Internal Medicine Journal 44 (2014)
Australian Centre for Sexual Health, Sydney, New South Wales, Australia Key words
erectile dysfunction, phosphodiesterase type 5 inhibitor, alprostadil, intrapenile prosthesis, In the past 30 years, advances in basic science have been instrumental in the evolution vacuum constriction device.
of the male sexual health treatment paradigm from a psychosexual model to a newmodel, which includes oral and intracavernosal injection pharmacotherapy, vacuum constriction devices and penile prostheses for the treatment of erectile dysfunction. This Chris G. McMahon, Australian Centre for Sexual progress has coincided with an increased understanding of the nature of male sexual Health, Suite 2-4, Berry Road Medical Centre, health problems, and epidemiological data that confirm that these problems are widely 1A Berry Road, St Leonards, NSW 2065, prevalent and the source of considerable morbidity, both for individuals and within Received 17 July 2013; accepted 27 September mately 5% among 40-year-olds, 10% among men intheir 60s, 15% among men in their 70s and 30–40% Community-based epidemiological studies suggest that among men in their 80s. It is projected that, by 2025, 322 erectile dysfunction (ED), the persistent inability to million men worldwide will have ED.5 achieve or maintain penile erection sufficient for satisfac- Prevalence studies show that, when controlling for tory sexual performance, is a common disorder in men, other factors, increasing age obesity, diabetes, hyperten- affecting up to 52% of men between the ages of 40 and sion, hyperlipidaemia and vascular disease are causative 70 years and is associated with reduced quality of life.1 factors.1 Although the incidence of ED rises significantly It is now recognised that vascular disease of the penile with increasing age, recent studies indicate that 55–70% arteries is the most common cause of ED, accounting for of men aged 77–79 years are sexually active. However, up to 80% of cases.2 The nitric oxide–cyclic guanosine- only half of the men who self-report ED are concerned 3'5'-monophosphate (NO-cGMP) system is important in producing the arterial dilation and venous occlusion nec-essary to attain and sustain an erection. Abnormalities ofthis vasodilator system due to endothelial dysfunction are present in atherosclerosis and play an important role in Penile erection is a neurovascular phenomenon that the pathophysiology of ED.3 Phosphodiesterase type 5 requires dilation of penile vasculature, relaxation of (PDE5) inhibitor drugs, which inhibit the breakdown of smooth muscle, increased intracavernosal blood flow and cGMP producing vasodilation and improve endothelial normal veno-occlusive function. Penile vascular disease is cell function, are very effective in treating ED.4 the most common cause of organic ED and may involveseveral pathophysiological mechanisms, including im- paired arterial inflow, impaired smooth-muscle caverno- Data from Australian, US and UK studies are similar, sal relaxation, chronic ischaemia-induced increased estimating the prevalence of complete ED as approxi- cavernosal smooth-muscle contraction, cavernosal fibro-sis, veno-occlusive dysfunction and chronic or episodichypoxaemia. Endothelial dysfunction appears to be the Funding: None.
final common pathway for many cases of ED.3 ED may Conflict of interest: C. G. McMahon is a consultant, advisory be an early manifestation of generalised endothelial board member and/or speaker for Bayer Schering, Auxilium andMenarini.
dysfunction, and a predictor and a precursor of other 2014 The Author Internal Medicine Journal 2014 Royal Australasian College of Physicians Erectile dysfunction in men Table 1 Causes of erectile dysfunction
increases with duration, poor glycaemic control and com-plications of DM, such as vascular and microvascular Ë Performance anxiety disease and neuropathies.7 Studies have revealed ED Ë Loss of attraction prevalence rates of 49% in patients with type 1 diabetes, Ë Relationship difficulties and 34% and 24% of severe and mild to moderate ED, respectively, in patients with type 2 diabetes.8,9 Ë Spinal cord injury Ë Pelvic surgery Many neurological disorders including spinal cord injury, Ë Pelvic radiotherapy multiple sclerosis and cavernous nerve damage following Ë Multiple sclerosis major pelvic cancer surgery, such as radical prostatec- Ë Diabetes mellitus tomy or anterior resection, commonly lead to ED.
Ë Intervertebral disc lesion Hormonal deficiency Ë Testosterone deficiency Endocrine disorders, such as hypogonadism, hyper- Ë Raised sex hormone-binding globulin prolactinaemia and thyroid disease play a significant role Ë Hyperprolactinaemia in ED physiology. Testosterone regulates cavernosal nerve structure and function, nitric oxide synthase expression and activity, PED5 and corporal smooth- Ë Diabetes mellitus muscle cell growth and differentiation.
Ë Hyperlipidaemia Ë Peripheral vascular disease Ë Metabolic syndrome Benign prostatic hyperplasia (BPH)
Ë Functional impairment of the veno-occlusive mechanism Men with BPH have a high prevalence of ED. The expla- nation for this association remains unclear, and the Central and/or direct effect, most commonly quality of life of men with BPH is reduced by its effects on Ë Antihypertensives sexual function.10 Ë Antidepressants Although most men with ED have an underlying vas- Ë Luteinising hormone releasing hormone analogues cular cause, usually related to endothelial dysfunction,there is always a contributing, sometimes substantial,psychogenic component related to performance anxiety.
Treatment of this component alone may be sufficient to forms of cardiovascular disease.6 More than half of men restore normal erections.
with ED who have no cardiac symptoms have an abnor-mal stress test, and 40% have been found to have signifi-cant coronary artery disease when studied.
Apart from age, the main risk factors are those for A full history and thorough clinical examination of the vascular disease (smoking, diabetes mellitus, hyperten- patient are needed to: sion, abnormal lipid profile, obesity and lack of exercise).
• Confirm that the patient is suffering from ED and/or Essentially, any condition that damages endothelial func- another sexual dysfunction, such as hypoactive desire or tion can result in ED. Other factors include depression premature ejaculation and endocrine disorders (Table 1).
• Assess the severity of the condition• Determine whether ED is psychogenic or organic inorigin • Identify risk factors or comorbid disease.
ED occurs at an earlier age in men with diabetes mellitus • Assess the fitness of the patient for resuming sexual (DM) compared with men without DM, and the age- adjusted probability of complete ED is nearly three times Several questionnaires have been developed to score higher. More than 50% of men develop ED within 10 the erectile problem objectively. The short five-question years of being diagnosed with DM. The prevalence of ED form of the International Index of Erectile Function 2014 The AuthorInternal Medicine Journal 2014 Royal Australasian College of Physicians Table 2 Sexual Health Inventory for Men (SHIM)
tion findings. General investigations include serumconcentrations of total testosterone (before 11am), How do you rate your confidence that you could get and keep an fasting glucose, fasting lipids and, in men over 50 years of 1 (very low) – 5 (very high) age, prostate-specific antigen. Further investigations may When you had erections with sexual stimulation, how often were your be required based on the results of these initial investi- erections hard enough for penetration (entering your partner)? gations, including serum concentrations of luteinising 0 (no sexual activity) – 5 (almost always or always) hormone, prolactin and high-density lipoprotein/low- During sexual intercourse, how often were you able to maintain your density lipoprotein fractions of cholesterol. Special inves- erection after you had penetrated (entered) your partner? tigations are not always required, but if patients fail to 0 (did not attempt intercourse) – 5 (not difficult) During sexual intercourse, how difficult was it to maintain your erection respond to minimally invasive treatments, such investi- to completion of intercourse? gations may be necessary before other options can be 0 (did not attempt intercourse) – 5 (almost always or always) explored. Colour Doppler imaging provides information When you attempted sexual intercourse, how often was it satisfactory about penile haemodynamics after maximal smooth- muscle relaxation has been induced with a vasoactive 0 (did not attempt intercourse) – 5 (almost always or always) agent. Its aim is to distinguish arterial insufficiency and The questionnaire is self-administered by the patient at the initial veno-occlusive dysfunction from other causes of erectile consultation. A total <21 indicates ED failure. Nocturnal penile tumescence and rigidity testing ED, erectile dysfunction.
to evaluate the frequency, duration and rigidity of noc-turnal erections is more of historical interest, and itscontemporary use is largely limited to medicolegal assess- (IIEF), the IIEF-5 or Sexual Health Inventory for Men is ment of erectile function.
useful for both diagnosis and assessment of response totreatment (Table 2).11 ED can be an early symptom of a significant systemic Impact of a diagnosis of ED
condition, such as diabetes mellitus or cardiovasculardisease. Findings from the history and examination of the It is increasingly recognised that a diagnosis of ED can patient can be supplemented by investigations to identify have a profound impact on the patient's and partner's the cause of erectile failure. The association between quality of life.12 ED can lead to withdrawal from intimacy, anxiety and ED should be established. Psychogenic ED is avoidance of all physical contact with a partner and an likely in younger men with no vascular risk factors who increase in emotional stress, which itself can perpetuate report an abrupt onset of ED and persistent early any psychogenic component to the ED. The condition morning or nocturnal erections. Psychogenic ED can be can affect a man's self-esteem and self-image, and lead to caused by several problems, principally performance anxiety and hence depression. Treatment of ED has been anxiety, but also guilt, depression, relationship problems, shown to lead to resolution of depression and restoration or fear and personal anxiety. Careful enquiry should be of self-esteem, and thus improvement in quality of life.13 made about current medications, such as beta-blockersand thiazide diuretics and antidepressants, as well as theuse of recreational drugs.
The treatment options for men with ED are now varied and effective when compared with those of 20 years ago.
The examination of a man with ED will be directed, to a The selection from these various treatment options certain extent, by his history and should include assess- depends on several factors, such as severity of ED, under- ment of the external genitalia, the endocrine and vascu- lying cause and patient and partner choice. The results of lar systems, and the prostate gland in most patients.
the few studies that have been performed indicate that The penis should be carefully palpated to exclude the the only lifestyle modification that may make a difference presence of fibrous Peyronie plaques and to check in ED incidence is continuation or initiation of physical for phimosis. Prostatic induration or a palpable nodule activity. Midlife changes in lifestyle other than physical should raise the suspicion of prostate cancer.
activity may not have a beneficial effect on ED because itis simply too late. Some studies have suggested thatsmoking cessation may improve erectile function, which other studies have refuted. In addition, use of some The degree to which men should undergo clinical inves- antihypertensive and lipid-lowering drugs may actually tigation depends on the patient's history and examina- exacerbate ED.
2014 The Author Internal Medicine Journal 2014 Royal Australasian College of Physicians Erectile dysfunction in men Table 3 Guidelines for prescribing ED treatment in patients with cardiac
Relationship difficulties, depression, guilt, problems with intimacy and lack of sexual experience may all increase anxiety and/or conflict, which may then manifest as ED.
Psychosexual treatments range from simple sex educa- Ë Controlled hypertension Manage in primary tion through improved partner communication to cogni- Ë Mild valvular disease tive and behavioural therapy and are often combined Mild stable angina with ED pharmacotherapy. Results of psychosexual Ë Recent MI or cerebrovascular Specialised evaluation therapy are relatively good in the short term, but long- accident (6 weeks) term results are disappointing.15,16 Ë Congestive heart failure Ë Murmur of unknown cause Ë Moderate stable angina Ë Uncontrolled angina Refer for cardiac Most patients suffering from ED will respond to the safe, Ë Severe heart failure effective oral pharmacological agents now available.
Ë Recent MI or cerebrovascular These include the PDE5 inhibitors sildenafil, tadalafil accident (2 weeks) and vardenafil. Other physical treatments, such as Ë High-risk arrhythmia vacuum devices and intracavernosal drugs, are used ‘on Ë Hypertrophic cardiomyopathy demand'; however, the rates of discontinuation with Ë Moderate/severe valve disease these treatment alternatives are high owing to side- ED, erectile dysfunction; MI, myocardial infarction.
effects, dislike of needles and unwillingness of thepartner to participate.
A large proportion of patients has a combination of Coronary artery disease and risk
psychogenic and organic ED. Organic ED may be associ- It is well known that ED is associated with numerous risk ated with progressively worsening performance anxiety, factors for coronary artery disease (CAD), including lipid which further worsens erectile function. To treat these abnormalities, hypertension, smoking, diabetes, obesity men holistically, the physician and psychotherapist may and lack of physical activity. However, most physicians do need to collaborate and combine counselling with a not routinely ask cardiac patients about ED, and these physical therapy, such as an oral pharmacological agent.
patients often are reluctant or embarrassed to discuss it.
In addition, there is a paucity of studies examining the effect of control of risk factors on ED once the ED hasbeen diagnosed.
Oral pharmacological agents
Accumulating evidence indicates that ED is a predictor of cardiovascular health. Men with proven vasculogenic PDE5 inhibitors are a breakthrough therapy in the treat- ED or multiple vascular risk factors and suspected ment of ED (Table 4). The PDE5 inhibitors selectively vasculogenic ED should be screened for silent myocardial inhibit PDE5 and increase the amount of cGMP available ischaemia by treadmill stress electrocardiogram or com- for smooth-muscle relaxation, inducing vasodilatation, puted tomography coronary angiography.
increased corporal blood flow and erection.
In men with CAD, fitness for renewed sexual activity Numerous studies have documented the efficacy, safety should be assessed with an exercise stress test before and tolerability of the potent, competitive on-demand initiating or resuming sexual activity. Ability to exercise PDE5 inhibitor drugs sildenafil (Viagra, Pfizer, Inc., New up to 3–6 METs without evidence of myocardial ischae- York, NY, USA), tadalafil (Cialis, Eli Lily and Company, mia suggests a low risk of experiencing cardiac symptoms Indianapolis, IN, USA) and vardenafil (Levitra, Bayer during sexual activity. In asymptomatic men, fitness for Schering, Pharma AG, Leverkusen, Germany), and daily renewed sexual activity can be confirmed by tolerance of dosing of tadalafil in the treatment of ED in a wide range a simple exercise challenge of walking 1.5 km briskly on of patients, including those with hypertension, diabetes, the level in 20 min (3–4 METs) or climbing two flights of spinal cord injury, other concomitant medical conditions stairs without limiting symptoms (6 METs) (Table 3).14 and in those patients taking a wide variety of concomitantmedications.4,17,18 The overall efficacy for the differentPDE5 inhibitors appears similar with 65–70% of men achieving completion of sexual intercourse. Efficacy is Psychosexual therapy for ED cannot be standardised related to the extent and severity of ED, with significantly because the source of anxiety varies between patients.
reduced efficacy demonstrated in patients with severe 2014 The AuthorInternal Medicine Journal 2014 Royal Australasian College of Physicians Table 4 On-demand/daily phosphodiesterase type 5 (PDE5) inhibitors
Ë Sexual arousal activates the nitric oxide/cGMP pathway. Inhibition of PDE5 results in increased corporal levels of cGMP, relaxation of penile vascular smooth muscle, increased corporal blood flow and augmented penile tumescence/erection.
Ë Sildenafil (Viagra, Pfizer Inc., New York, NY, USA), tadalafil (Cialis, Eli Lily and Company, Indianapolis, IN, USA) and vardenafil (Levitra, Bayer Schering, Pharma AG, Leverkusen, Germany) Ë Sexual arousal is essential for a response Ë May occur as early as 20 min after on-demand administration Ë High fat meal limits speed and extent of absorption of sildenafil and vardenafil, but not tadalafil Ë Detumescence occurs immediately following ejaculation or cessation of sexual arousal Duration of response following on-demand dosing Ë Sildenafil 4–6 h Ë Vardenafil 6–8 h Ë Tadalafil up to 36 h Ë On-demand sildenafil, tadalafil and vardenafil or daily dosing of tadalafil Ë Assess patient fitness for renewed sexual activity prior to initiating treatment On-demand- 30–60 min Reduce dose in elderly, renal On-demand- 60–120+ min On-demand- 20–60 min Ë Choice of drug should be individualised to patient's needs Ë No ‘head-to-head' comparative studies are available Ë The extended period of response to tadalafil may suit some patients Ë Daily dosing of tadalafil may offer some patients additional sexual spontaneity Ë Rapidly absorbed after oral administration Ë Maximum plasma concentrations are reached within 30–120 min in the fasted state Ë Pharmacokinetics are dose-proportional over the recommended dose range Ë Extensively metabolised by CYP3A4 (major route) and CYP2C9 (minor route) hepatic microsomal isoenzymes Ë Adverse effects are dose related and are usually of mild to moderate severity Ë Most common are headache, facial and upper trunk flushing, dyspepsia, muscle/back ache and nasal congestion.
Ë Transient alteration in colour vision may occur with sildenafil and vardenafil Ë No cases of priapism have been reported in routine clinical use Drug interactions Ë Concomitant use of potent cytochrome P450 3A4 inhibitors (e.g. erythromycin, ketoconazole, itraconazole and protease inhibitors) as well as the non-specific CYP inhibitor, cimetidine, is associated with increased plasma levels Ë Concomitant administration of CYP3A4 inducers, such as rifampin, will decrease plasma levels Ë Potentiation of the hypotensive effects of nitrates and administration in patients who use nitric oxide donors or nitrates in any form is therefore cGMP, cyclic guanosine-3'5'-monophosphate; CYP, cytochrome P450.
vasculogenic ED, diabetic ED and post-radical prostatec- of sildenafil and vardenafil are 4–5 h and that of tadalafil tomy ED. Data indicate that there are differences among sildenafil, tadalafil and vardenafil in pharmacokinetic Daily dosing with tadalafil (Cialis 2.5, 5 and 10 mg) properties, efficacy, potency, half-life and adverse effect results in efficacy and side-effect rates comparable with profiles (Table 4). Food high in fat delays and reduces the those of on-demand application of the highest doses of absorption of sildenafil and vardenafil, but does not affect either tadalafil or other PDE 5 inhibitors, and can be the rate or extent of absorption of tadalafil. The mean time considered first-line therapy, especially in men who to maximum plasma concentration of sildenafil and engage in frequent intercourse or regard spontaneity of vardenafil is 1 h and for tadalafil is 2 h, while the half-lives sexual intercourse as a key treatment goal.19 Daily dosing 2014 The Author Internal Medicine Journal 2014 Royal Australasian College of Physicians Erectile dysfunction in men may improve endothelial function and improve or Table 5 Alprostadil
restore erectile function. Salvage of on-demand tada- lafil failures with daily or alternate day administered Ë Relaxation of trabecular smooth muscle and dilatation of cavernosal high-dose tadalafil (10–20 mg) has been reported but is arteries, expansion of lacunae and entrapment of blood by limited by the relatively high cost of treatment.20 compression of the drainage venules against the tunica Treatment with PDE5 inhibitor drugs is generally well tolerated and the adverse effects reported are usually Administered by direct intracorporal injection (Caverject, Pfizer Inc., New York, NY, USA) transient, mild to moderate in nature, dose dependent and often attenuate or disappear with continued use.
Ë 5–15 min of intracavernosal injection (ICI) The most commonly reported adverse effects are headache Ë Arousal is usually required to produce a maximal response.
Ë With correct dosing, detumescence should commence within muscle/back ache (0–4%) and nasal congestion (2–9%).
10−20 min of ejaculation, but a fully flaccid penis may not occur for In most instances, adverse effects are mild, are best a further 1–2 h.
managed symptomatically and will resolve with 4–6 Ë Assess patient fitness for renewed sexual activity weeks, but on occasions, cessation and/or a trial to a Ë Administered 5–15 min before planned sexual activity second PDE5 inhibitor drugs and another treatment may Ë Individualise dose by initial in-office physician supervised dosage be indicated. Blindness due to non-arteritic anterior titration using the lowest possible effective dose ischaemic optic neuropathy has been linked to the use of Caverject Impulse PDE5 inhibitors. Although a causal relationship has not Ë 1 mL ampoules as Caverject Impulse 10 (10 mcg), Caverject Impulse been established, loss of vision or reduced vision, whether painful or painless, demands urgent patient assessment Instruct patient in sterile injection technique, used needle disposal, management of prolonged erections and immediate cessation of PDE5 inhibitor use.
Ë Maximum frequency of use is no more than three times a week, PDE5 inhibitor drugs are contraindicated in patients with at least 24 h between each dose.
taking aerosol, tablet or topical short- or long-acting Ë Start with 5 mcg and titrate in 5 mcg increments to a maximum of organic nitrates, such as nitroglycerin or isosorbide dinitrate. PDE5 inhibitors have been shown to cause Ë Start with 1.25 mcg and titrate in 1.25 mcg increments in spinal greater decreases in blood pressure in some patients on cord injured (SCI) patients organic nitrates. There is currently no evidence of any Management of prolonged erection Ë Use lowest possible effective dose direct deleterious effect on myocardium, and there is an Ë If still rigid increasing body of evidence to support the concept that Ë 2 h after administration – 120 mg pseudoephedrine PDE5 inhibitors improve endothelial function and, there- Ë 4 h after administration – 120 mg pseudoephedrine/walk briskly for fore, are likely to be cardioprotective.
Ë 6 h after administration – contact treating doctor or hospital A&E Ë Some patients may require aspiration of corpora/irrigation with Intracavernosal injection (ICI) therapy
dilute vasoconstrictors/surgical drainage Treatment with patient-administered ICI therapy using Ë Short duration of action and a brief plasma half-life vasodilator drugs, such as alprostadil (Caverject Impulse, Ë 30% of the drug is metabolised within the corpora cavernosa and/or Pfizer) alone, or in combination with papaverine and urethral mucosa and up to 80% after the first pass through the lung phentolamine, which relax the arterial and trabecular to inactive metabolites.
smooth muscle, is an effective treatment for ED.21 ICI therapy can be used in most men with ED but is espe- Caverject, Pfizer Inc.
cially useful in men who fail to respond to oral pharma- Mild penile pain (15–20%), priapism (0.25%) AND corporal fibrosis (5–10%) with long-term use cological agents (Table 5).22 Ë Approximately 30% of users discontinue ICI each year Alprostadil resulted in an erection of sufficient rigidity Drug interactions for sexual intercourse in 72.6% of men with ED.21 The Ë Systemic drug–drug interactions are unlikely due to low or principal side-effects of ICI of alprostadil are pain at the undetectable levels of alprostadil in the peripheral venous site of injection, which occurs in up to 30% of patients, and corporal fibrosis resulting in the development ofpenile nodules and curvature in 9–23.3% of mid- andlong-term users. Priapism is a rare complication that cancause irreversible ischaemic damage to the corporacavernosa with subsequent fibrotic damage and perma-nent loss of erectile function. Systemic side-effects are 2014 The AuthorInternal Medicine Journal 2014 Royal Australasian College of Physicians uncommon (∼1%), include dizziness, tachycardia and may be more reliable in certain selected patients, the hypotension, and result from leakage of the drug into the incidence of morbidity and complications is significantly circulation. Alprostadil has superior efficacy and reduced greater than with medical treatment.
risk of priapism and intracorporal fibrosis compared withpapaverine alone or in combination with phentolamine.
As such, papaverine should be restricted to informed Penile prosthetic implants
patients refractory to alprostadil.
Combination pharmacotherapy of alprostadil com- Malleable or multicomponent inflatable penile implants bined with other agents, such as papaverine and phen- are usually reserved for patients in whom more con- tolamine, is effective in 91.6% of patients and appears servative therapy has failed and are associated with high effective as ‘salvage therapy' in treating patients with satisfaction rates. Device failure and prosthetic infection severe vasculogenic ED.21 are uncommon. Infection is the most problematic com- The self-injection technique should be taught by either plication following surgery and often requires removal of the physician or the practice nurse. Relative contrain- the prosthesis, and either immediate replacement or dications to ICI therapy include anticoagulation, previous staged reimplantation at a later stage.
poor compliance and a history of priapism.
Vacuum constriction devices
ED in special populations
The vacuum constriction device involves application of a vacuum to the penis in a vacuum cylinder causing tumes-cence and rigidity, which is sustained using a constricting Peyronie's disease is curvature of the penis due to ring at the base of the penis. The penile physiological fibrosis within the tunica albuginea. The affected corpora changes differ from a normal erection in that trabecular cavernosa cannot lengthen on erection, leading to curva- smooth-muscle relaxation does not occur, and blood is ture. The condition is most common in middle-aged men simply trapped in both the intracorporal and extra- who are sexually active. Its exact aetiology remains corporal compartments of the penis distal to the con- unknown, but it may result from trauma and bleeding stricting ring.
into the tunica, followed by activation of the inflamma- Vacuum constriction devices require a motivated tory process and fibrosis. It is regarded as a disorder of patient and a cooperative partner. They are more wound healing, is associated with similar conditions such popular in middle and old age group couples and are as Dupuytren's contracture and Ledderhose disease, and uncommon treatment choices in single younger men.
may have an inherited basis.23 Approximately 60–70% of men find the device straight- ED occurs in 30–40% of men with Peyronie disease.
forward. Satisfaction rates, both short and long term, Although the mechanism of their ED is not clearly under- vary considerably from as low as 27% to 68% short term, stood, most appear to have a vascular problem, such as to as high as 69% with 2 years follow-up. Complications arterial insufficiency where the fibrosis actually distorts include petechiae, pain occurs at the site of the ring and the vessels or failure of the veno-occlusive mechanism.
ejaculatory changes, including pain on ejaculation and To a certain extent, treatment is determined by whether blocked ejaculation, numbness and pivoting of the penis the patient has ED and Peyronie disease. If the patient at the base. Vacuum constriction devices are relatively has this combination, he may be best advised to undergo contraindicated in men taking warfarin and in men with insertion of a penile implant, as surgical straightening of an increased risk of intravascular thrombosis due to the penis alone is unlikely to overcome the ED. If penile myeloproliferative diseases and sickle-cell anaemia.
curvature alone is the factor that precludes intercourse,medical or surgical treatment may be indicated. Medicaltreatment is limited to non-calcified plaques, curvatures less than 70 degrees, and is usually multimodal and Surgical treatment of ED is usually reserved for patients may include antifibrotic agents, such as pentoxifylline in whom more conservative therapy has failed or for (Trental, Paris, France) and intraplaque infiltrations with whom conservative therapy is contraindicated. Most of verapamil. Curvature can be surgically corrected by these patients will have significant arterial or venous plaque excision and grafting or a Nesbit operation. This disease, penile corpus cavernosum fibrosis or Peyronie procedure involves shortening of the contralateral corpus disease, or will, by choice, prefer the prospect of a ‘one- cavernosum. Patients should be warned of the risks of off' solution. While the outcome of surgical intervention penile shortening and onset of ED after surgery.
2014 The Author Internal Medicine Journal 2014 Royal Australasian College of Physicians Erectile dysfunction in men neurological and vascular impairment, which may bedifficult to treat.
Chronic renal impairment is associated with a high inci-dence of ED, with the incidence increasing with the levelof creatinine. ED is present in about 50% of patients by the time they require dialysis and is associated with Pelvic radiation therapy, whether by external beam or anaemia, autonomic neuropathy, reduced testosterone brachytherapy with radioactive seeds inserted into the levels with elevated prolactin, accelerated arterial disease, prostate, can produce ED. While ED rates immediately other drug therapies and psychological stress. Erythro- after external radiotherapy are low – less than 10% at 1 poietin treatment and transplantation with normalisation month and 12 months – they increase over time, with of renal function often restore or improve the patient's 33% of patients reporting ED at 36 months and a mean overall quality of life and erectile function.
time to ED of 14.5 months.
BPH with lower urinary tract symptoms (LUTS)
Damage to cavernous and other pelvic nerves following Recent studies have shown a clear association between surgery to the rectum, bladder or prostate is often asso- ED and BPH with LUTS. The association is independent ciated with erectile and/or ejaculatory dysfunction. Ana- of age, but the more severe the LUTS, the more severe the ED. Recent data have not only confirmed this asso- damage and reduce the risk of ED. Patients who undergo ciation but also demonstrated a moderate effect of gastrointestinal surgery that results in an ileostomy or tadalafil on patients with LUTS.
colostomy may suffer depression or loss of self-esteem,which may cause ED. Preliminary evidence suggests thatthe sooner pharmacological treatment is started after an operation, the more likely the patient is to regain normal ED is a common compliant and is often associated with a erectile function.
reduced quality of life for sufferer and partner. ED isassociated with a variety of risk factors, including diabetesmellitus, hypertension, hyperlipidaemia and cigarette smoking. ED may be the first manifestation of generalised Blunt or penetrating injuries can cause a penile fracture, endothelial dysfunction and is a predictor of overall car- rupture of the tunica albuginea or neurovascular bundle diovascular health and silent myocardial ischaemia.
damage, with resultant ED. Complete urethral disruption Treatment with ED pharmacotherapy alone or in combi- injuries from a pelvic fracture are almost universally nation with graded psychosexual therapy is effective in associated with ED, often due to a combination of improving and/or restoring sexual function in most men.
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Submitted By: Parish Disaster Committees Date of Event: August 28, 2008 St. James Type: Tropical Storm Gustav INTRODUCTION AND BACKGROUND Summary:Tangle River - (break away of a section of the road to the bottom end and upper middle a long crack in the surface. Johnson - huge landslide blocking more than half the roadway bringing traffic to a snarl. Further into Johnson before reaching the Church there was another huge breakaway in the road. Heading to Niagra/Arcadia were flooded waters across the main roads.

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