRP) was offered to all patients who underwent radical prostatectomy from 1 January 2010 to 31 December 2019. The first consultations were performed by a urology specialist nurse, explaining the IAI procedure and possible complications. The program was considered successful when the patients achieved autonomy in the drug preparation with a good injection technique. A medical consultation was performed at 6 months evaluating the IAI usage and adverse events. In case of dropout, a questionnaire about reasons for dropout was performed. The primary endpoint was the rate of compliance and dropout of the program. Secondary endpoints were the reasons for dropout and adverse events. 340 patients underwent radical prostatectomy at our institution, and 123 patients accepted to participate in the rehabilitation program. A total of 96 patients (78%) successfully completed the SRP, and at 6 months 60 (62.5%) still used IAI. Concerning the reasons for dropping out, the most frequent were the need of injectable therapy and pain. Regarding complications, 17 patients (13.8%) reported pain related to the injection and 1 patient (0.8%) had a priapism, managed with conservative treatment. Management of post-radical prostatectomy ED by a nursing program achieved good rates of patients' self-injection accomplishment and treatment compliance. Close monitoring for dose adjustment and management of post-injection penile pain is required during the follow-up.

MP43-19 A CONTEMPORARY ASSESSMENT OF NORMAL ERECTION PHYSIOLOGY

You have accessJournal of UrologySexual Function/Dysfunction: Basic Research & Pathophysiology I1 Apr 2018MP43-19 A CONTEMPORARY ASSESSMENT OF NORMAL ERECTION PHYSIOLOGY Katherine Cockerill, Ram Pathak, Ciarra Boyne, and Gregory Broderick Katherine CockerillKatherine Cockerill More articles by this author , Ram PathakRam Pathak More articles by this author , Ciarra BoyneCiarra Boyne More articles by this author , and Gregory BroderickGregory Broderick More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1418AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Classic studies using invasive caversonometry have associated a rigid erection with sustained intracavernous pressures > 80-90 mm Hg with erection pressures reaching supra-diastolic pressures during activation of bulbocavernous muscle contraction associated with pelvic stimulation. The contemporary assessment of erectile complaints relies on non-invasive color duplex Doppler ultrasound imaging (CDDU). The CDDU parameters associated with rigid erection are End Diastolic Flow Velocity = 0 (EDV0) or EDV reversed (EDVr), when intracavernous pressures equals or exceeds the diastolic blood pressure, respectively. The aim of our study is to identify age-specific diastolic blood pressure (DBP) parameters for patients who achieved normal rigidity following penile injection of Alprostadil associated with EDV0 or EDVr during CDDU. METHODS We retrospectively reviewed 97 men complaining of erectile dysfunction (ED) who demonstrated normal/sustained rigidity. Blood pressure measurements were recorded at the time of CDDU. Other parameters recorded were Peak Systolic Velocity, Resistive Index, EDV, age, BMI, co-morbidities and duration of erectile dysfunction complaints. RESULTS A total of 97 patients with a median age of 57 years and a mean BMI of 26.6 underwent CDDU. All patients achieved rigid erection following PGE1 injection; all but three patients required alpha-adrenergic injection for erection reversal at 60 minutes. Fourteen patients were classified as EDV0 (18.5%) and 83 patients were classified as EDVr (85.5%). Twenty-nine patients (29.9%) had a diagnosis of hypertension. The mean DBP at time of CDDU was 76.7 mm Hg (with SD = 10.7). The mean diastolic blood pressure between men with EDV0 and EDVr was not significantly different (79.7 vs. 75.8 mm Hg, p = 0.13). For patients age <50 years with EDV0, the median DBP was 79 with interquartile range (71, 83). For patients age > 50 years with EDV0, the median DBP was 85 with IQR (73, 89). For patients age < 50 years with EDVr, the median DBP was 76 with IQR (70, 81). For patients age > 50 years with EDVr, the median DBP was 78 with IQR (66, 84). CONCLUSIONS Our study suggests that the previously established parameters for intracavernous pressure >80-90 mm Hg for normal erection may be too high. We found mean diastolic blood pressures of 75-79 mmHg in men complaining of ED who had vascular normal erections following intracavernous Alprostadil. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e586 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Katherine Cockerill More articles by this author Ram Pathak More articles by this author Ciarra Boyne More articles by this author Gregory Broderick More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Satisfaction and treatment adherence in erectile dysfunction in the medium and long term

IntroductionThe aim of this study was to show the satisfaction and treatment adherence in erectile dysfunction (ED) in the medium and long term. Material and methodsA descriptive, comparative study was conducted in 2 centres through telephone interviews with patients who came for an initial visit between 2012 and 2014 for ED.A complete case history review was conducted on the use of and withdrawal from treatment. For current use, the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and the Global Assessment Questionnaire (GAQ) were filled out; for past use, only the GAQ was filled out.For the statistical analysis, we employed Fisher's exact test for comparisons of percentages and the Kruskal–Wallis test to compare means. ResultsThe study included 250 patients; 20.8% were prescribed intraurethral alprostadil (ALP-IU), 17.2% were prescribed intracavernous alprostadil (ALP-IC), 92.8% were prescribed a first IPD5, and 24.8% were prescribed at least a second IPD5.The treatment withdrawal rate was 62.07% for the first IPD5, 41.94% for the last IPD5, 69.23% for the ALP-IU and 65.11% for the ALP-IC (p=0.007). The main reason for withdrawal for the IPD5 was a lack of response (32.76% of those who took IPD5). In addition to withdrawal, there were adverse reactions for ALP-IU and ALP-IC (28.85% and 11.63%, respectively). The mean duration of use until withdrawal was 4.3 months for IPD5, 2.2 months for ALP-IU and 5.5 months for ALP-IC (p=0.064). The most favourable GAQ and EDITS scores were observed for IPD5 (EDITS score of 74). Sildenafil and tadalafil had the longest usage times (mean >5 months). ConclusionsThe withdrawal rate for treating ED is high, with short usage times of a few months. A lack of response and adverse reactions were the main causes for withdrawal. The drugs that provide greater satisfaction are the IPD5, although there are no significant differences in the mean usage time between the different types and in aspects such as the mean usage time to withdrawal or the withdrawal rates.

Satisfacción y adherencia al tratamiento en disfunción eréctil a medio y largo plazo

IntroductionThe aim of this study was to show the satisfaction and treatment adherence in erectile dysfunction (ED) in the medium and long term. Material and methodsA descriptive, comparative study was conducted in 2 centres through telephone interviews with patients who came for an initial visit between 2012 and 2014 for ED.A complete case history review was conducted on the use of and withdrawal from treatment. For current use, the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and the Global Assessment Questionnaire (GAQ) were filled out; for past use, only the GAQ was filled out.For the statistical analysis, we employed Fisher's exact test for comparisons of percentages and the Kruskal-Wallis test to compare means. ResultsThe study included 250 patients; 20.8% were prescribed intraurethral alprostadil (ALP-IU), 17.2% were prescribed intracavernous alprostadil (ALP-IC), 92.8% were prescribed a first IPD5, and 24.8% were prescribed at least a second IPD5.The treatment withdrawal rate was 62.07% for the first IPD5, 41.94% for the last IPD5, 69.23% for the ALP-IU and 65.11% for the ALP-IC (P=.007). The main reason for withdrawal for the IPD5 was a lack of response (32.76% of those who took IPD5). In addition to withdrawal, there were adverse reactions for ALP-IU and ALP-IC (28.85% and 11.63%, respectively). The mean duration of use until withdrawal was 4.3 months for IPD5, 2.2 months for ALP-IU and 5.5 months for ALP-IC (P=.064). The most favourable GAQ and EDITS scores were observed for IPD5 (EDITS score of 74). Sildenafil and tadalafil had the longest usage times (mean >5 months). ConclusionsThe withdrawal rate for treating ED is high, with short usage times of a few months. A lack of response and adverse reactions were the main causes for withdrawal. The drugs that provide greater satisfaction are the IPD5, although there are no significant differences in the mean usage time between the different types and in aspects such as the mean usage time to withdrawal or the withdrawal rates.

Evaluation of penile vascular status in men with epilepsy with erectile dysfunction

PurposeErectile dysfunction (ED) is common in males with epilepsy, likely of multifactorial etiology, including possible systemic vascular comorbidities and medication effects. Here we examined male patients for the possibility of a vasculogenic element of ED. MethodsResearch participants included 47 men with epilepsy (mean age=30.98 years; duration of illness=13.98 years) and 25 healthy matched men (mean age=30.36). Erectile function was assessed using the International Index of Erectile Function Questionnaire (IIEF-5). Penile blood flow was assessed using Duplex Ultrasonography (PDU) after intracavernous alprostadil injection. Penile peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistance index (RI) were the functional parameters analyzed. Carotid artery intima media thickness (CA-IMT) was also measured. ResultsThirteen of the 47 men with epilepsy (23.40% versus 0% for controls) reported ED, and of these patients, 11 (84.62%) had abnormal PDU [PSV=28.23±6.1cm/s, P=0.0001; EDV=2.22±5.71cm/s, P=0.004; RI=0.89±0.22, P=0.071] suggesting vasculogic ED. Penile arterial insufficiency was identified in 5 (45.45%), while 6 (54.54%) had mixed arterial insufficiency and venous leak. Compared to patients with high PSV, patients with low PSV had lower IIED-5 scores, higher EDV, lower RI, higher diastolic blood pressure and higher CA-IMT values. There were no differences in depression, anxiety or concentrations of sex hormones. Significant correlations were evident between PDU variables and duration of illness, depression and anxiety scores and CA-IMT values. In multivariate analysis, the association between PDU parameters and CA-IMT values remained significant even after adjustment for other confounding variables. ConclusionsVasculogenic ED is frequent with epilepsy and its relationship to systemic atherosclerosis cannot be excluded.

Adherence to phosphodiesterase type 5 inhibitors in the treatment of erectile dysfunction in long-term users: how do men use the inhibitors?

IntroductionThe high effectiveness of phosphodiesterase type 5 inhibitors (PDE5-i) in the treatment of erectile dysfunction (ED) has been demonstrated. However, previous research shows that PDE5-i treatments have high discontinuation rates.AimThe main goals of this study were to (i) characterize the way men use PDE5-i and (ii) analyze the adherence to treatment, identifying the factors that influence PDE5-i use.MethodsA total of 148 men with clinical diagnosis for ED who maintained the treatment with PDE5-i for over 3 years were interviewed. Interviews concerning their ongoing treatment were carried out using a standardized questionnaire with quantitative and qualitative items.Main Outcome MeasuresPhysiological measures included the intracavernous alprostadil injection test, associated with penile rigidometry and penile Doppler ultrasound. The qualitative measure included two questions: “Do you use the drug in every sexual intercourse?” and “How do you use the inhibitor?”ResultsED causes were classified as venogenic (31%), arteriogenic (23%), psychogenic (18%), iatrogenic (13%), neurogenic (8%), and diabetic (7%). Participation rate was 71.8%. Of the 148 patients studied, 75% claimed not to use PDE5-i in every intercourse. Most used tadalafil (66%), followed by sildenafil (20%), vardenafil (10%), and 4% alternated the type of medicine. Four main categories emerged concerning the factors that determine the intake of PDE5-i in some intercourse situations and not in others: (i) psychological factors; (ii) medication-related factors; (iii) circumstantial factors; and (iv) relational factors.ConclusionThe analysis of men's narratives revealed a combination of factors that influence the adherence to PDE5-i. The psychological and medication-related factors were the most prevalent. This study highlighted the importance of taking these factors into account, both at the time of prescription and during the follow-up in order to improve adherence. Carvalheira A, Forjaz V, and Pereira NM. Adherence to phosphodiesterase type 5 inhibitors in the treatment of erectile dysfunction in long-term users: How do men use the inhibitors? Sex Med 2014;2:96–102.

Sexual Quality of Life in Women Partnered with Men Using Intracavernous Alprostadil Injections after Radical Prostatectomy

The effects of intracavernous alprostadil injection (IAI), a primary treatment for post-radical prostatectomy (RP) erectile dysfunction (ED) (pRPED), on the sex life of women partnered with men who have undergone RP have received little attention. The aim of this study is to investigate the sexual quality of life in female partners of men receiving IAIs for pRPED. We retrospectively studied the sex lives of 152 women partnered with men who were being treated for pRPED with IAI and previously had normal erectile function. Women completed the Index of Sexual Life (ISL) questionnaire 1 year after their partner's RP. Male patients completed the International Index of Erectile Function (IIEF-15), the Erection Hardness Score (EHS) questionnaire, the International Consultation on Incontinence Questionnaire (ICIQ), and the UCLA Prostate Cancer Index (UCLA-PCI) urinary function questionnaire. Penile pain was assessed using the visual analog scale (VAS). Statistical analysis was performed using t-tests, Spearman correlation, and multiple linear regression. Female sexual life satisfaction (SLS), sexual drive (SD), and general life satisfaction (GLS) were assessed using the ISL questionnaire. Mean ages for the 104 couples included were 62.3 and 59.8 years for the men and women, respectively. Mean ISL, SD, SLS, and GLS scores at 12 months were 25.4, 3.8, 14.1, and 7.5, respectively. ISL scores were strongly correlated with IIEF-15 domains, mainly erectile function (r > 0.41, P < 0.00002) and intercourse satisfaction (r > 0.27, P < 0.005). Age and VAS, ICIQ, and UCLA-PCI scores were negatively correlated with some ISL domains. IIEF-15 erectile function and intercourse satisfaction were the most significant domains predicting female SLS. An IIEF-15 erectile function of 25 corresponded to a 75% chance of an SLS score ≥18. Indexes of female sexual quality of life were low overall but were highly correlated with the partner's response level to IAI treatment. IAI-related pain, increased age, and poor urinary function of the male partner appear to negatively impact female sex life.

Long-Term Satisfaction and Predictors of Use of Intracorporeal Injections for Post-Prostatectomy Erectile Dysfunction

Intracorporeal injections have low use rates and high discontinuation rates. We examined factors associated with intracorporeal injection use, long-term satisfaction with intracorporeal injection and reasons for discontinuation in men treated with radical prostatectomy. Between October 2000 and September 2003, 731 men who underwent open radical retropubic prostatectomy were enrolled in a prospective outcomes study. The 8-year followup evaluation included the UCLA-PCI, and a survey capturing intracorporeal injection use, satisfaction and reasons for discontinuation. Logistic regression was used to determine associations between intracorporeal injection use and preoperative variables. The 8-year self-assessment was completed by 368 (50.4%) men. Of these men 140 (38%) indicated prior or current intracorporeal injection use, with only 34 using intracorporeal injection at 8 years. Overall, 44% of the men were satisfied with intracorporeal injections. Reasons for discontinuation included dislike (47%), pain (33%), return of erection (19%), inefficacy (14%) and no partner (6%). Men trying intracorporeal injections had greater preoperative UCLA-PCI sexual function scores (75.2 vs 65.62, p = 0.00005) as well as greater decreases in this score at 3 months (p = 0.0002) and 2 years (p = 0.003). Higher preoperative sexual function scores were independently associated with the use of intracorporeal injections in a model adjusted for age, marital status, nerve sparing status and body mass index (OR 1.021, 95% CI 1.008-1.035). Men pursuing intracorporeal injections have better baseline erectile function and experience greater deterioration in erectile function during the early postoperative period. Despite the high efficacy of injections, many men discontinue intracorporeal injections due to dislike or discomfort. Satisfaction rates for intracorporeal injections indicate their long-term role in restoring sexual function in men with post-prostatectomy erectile dysfunction.

Erectile rehabilitation with intracavernous alprostadil after radical prostatectomy: refusal and dropout rates

Study Type--Therapy (outcomes) Level of Evidence 2a. What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a well known implication of radical prostatectomy (RP). Despite the search for technical improvement in the surgical procedure (e.g. nerve-sparing surgery, robot-assisted RP), many patients still suffer from an inability to achieve a satisfactory erection after surgery. In the last 20 years a great effort has been made to re-establish good sexual function in these patients. Many different approaches have been used, such as intracavernous prostaglandin E1 (PGE1), phosphodiesterase-5 inhibitors, vacuum devices and penile prostheses. Although many studies have addressed the main questions about efficacy of different approaches to ED, there is a lack of data about adherence to therapy and the main reasons why patients drop out of these treatment programmes. In the present study, a cohort of men treated with RP underwent a postoperative rehabilitation protocol with PGE1 intracavernous injections. During the follow-up period, we were able to assess a real-life practice pattern of adherence and dropout, evaluating the main causes of therapy discontinuation. This could be of help in the counselling of these patients during the path towards erection recovery. • To assess the rate of compliance in the first 6 months of a rehabilitation protocol that includes intracavernous alprostadil administration in patients undergoing radical retropubic prostatectomy. • To determine the reasons for and timings of dropout from the protocol by the patients and their subsequent outcomes. • All patients undergoing radical prostatectomy (RP) at our institution between 1 January 2007 and 31 December 2009 were considered for a protocol of postoperative intracavernous sexual rehabilitation and were administered entry questionnaires to evaluate their preoperative sexual activity. • Four weeks after surgery, the patients were invited to return for a first visit, where the aim of the protocol and possible risks and benefits were explained. For those who agreed to attend, subsequent visits to include assisted self-administration of increasing doses of intracavernous alprostadil and a period of autonomous homely self-administration were planned. • Patients were followed up at 3-month intervals, where data on functional outcomes, patient satisfaction, and the number of patients who dropped out and their reasons, were recorded by means of appropriate questionnaires. • Statistical analysis was performed using Student's t-test or a chi-squared test, where appropriate. • Of 430 patients, 157 (36.5%) refused to undergo the protocol of rehabilitation and 18.6% of the patients who began the protocol dropped out over the first 6 months. • Reasons for refusal were: patient's lack of sexual interest (51.6%); lack of interest by the partner (30.2%); and presence of transitory incontinence (26.7%). • Reasons for dropout were: disappointment with treatment efficacy (64.7%); injection pain (45%); and difficulties with or fear of performing the injection by themselves or by the partner (35.2%). No patient claimed the cost of the drug to be a cause for dropout. • The protocol we used, involving intracavernous alprostadil injection, proved to be a safe and efficient way of achieving sexual rehabilitation in patients who have undergone RP. Nevertheless, high patient motivation and adherence to the protocol were required. • Factors influencing patients refusal and early-to-medium time dropout were both patient- and partner-related. Appropriate information, counselling and support of the couple before the beginning and at all stages of the rehabilitation play a fundamental role in reducing the dropout rate. • The situation regarding those patients who still need adjuvant therapy after surgery is less clear and further research on this is required.

Poor Response to Alprostadil ICI Test is Associated with Arteriogenic Erectile Dysfunction and Higher Risk of Major Adverse Cardiovascular Events

Intracavernous alprostadil injection (ICI) test has been considered useless in assessing the vascular status of subjects with erectile dysfunction (ED). To analyze the clinical correlates of ICI test in patients with ED and to verify the value of this test in predicting major adverse cardiovascular events (MACE). A consecutive series of 2,396 men (mean age 55.9 ± 11.9 years) attending our outpatient clinic for sexual dysfunction was retrospectively studied. A subset of this sample (N = 1,687) was enrolled in a longitudinal study. Several clinical, biochemical, and instrumental (penile color Doppler ultrasound; PCDU) factors were evaluated. All patients underwent an ICI test, and responses were recorded on a four-point scale ranging from 1 = no response to 4 = full erection. Among the patients studied, 16.4%, 41.2%, 40.2% and 2.2% showed grade 4, 3, 2, and 1 ICI test response, respectively. After adjusting for confounders, subjects with grade 1 ICI test response showed reduced perceived sleep-related, masturbation-related, and sexual-related erections when compared with the rest of the sample. In addition, a worse response to ICI test was associated with a higher prevalence of hypogonadism-related symptoms and signs along with lower testosterone levels. The prevalence of both diabetes mellitus and metabolic syndrome was inversely related to ICI test response. Accordingly, dynamic and basal peak systolic velocity (PSV), as well as acceleration at PCDU, decreased as a function of ICI test response. In the longitudinal study, after adjusting for confounders, grade 1 response was independently associated with a higher incidence of MACE (hazard ratio = 2.745 [1.200-6.277]; P < 0.05). These data were confirmed even when only subjects with normal PSV (>25 cm/s) were considered. Our results demonstrate that poor ICI test response is associated with several metabolic disturbances and higher incidence of MACE. We strongly recommend performing ICI test with alprostadil in all ED subjects.

Sexual Rehabilitation and Penile Pain Associated with Intracavernous Alprostadil after Radical Prostatectomy

Intracavernous alprostadil injection (IAI) is widely used for sexual rehabilitation (SR) after radical prostatectomy (RP). However, the rate of spontaneous erection recovery with IAI remains unclear, and IAI causes pain that may hinder SR. To assess SR in IAI users after RP and to evaluate the course and impact on SR of postinjection penile pain. We prospectively studied 87 patients who underwent nerve-sparing laparoscopic RP, reported normal preoperative erectile function, and used IAI for 12 months. Patients started with 2.5 µg alprostadil and were advised to increase the dose gradually until erection hardness allowed vaginal penetration. At 6 and 12 months, the International Index of Erectile Function (IIEF-15) and Erection Hardness Score (EHS) were determined with and without IAI, and injection-related penile pain was assessed using a numeric rating scale. Correlations linking penile pain, IIEF-15, and EHS scores were evaluated. The mean alprostadil dose was 8.1 µg after 6 months and 9.9 µg after 12 months. With/without IAI, mean IIEF-15 scores for erectile and orgasmic function and mean EHS score were 14.6/4.6, 4.1/2.1, and 2.5/0.4, respectively, after 6 months; and 17.2/5.4, 4.9/2.6, and 2.7/0.9 after 12 months. Pain scores were 3.2±2.5/10 and 2.5±2.5/10 after 6 and 12 months, respectively. Pain intensity correlated with erectile function (r=-0.23), intercourse satisfaction (r=-0.23), and overall satisfaction (r=-0.24) after 6 months but not after 12 months. Follow-up was short and only patients who used IAI for 12 months were included. In patients who were willing and able to use IAI, erectile function improved after 1 year but remained below preoperative levels. The adverse impact of pain on SR was significant during the first 6 months and diminished over time. These data may help to counsel IAI users with painful erections.

Évaluation d’un programme infirmier d’éducation thérapeutique pour les injections intra-caverneuses d’alprostadil après prostatectomie radicale

To evaluate a nurse educational program for penile rehabilitation after radical prostatectomy (RP) based on intracavernous alprostadil injection (IAI). One hundred consecutive patients started IAI one month after RP under the supervision of a nurse practitioner (day 0). Patients performed the first injection (2.5 μg); they were advised to increase gradually the dose of alprostadil until having satisfactory erections. Patients having difficulties with IAI were called back by the nurse. They received a medical follow-up at the uro-oncology department at 6 months. We assessed at D0, D15 and at 6 months: the ability to complete the IAI, the occurrence of priapism, the injected doses, the recovery of sexual function (EHS and GAQ scores), and pain in erection (numeric rating scale). Eighty-one percent of patients were very satisfied with the educational program. On day 15, 93% of patients achieved IAI (mean injected dose: 5.2 μg). No priapism was noted. The treatment had ameliorated erections in 80% of cases (GAQ); 47% of patients had erections hard enough to allow penetration (EHS>2) and 39% had sexual intercourses. Pain to erection (3.9/10 on average) represented a motive of request for recall for 2/3 of the patients. At 6 months, the dropout rate was 31%; mean pain level, EHS score and injected dose were respectively 3.2/10, 2.9/4 and 8.8 μg. The nurse educational program for penile rehabilitation after RP was associated with satisfactory rates of self-injection accomplishment and treatment observance. However, close and prolonged follow up was necessary because of post-IAI penile pain.

Therapie männlicher Sexualstörungen

Phosphodiasterase type 5 inhibitors (sildenafil, vardenafil, tadalafil) are the first line symptomatic therapy for patients with erectile dysfunction. The patient should receive a meticolous information on the use of these drugs and their possible side effects. These drugs are safe and can be used even in patients with stable cardiovascular disease. Patients not responding to oral drugs may be offered intraurethral or intracavernous alprostadil. Vacuum constriction devices are a second line option more acceptable to older patients. Penile prosthesis are very seldom used in Switzerland and vascular surgery is a vanishing option. Testosterone substitution is seldom needed in this setting. Treatment of premature ejaculation subdivides into behavioural therapy ("stop-start" or "squeeze" technique) and drug therapy as well. Topical therapy with lidocaine/prilocaine-containing medications to be applied before sexual intercourse and a oral daily off label use therapy with selective serotonin re-uptake inhibitors (paroxetine, fluoxetine, sertraline) can be offered. Dapoxetine, a potent selective serotonin reuptake inhibitor with short half life time, is the first officially approved medication for the treatment of premature ejaculation and should be available soon in Switzerland.

Increased Levels of Osteocalcin-Positive Endothelial Progenitor Cells in Patients Affected by Erectile Dysfunction and Cavernous Atherosclerosis

Erectile dysfunction (ED) was shown to be the expression of a systemic vascular disease that can precede coronary artery disease of some years. Endothelial progenitor cells (EPCs) are a population of circulating cells with endothelial-regenerative potential that may be reduced in ED and coronary patients. Recently, increased levels of osteocalcin (OCN)-positive EPC have been reported in coronary patients. Investigate the correlation between OCN-positive EPC and cavernous atherosclerotic lesion in ED patients. A total of 35 subjects (20 ED patients and 15 controls) were evaluated in our andrological center and enrolled in the study. All subjects underwent routine clinical examination. Patients were also evaluated with high resolution echo color doppler of penile districts (intima media thickness [IMT] before and after intracavernous alprostadil injection) and circulating levels of progenitor cells (PC), EPC, and OCN-positive fraction of EPC. A progressive reduction of circulating EPC with the severity of cavernous artery atherosclerosis was found. Conversely circulating OCN-positive EPC levels undergo to a significant increase with cavernous atherogenesis progression. OCN-positive EPC levels in association with penile-color Doppler ultrasound evaluation of cavernous IMT could be predictive markers of subsequent coronary artery disease in ED patients.

A comparison of colour duplex ultrasonography after transurethral alprostadil and intracavernous alprostadil in the assessment of erectile dysfunction.

This study aimed to investigate whether transurethral alprostadil could be used for the diagnosis of erectile dysfunction using colour duplex ultrasound. The ultrasonography results were compared after transurethral and intracavernous alprostadil administration in 20 patients with erectile dysfunction. There were no significant differences in the mean peak systolic velocities (PSVs) between the two routes of administration, but the mean end diastolic velocities (EDVs) showed significant differences, with patients treated with transurethral alprostadil having higher EDVs. Linear regression analysis of the PSVs reached following the two routes of administration showed a moderate relationship, but linear regression analysis of the EDVs showed no relationship. We concluded that transurethral alprostadil was an inappropriate vasoactive drug to use with colour duplex ultrasonography for the evaluation of patients with erectile dysfunction because it required a longer scan time and it was less effective and less reliable than intracavernous alprostadil at stimulating complete corporeal smooth muscle relaxation.