original article
Journal of Andrological Sciences 2011;18:64-71
Up-to-date on erectile dysfunction and treatment
V. Gentile, S. Salciccia, P. Fele*, G.M. Busetto Dipartimento di Scienze Ginecologico-Ostetriche e Scienze Urologiche, Sapienza Università di Roma, Italy; * Dipartimento di Scienze Ostetrico-Ginecologiche, Urologiche e Medicina della Riproduzione, Università Federico II di Napoli Erection is a haemodynamic event that involves the central nervous system and local factors and is the recurrent or persistent inability to achieve and or maintain an erection to allow satisfactory intercourse.
The ED is a disease of great social impact: it is estimated that in Italy, 11-13% of men, or about 3 million are affected in part by ED.
Main risk factors are: age, education level, anxiety, reactive depression, dia- betes, heart disease, high blood pressure; disorders (hepatic failure, chronic renal failure, obesity, dyslipidemia); hormonal disorders (hypogonadism, hy- perprolactinemia, hypo/hyperthyroidism); neuropathies (Alzheimer’s disease, Parkinson’s disease, degenerative diseases); urologic surgery, colorectal and Regarding therapy first and most important form of treatment for a patient suffering from erectile dysfunction is to identify and possibly modify or remove Key words
all hazardous conditions for sexual health. First line treatments are selective Erectile dysfunction • Inhibitors inhibitors of 5-phosphodiesterase; second-line treatments essentially include of 5-phosphodiesterase • Intracavernous intracavernous injection of vasoactive substances and third line treatments injection • Revascularization of the penis include revascularization of the penis and prostesis implants.
Incidence and epidemiology
Erection is a hemodynamic event that involves the central nervous
system and local factors. It is governed by relaxation of the caver-
nosal arteries and the smooth muscle of the corpus cavernosum.
An adequate blood flow to the penis plays an important role in this
process. In the state of flaccidity, the sympathetic innervation pro-
duces a tonic contraction of smooth muscles of the arteries and the
body, reducing the flow of blood through the artery cavernous in
the cavernosal spaces. Psychogenic stimuli central and / or sensory
stimuli from the penis increase the activity of parasympathetic and
reduce sympathetic activity, it is therefore a relaxation of the smooth
muscles in the penis and increases blood flow through the arteries and
cavernous helicine arteries. The smooth muscle relaxation increases
the distensibility of the cavernous spaces, leading to congestion and
erection. The increase in the volume of blood and the compression
of the trabecular-smooth muscle issued against the tunica albuginea,
relatively rigid, reduces the venous flow in the output (veno-occlusive
mechanism). It follows an erection with a certain degree of rigidity
Corresponding authorGian Maria Busetto, Sapienza University of Rome, Department of Gynecological-Obstetrics Sciences and Urological Sciences, viale del Policlinico 155, 00161 Rome, Italy – Email: [email protected] – Tel. +39 064450683 Up-to-date on erectile dysfunction and treatment and decreased blood flow through the cavernous warning sign for the overall health of the individual.
arteries. When he increased sympathetic activity, The risk factors are as follows:the tone of the helicine arteries and contraction of • age, education level, diabetes, heart disease, the trabecular-smooth muscle we have the detu- mescence. The blood flows through the arteries and • disorders/hepatic failure, chronic renal failure, veins of the penis and intracavernous pressure is reduced to the levels prior to the stimulation of the • hormonal disorders (hypogonadism, hyperpro-penis returning to the state of flaccidity.
lactinemia, hypo/hyperthyroidism), anxiety/reac- Erectile dysfunction (ED) is the recurrent or persis- tent inability to achieve and / or maintain an erection • neuropathies (Alzheimer’s disease, Parkinson’s to allow satisfactory intercourse. The ED is a disease disease, degenerative diseases), urologic sur- of great social impact: it is estimated that in Italy, 11- 13% of men, or about 3 million are affected in part It has been seen how it (ED) can anticipate, even by ED 1. Data from studies conducted previously in years, the event of serious cardio-circulatory prob-the United States, concerning the male population lems, or may represent the first sign of a latent dia-between 40 and 70 years, results were even more betes or hypertension 3.
severe: the presence of ED, from the most mild to the most severe, was detected in more than 50% of Risk factors:the cases 2.
The increased incidence of impotence with age was • smoking;noted by Kinsey in 1948, only 1 man in 50 at the • diabetes;age of 40 years was powerless against 1 in 4 men • obesity and dyslipidemia;at the age of 65 years. In 1990, Diokno and C. found • ipertension;that 35% of married men aged over 60 years suf- fer from erectile impotence. In the US data on ED • aterosclerosis;have been obtained through modern technology: • endocrinopathies (hypogonadism, hyperprolac-the Massachusetts Male Aging Study (MMAS) and the National Health and Social Life Survey (NHSLS). • Chronic systemic fiseases (CRF, liver disease);MMAS includes 1709 non-institutionalized men aged • neurological diseases central and peripheral (Par- between 40 and 70 years old, living in the vast area of Boston, evaluated for the first time between 1987 • pelvic surgery;and 1989 and re-evaluated between 1995 and 1997. • abuse of alcohol and drugs;The components of this study were included physi- • drugs (antihypertensives, antidepressants); ological assessments, demographic information and • Luts/BPH and relative therapies.
self-assessment of the state of erectile dysfunction. MMAS was the first epidemiological study cross, Overall, from a point of view etiopathogenetic and community, randomized on erectile dysfunction and pathophysiological, erectile dysfunction may be due its psychological and psychosocial aspects in men to vascular factors (ED arteriogenica or venogenica), in the US 2.
neurological, hormonal and/or psychological, as well as to alterations of the pathway of NO/GuanosinMo-nophosphat (cGMP) or other factors of electrophysi- Etiopathogenesis and classification
ological microregulation. All conditions ultimately If in the past the main cause of this disorder was become potentially responsible for an imbalance usually sought in the psychic sphere, researches of between the process of relaxation and contraction of the past 20 years have made me understand how at smooth muscles of the corpora cavernosa 4.
least 70% of ED cases due to causes (or concomi-tant causes) of organic status. At the origin of these Arteriogenic Erectile Dysfunction organics problems, there may be various conditions Follows a deficit of arterial inflow load of the hypo-such as obesity, sedentary lifestyle, cigarette smok- gastric artery – cavernous arteries – helicine arteries. ing, excess blood cholesterol, diabetes, chronic Typically it can be observed in case of: intake of different medicines or the consequences • atherosclerosis and dyslipidemia;of many interventions surgery. It is important to note • diabetes;that sometimes a sudden onset of ED may be a • pelvic radiotherapy; • trauma: perineal/pelvic (crural injury and/or pu- pathophysiological substrate for the appearance of ED in these cases is likely to be multifaceted. In fact, all these conditions can lead to the development of peripheral neurological disorders (eg, pudendal This form of ED finds its moment etiopathogenetic nerve injury and/or cavernous), deficit of arterial load in an inadequate activation of the veno-occlusive of the hypogastric artery/arteries cavernous helicine mechanism (VOM) of the corpora cavernosa, re- arteries, as well as inadequate activation of veno- sponsible for the maintenance phase of the erection occlusive mechanism 2.
same. The deficit of the veno-occlusive mechanism at the level of the corpora cavernosa, a conditioning Psychogenic erectile dysfunctionvenous leakage, has been described as one of the The psychogenic erectile dysfunction is defined as etiological conditions most commonly associated the persistent inability to achieve or maintain penile with vasculogenic forms of erectile dysfunction. A erection that they can have sex exclusively or mainly lack of integrity of the veno-occlusive mechanism due to psychological factors or interpersonal. This of the corpora cavernosa, which is responsible for definition has been adopted recently by the Inter-excessive venous outflow, can achieve two funda- national Society of Sexual and Impotence Research mental pathophysiological conditions: an incomplete (ISSIR) pointed out that three basic concepts: smooth muscle relaxation or to structural abnormali- • the psychogenic erectile dysfunction is a diag- ties of the erectile tissue. This type of pathophysi- nosis of certainty should not be used when it is ologic conditions may occur in anxious subjects, before a clinical picture fuzzy or unknown; with an excessive adrenergic tone or in patients • psychosocial factors must be identified as the with inadequate relaxation of neurotransmitters by predominant or exclusive of erectile dysfunction the parasympathetic nerve endings. Similar cases in the subject, so patients with a combination of are found where there is an alteration of functional organic and psychogenic factors should be clas- alpha-receptors as well as other nerve receptors, sified as having mixed erectile dysfunction; which leads ultimately to an increase of the basic • other elements of this refer to the most recent tone at the level of smooth muscle cells, impairing definitions of erectile dysfunction.
The psychogenic erectile dysfunction often coex-ists with other disorders such as decreased sexual desire (hypoactive sexual desire) and / or major Issues central and / or pictures of peripheral suffer- psychiatric disorders, such as anxiety disorders and ing can affect the appearance of erectile dysfunction depression. In these latter cases it is very difficult to as a symptom of nerve conduction deficit, deficit of make a diagnosis of psychogenic erectile dysfunc-release of neurotransmitters or neuromodulators.
tion and treatment of primary psychiatric disorder exquisitely is indicated as the first step for the care Erectile dysfunction may result from alteration of
the control mechanisms for hypothalamic-pituitary,
of local neuroendocrine control, as well as the lack Diagnosis
of a suitable substrate steroid desire to support and As with any medical problem, it is necessary first of
mechanism erectogenic.
all a detailed collection of symptoms and medical history, especially addressed to the identification of possible risk factors for ED (lifestyle, drug use, May induce the appearance of erectile dysfunction presence of chronic disease medications, interven-urological surgical procedures, including endoscop- tions surgical suffered) or significant psychological ic resection of the prostate (TURP), proceedings of or relational components which require specialist laser-ablation therapy or by vaporization of the pros- advice. With regard to the assessment of specific tate, radical surgery for prostate cancer or bladder, symptoms, particular attention should be placed on as well interventions urethroplasty for stenosis in the quantification of the disturbance (ED) seeking to load tract membranous urethral duct. These are sup- clarify the duration and severity (very useful for this plemented by the surgical oncology, and at the ex- purpose will reveal the specific questionnaires that pense of the rectum and pelvis in general. We must have been validated at international level) will be not forget the pictures of post-traumatic lesion. The important to investigate the presence or absence of Up-to-date on erectile dysfunction and treatment spontaneous erections upon awakening, any loss of There are also instrumental examinations of a sec-libido, the occurrence of premature ejaculation.
ond level that are indicated in selected cases. Physical examination is directed on the apparatus Among these:urogenital, endocrine, vascular and neurological • the test response to the drug-stimulation intra-systems, will reveal whether there are abnormalities cavernous consists of the evaluation of the erec- genital, congenital or acquired, of hormonal prob- tile response of the patient after intracavernous lems, neurological or prostate disease. It is very im- injection (ie in the penis) of a vaso-active drug in portant for the specialist, to establish from the outset dosage standardized (prostaglandin E1 mcg or a good communication with the patient explaining in detail the following diagnostic steps and possible • it is a rapid test and inexpensive because the treatment options, dealing with the expectations of quality of the response is evaluated by the spe- the patient and partner. The involvement of partners cialist by observation and palpation. Currently, in is highly desirable (ED inevitably affect the harmony highly specialized andrology centers, this test is of the couple). The correct information is an essential performed in conjunction with computerized re- cording real-time (RigiScan FIC-test): this allows an objectivization of the result and a possible Currently, it is considered necessary, the execution • the computerized recording of the erectile re-of the following tests: sponse to visual erotic stimulus adequate (RigíS- canVSS) performed at baseline and after oral administration of pro-erectile drugs: the results will be compared with each other and with the examination Night (NPT test) and allow the spe- cialist to draw important diagnostic deductions • PSA (for patients older than 50 years) 6.
and at the same time evaluate the effectiveness These tests are useful to detect any endocrine or metabolic abnormalities can cause ED 3. The results • the cavernosometry/graphy dynamics (LINK 15-of these investigations, together with the information 16-17-18) that allows to study the integrity of the obtained from a proper medical history and a thor- mechanisms of entrapment of the blood inside ough physical examination, in many cases allow the the penis, during erection and to identify the specialist to move towards a diagnosis of the utmost causes of ED, so that we can begin the treatment • the study neurological reflex bulbo-cavernous most appropriate.
provides indirect information, but very useful when there is a suspicion of a neurological com- Among the specialized equipment needed to further • the test of ejaculatory latency with vibrostimola-test the diagnostic, we can distinguish at least three tion that allows to check for sensory discomfort in the peripheral and to quantify the extent of a • the night penimetry computer (nptr-test), which If eventually the patient is a candidate for surgery, consists in the recording of episodes of spon- for example, a young subject who has suffered a taneous erection that always occur during sleep trauma of the pelvis or in cases of acquired fibrosis in healthy subjects. This test is very useful for an of the penis, may be indicated special examinations initial discrimination between prevailing psycho- • digital selective hypogastric-cavernous arteriog- • the Eco-color Doppler dynamic of the penis, raphy that, through the introduction of contrast which is indicated for the evaluation of the integ- medium in the arterial tree radiological allows rity of the vascular penis. This is a dynamic study, to obtain very detailed images of small arterial namely functional, performed in basal conditions branches that bringing blood to the penis allow and after stimulation with vaso-active drugs in- jected inside the penis, with the aim of studying • angio-MRI with gadolinium: it is a very recent and the inflow and the outflow of blood in the condi- elegant method that synthesizing the information tion of erection induced pharmacologically 5.
offered by the two previous (arteriography cav- ernosa of the penis and dynamic MRI) allows to ferent therapies of DE we can distinguish different obtain anatomical and functional frameworks that levels, which are different for the progressive greater • dynamic MRI of the penis which is the imaging modality is most appreciated by the surgeon and First-line treatmentsthe patient to the clarity of the anatomical image Selective inhibitors of 5-phosphodiesterase that are of great help in pre-operative phase.
During the 90s it was discovered a family of drugs • It should be stressed that the diagnostic-thera- which, administered by mouth, allow a truly effective peutic approach of patients with ED often require treatment of almost all forms of ED: these are selec- a multidisciplinary collaboration, which will see tive inhibitors of 5-phosphodiesterase (PDE5).
the specialist urologist use, where indicated, con- The action of all these drugs is carried out at the pe- sulting psychologist, endocrinologist, cardiolo- ripheral level (ie directly into the penis) and consists gist, neurologist, or any another specialist whose in improving and maintaining the flow of blood in specific skills become necessary in the progress the corpora cavernosa (erectile structures of the pe- nis), and leading to a better quality of erection. The Phosphodiesterase (PDE) catalyze the hydrolysis of the second messengers cAMP and cGMP, which are responsible for the activation of a course of events The first and most important form of treatment for that ultimately lead to the relaxation of smooth mus- a patient suffering from erectile dysfunction is to cles. Both of these second messengers are involved identify and possibly modify or remove all hazardous in signal paths within the corpus cavernosum. The conditions for sexual health, whether they are repre- superfamily of proteins cyclic nucleotide PDE can sented by bad habits (excessive sedentary lifestyle, be divided into at least 11 families of structurally chronic stress, cigarette smoke etc.) or overeating and functionally related enzymes. Until now, differ- (obesity, alcohol abuse) or eventually recruitment of ent isoforms have been characterized, all different drugs and medicines involving depressing side ef- in their primary structure, specificity for cAMP and cGMP and mechanisms of regulation and tissue dis- The causes and modifiable risk factors are the fol- tribution. Molecular studies have demonstrated the presence of different isoforms but functional stud- • lifestyle and psychosocial factors (smoking, alco- ies have revealed an active role only for PDE3 and holism, substance abuse, relationship conflicts, PDE5. Three different isoforms of PDE5 were cloned lack of information, lack of experience, depres- into the tissue of the human penis. Two isoforms were identical to PDE5A1 and PDE5A2, by not penile • sex education: awareness, changes in age, fore- tissue, while the third PDE5A3 was new. This isoform was present in tissues with a component of smooth • drugs (change class or dose): antihypertensives, muscle or cardiac muscle. Recently, the three-di- antipsychotics, antiarrhythmics, anti-androgens, mensional structure of the catalytic domain (residues 537-860) of human PDE5 complexed to the three • hormone replacement therapy: hypogonadism, molecules Sildenafil (Viagra), Tadalafil (Cialis) and Vardenafil (Levitra) was determined by offering the It is clear that in cases where it can be detected opportunity to design potent and selective inhibitors.
underlying disease can cause the onset of ED (dia- Tadalafil is a potent inhibitor of PDE5, has a half-life betes, hypertension, hypercholesterolemia, etc.), of 17.5 h and a lasting effect up to 36 h after dosing. The correct therapeutic approach will be to correct Tadalafil is effective and well tolerated. In a recent or cure the disease to obtain a satisfactory com- study, it was demonstrated that the Tadalafil 20 mg, administered on alternate days in patients with an Unfortunately, in most cases, it is not possible to increased cardiovascular risk, causes improvement recognize a definite cause of ED, so the specialist is in endothelial function regardless of the degree of forced to propose a “symptomatic” therapy ie pallia- ED. The study showed a significant effect of Tadalafil tive a solution that corrects the “symptom” DE with- compared to placebo on FMD (flow-mediated dila- out being able to provide the patient with a future tation) of the brachial artery. However, this was a resumption of the natural erectile function.
small study (32 patients), therefore, no definitive As in the case of diagnostic tests, even for the dif- conclusion can be drawn. Through a study of healthy Up-to-date on erectile dysfunction and treatment volunteers, it was shown that therapeutic concentra- tions of Tadalafil do not produce clinically significant • gastrointestinal disorders;changes in the clearance of drugs metabolized by • mild hypersensitivity sight.
CYP3A. In fact, in a recent clinical study, the phar- macokinetics of midazolam and lovastatin, 2 differ- Very recently observational and epidemiological ent CYP3A substrates, was substantially unchanged studies indicate the existence of a possible link be- after taking Tadalafil co-administered. For Tadalafil, tween LUTS and ED 11, it is necessary to question like Sildenafil and Vardenafil, we studied the possible whether LUTS to have an impact on sexual function interaction with alpha-blockers, important drugs or if both conditions are linked by a common underly- in the treatment of benign prostatic hypertrophy. ing mechanism. In this regard, several pathogenetic Tadalafil (20 mg), enhances the hypotensive ef- hypotheses have been proposed to explain this Link: fect of doxazosin, producing an average decrease adrenergic hypertonia activation of Rho kinase, pel- in standing systolic blood pressure significantly vic atherosclerosis 12. On closer inspection the com- greater than placebo. In contrast, in patients treated plexity of the pathophysiological mechanisms were with tamsulosin, 10 and 20 mg Tadalafil produced involved in order to explain the link between LUTS / a mean reduction in systolic blood pressure simi- BPH appear to have different mechanisms in com- lar to placebo, suggesting that the drug should be mon and interconnected, so how these theories have used with caution when patients using doxazosin. several common points with the pathophysiological Useful to consider that grapefruit juice causes the ir- mechanisms proposed to explain medical conditions reversible inactivation of cytochrome P450 3A4. This coma syndrome or the metabolic role of inflamma- means that it can interact with Sildenafil, Tadalafil or tion in prostate disease 6. This broad connection be- Vardenafil, resulting in severe systemic vasodilation, tween the different theories proposed seems to have especially when combined with a nitrate therapy.[8] a major impact in clinical practice for patients with The therapeutic aspect of great interest that these LUTS and ED disorders 5. On the one hand, certainly molecules present, consists, as well as its efficacy, can complicate the diagnostic workup of patients in the fact that they act only in the presence of an with ED and LUTS on the other hand seems to open adequate stimulus sexual: this translates in an excel- new scenarios therapeutic and broaden the range of lent acceptance by the patient and the partner. The treatment options available to us so that treatment best known and founder of such drugs is Sildenafil options can overlap, allowing prevention or treatment (known to all as Viagra), to which are added two of both conditions simultaneously. It has not yet other molecules: Tadalafil (brand name Cialis) and certain about the data, you must change the clinical Vardenafil (trade name Levitra or Vivanza).
approach to the patient with concomitant LUTS and These pills should be taken “as needed” or about ED, not treating them more as two distinct condi- 40 minutes before attempting to have sex and their tions that are often approached by different special- effect wears off in the next 4 hours. From this point ists, but rather with a clinical approach integrated so of view, is characterized Tadalafil (Cialis), the ef- each patient with LUTS should also evaluated from fectiveness of which lasts for more than 24 hours. the point of view of sexual function, as well as each The effectiveness of this class of drugs is very good: patient with ED should be evaluated from the point about 70% of all men with ED of all degrees, re- of view of the urinary function. An approach of this sponds positively to selective inhibitors of PDE5  9. kind would certainly help the clinician in the choice of Categories of patients who do not get the benefit treatment appropriate for each patient in view of the of taking them are essentially those classified as fact that the current therapies for LUTS are burdened “severe organic”, in particular those with severe by side effects at different levels of sexual function vascular disease or patients undergoing demolition (libido, erection, ejaculation) and above in the light of surgery (usually necessary to remove a tumor) that numerous scientific evidence for a role of PDE-5 in resulted in the disruption of neural circuits neces- the treatment of LUTS, as revealed by a recent meta- sary to trigger an erection (removal of the bladder or analysis on this topic. On this basis, each patient with rectum, enlarged removal of prostate). These drugs LUTS should be carefully informed of any possible are well tolerated, as side effects are usually mild adverse effects on sexual function related to drug and decreased over time 10.
therapy and surgical treatment of LUTS / BPH, as well as the clinical in follow-up treatment of patients with LUTS should carefully monitor the sexual func- • redness of the face with hot flashes; tion through validated questionnaires 14.
physiotherapy rehabilitation after radical surgery pel- Part of action of the first level is included hormone vis. The introduction of oral drugs effective in treat-therapy that actually should be considered sepa- ing ED has certainly reduced the indications for this rately. The indication to the administration of testos- type of treatment which, until recently, was widely terone (the male sex hormone) is in fact reserved for used all over the world. Remains a very effective cases of proven deficiency of this hormone in the (complete response in more than 80% of patients) blood. However, it should be considered that there is and is indicated in the percentage of patients suffer- an age-related physiological decline in testosterone, ing from ED who cannot benefit from oral therapy, so that it is estimated that about a quarter of men or because they precluded (heart patients who take over the age of 60 years present a hypogonadism nitrates, recent myocardial infarction) or because mild or moderate. Thus, in recent years it has come results non-responder (approximately 30%). The spreading among specialists a particular interest in vaso-active drugs injected directly into the penis, this category of persons of mature age (over 60 years) producing an erection regardless of sexual stimula- in which can recognize the presence of a combina- tion, which makes this type of treatment the first tion of symptoms and physical signs and laboratory choice for those who have been damaged neural findings (ie what is known as a syndrome) defined circuits that carry the impulse erection (for example LOH, or “androgen deficiency in later life”. The main patients who have undergone surgery with excision symptoms of this syndrome consist of a decrease in of the rectum or the bladder for tumors). sexual desire, erection, mass and muscle strength in thinning of hair, in a certain mood instability with a Third line treatments tendency to irritability and depression and memory. Revascularization of the penis When this corollary of signs and symptoms is as- They are part of the therapeutic possibilities of choice sociated with evidence of a deficiency of testoster- for the treatment of ED, even revascularization sur- one in laboratory tests, it is feasible to testosterone gery, ie the artery bypasses that restore blood flow therapy, the administration of which is represented to the penis. Candidates for this type of operation by the most current formulation in gel. In the cases are only young patients (younger than 50 years), non- mentioned, the daily application on the skin of the smoking or diabetes, who have suffered a trauma to back or abdomen of testosterone gel (contained in the pelvis or perineum (the area between the testicles special bags) quickly restores the normal level of and the anus) that has lesioned one or both arteries this hormone in the blood, thus correcting most of that ensure the normal flow of blood to the penis.
the problems related disorders including sexual. The Implants possible side effects associated with the administra-tion of testosterone (urinary retention, swelling of the This intervention was proposed over 30 years ago breasts) are generally absent or very well tolerated and today in the world tens of thousands of men when used in compliance of the dosage schedule. are carriers of this device. The prosthetic implant In the past it was emphasized a particular aspect has always represented “the ultimate solution” for a related to hormone therapy in the mature: the risk of patient suffering from erectile dysfunction, but at the unmask a possible prostate cancer 15.
same time is the only effective solution to 100% in any case of ED. The technological evolution has led to major advances in materials and the experience Essentially include intracavernous injection of vaso- of thousands of procedures performed around the active substances. The corpora cavernosa are the world mean that complications are currently very functional erectile structures of the penis that are limited, and you have less than 10% of cases. The easily achieved by using short and thin needles degree of satisfaction of patients who have under-(such as those for insulin) and injecting the lateral gone surgery is usually very high. wall of the penis. The patient is instructed in the cor- There are different types of penile prostheses, di- rect use of the drug by the specialist and, generally, vided into two main categories:three outpatient sessions are sufficient to identify the dose of medication suited to the specific case and • non-hydraulic.
make the patient alone to initiate therapy at home. The hydraulic prostheses are the most suitable for With regard to the intracavernous injection therapy patients with a complete ED and wish to maintain in the treatment of ED, patients are candidates did a normal appearance of the penis at rest. The main not respond or contraindicated to oral therapy and limitation of these prostheses is represented by the Up-to-date on erectile dysfunction and treatment high cost and the need for a minimal manual dexter- lower urinary tract symptoms due to benign prostatic hyperplasia. Eur Urol 2011;60:809-25.
ity required for activation and deactivation of the cyl- inders. The aesthetic and functional result, however, Serefoglu EC, Mandava SH, Sikka SC, et al. Penile Doppler sonographic and clinical characteristics in Peyronie’s disease and/or erectile dysfunction: an The not-hydraulic prosthesis will consist of a pair of analysis of 1500 men with sexual dysfunction. BJU Int cylinders of various material, which, depending on their size and different stiffness can be distinguished in: 8 Mirone V, Fusco F, Rossi A, et al. Tadalafil and Varde- nafil vs Sildenafil: a review of patient-preference stud- ies. BJU Int 2009;103:1212-7.
The hydraulic penile implants and soft, are the final Fusco F, Razzoli E, Imbimbo C, et al. A new era in the treatment of erectile dysfunction: Chronic phosphodi- solution to many problems of severe erectile dys- esterase type 5 inhibition. BJU Int 2010;10:1634-9.
10 Corona G, Mondaini N, Ungar A, et al. Phosphodies- terase type 5 (PDE5) inhibitors in erectile dysfunction: the proper drug for the proper patient. J Sex Med References
1 Fusco F, Sicuteri R, Valle D, et la. An identikit of pa- 11 Seftel AD, de la Rosette J, Birt J, et al. Coexisting lower tients seeking treatment for erectile dysfunction in Italy: urinary tract symptoms and erectile dysfunction: a sys- results from the EDOS italian database. Arch Ital Urol tematic review of epidemiological data. Int J Clin Pract 2 Feldman HA, Golstein I, Hatzichristou DG, et al. Im- 12 Wibberley A, Chen Z, Hu E, et al. Expression and func- potence and its medical and psychosocial correlates: results of the Massachusetts Male aging Study. J Urol tional role of rho-kinase in rat urinary bladder smooth muscle. Br J Pharmacol 2003;138:757-66.
Chughtai B, Lee RK, Te AE, et al. Metabolic syndrome Shiri R, Hkkinen JT, Hakama M, et al. Effect of lower and sexual dysfunction. Curr Opin Urol 2011;21:514-8.
urinary tract symptoms on the incidence of erectile dysfunction. J Urol 2005;174:205-9; discussion 209.
Cirino G, Fusco F, Imbimbo C, et al. Pharmacol- ogy of erectile dysfunction in man. Pharmacol Ther Rosen R, Altwein J, Boyle P, et al. Lower urinary tract symptoms and male sexual dysfunction: the multina- 5 Mirone V, Imbimbo C, Palmieri A, et al. Erectile tional survey of the aging male (MSAM-7). Eur Urol dysfunction after surgical treatment. Int J Androl 15 Greenspan MB, Barkin J. Erectile dysfunction and 6 Gacci M, Eardley I, Giuliano F, et al. Critical analysis testosterone deficiency syndrome: the “portal to men’s of the relationship between sexual dysfunctions and health”. Can J Urol 2012;19(5 Suppl 1):18-27.



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