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Erectile dysfunction in common neurological conditions: A narrative review
Summary
Neurogenic erectile dysfunction (NED) can be defined as the inability to achieve or maintain an erection due to central or peripheral neurologic disease. Neurologic diseases can also affect the physical ability and psychological status of the patient. All these factors may lead to a primary or secondary NED. Medication history plays an important role since there are many drugs commonly used in neurologic patients that can lead to ED. The assessment of NED in these patients is generally evolving with the application of evoked potentials technology in the test of somatic and autonomic nerves and functional magnetic resonance imaging. With the electrophysiological examinations, neurogenic causes can be determined. These tools allow the categorization of neurologic lesions and assess the patient's prognosis. The first-line treatment for NED is phosphodiesterase inhibitors. Second-line treatments include intracavernous and intraurethral vasoactive injections. Third-line treatments are penile prostheses. The efficacy and safety of each treatment modality depend on the specific neurologic condition. This review discusses the physiology, pathophysiology, diagnosis, and treatment of ED in multiple peripheral and central neurologic conditions, as well as for future research.
INTRODUCTION
Erectile dysfunction (ED) is common (affecting 10-20 million men in the USA) and multifactorial disease due to organic and/or psychological factors that strongly impair the quality of life in man. During the past decade, many advances in the understanding of the pathophysiology of ED have been made and new therapeutic strategies have become available (1). ED is the inability to achieve or maintain an erection that is sufficient for satisfactory sexual performance and affects a considerable proportion of men at least occasionally. The severity of ED is often described as mild, moderate, or severe according to the five-item International Index of Erectile Function (IIEF-5) questionnaire, with a score of 1-7 indicating severe ED, 8-11 moderate ED, 12-16 mild-moderate ED, 17-21 mild ED and 22-25 no ED (2). Risk factors for ED are numerous, with patients over 40 years old demonstrating a significant association between ED and cardiovascular risk factors including hypertension, dyslipidemia, diabetes mellitus (DM), coronary artery disease, and metabolic syndrome (3). Organic causes are responsible for about 60% to 90% of all causes of ED. The most frequent pathologies involved are vasculogenic. The most common etiologies are due to low blood inflow (large vessel atherosclerosis), DM, endocrinologic disorders, neurogenic, trauma, penile disease, iatrogenic, and drugs. It was estimated that 10-19% of the organic ED are neurogenic. The main causes are intracerebral (Parkinson's disease, cerebrovascular disease, stroke, encephalitis, or temporal lobe epilepsy) or spinal cord etiologies (trauma, multiple sclerosis, myelodysplasia). Peripheral nerves are also affected in alcoholic neuropathy, diabetic neuropathy, after surgery (radical pelvic surgery), and trauma (4). The first distinction of ED that should be established is psychogenic from organic.
Clues to suggest a psychogenic etiology include sudden onset, good quality spontaneous or self-stimulated erections, major life events, or previous psychological problems. Conversely, gradual onset, lack of tumescence, and normal libido are more suggestive of an organic etiology (5). Identification of ED can be made through questionnaires or a complete medical and sexual history. Anamnesis and laboratory tests are sufficient in most cases to identify ED and to manage the treatment. Supplementary tests are used in special cases or where confirmation of an etiological diagnosis is required (6). The current standard of care for ED consists of lifestyle changes such as management of diet, diabetes, hypertension, and weight loss, along with pharmacotherapies. The current gold standard treatment is the use of phosphodiesterase 5 inhibitors (PDE5i) (7). PDE5i are the most effective oral drugs for the treatment of ED, including ED associated with DM, spinal cord injury, and antidepressants. Intraurethral and intracavernosal injections (ICI), vacuum pump devices, and surgically implanted penile prostheses are alternative therapeutic options when PDE5i fail. Testosterone supplementation in men with hypogonadism improves ED and libido (8). More invasive options exist for patients who do not respond to PDE-5i therapy or in whom it is contraindicated. Alprostadil (prostaglandin E1) causes smooth muscle relaxation and subsequent vasodilation by acting on adenylate cyclase to increase the intracellular cyclic adenosine monophosphate (cAMP) concentration.
Prostaglandin E1 may be administered intraurethral, where it is absorbed and transported throughout the erectile bodies. Vasoactive drugs may also be injected intracavernosal. Such therapy represents an important second-line therapy for ED. It is the most effective pharmacologic treatment but has a high dropout rate because of the associated pain (9). Penile prostheses are the only surgical therapy option maintaining its significance as a cure for ED. There are convincing long-term results with a high degree of patient and partner satisfaction, high patient acceptance, and good functional durability of the mostly three-piece inflatable devices (10).
In patients where pharmacological therapy is unhelpful or contraindicated, another option is the surgical approach. Penile vascular surgery is suitable only for healthy men with acquired ED due to isolated stenosis of extra-penile arteries without any kind of generalized vascular disease. Penile prosthesis implant is recognized, at present, as the most effective option to obtain an artificial erection satisfactory for sexual intercourse in those patients in which the pharmacological approach is contraindicated or ineffective (11). We performed a narrative review to discuss the physiology, pathophysiology, diagnosis, and treatment of ED in multiple peripheral and central neurologic conditions. We also presented the novel therapies for ED in some neurologic diseases.
*Erectile dysfunction (ED) in patients with spinal cord injury
*Erectile dysfunction (ED) in patients with Cerebrovascular accident
*Erectile dysfunction(ED) in patients with Parkinson’s disease
*Erectile dysfunction (ED) in patients with multiple sclerosis
*Erectile dysfunction (ED) in patients with epilepsy
*Erectile dysfunction (ED) in patients with Herniated disc
*Erectile dysfunction (ED) in patients with multiple system atrophy
*Erectile dysfunction (ED) in patients with peripheral neuropathy
CONCLUSIONS
Sexual and function are important factors contributing to the quality of life in patients with neurologic disease. Neurogenic ED is a complex problem. Sexual functioning should be regularly evaluated during a long-term rehabilitation program and any existing ED should be included in the treatment plan. New drugs and treatment options may help to improve the treatment and quality of life of patients with neurologic conditions.
Summary
Neurogenic erectile dysfunction (NED) can be defined as the inability to achieve or maintain an erection due to central or peripheral neurologic disease. Neurologic diseases can also affect the physical ability and psychological status of the patient. All these factors may lead to a primary or secondary NED. Medication history plays an important role since there are many drugs commonly used in neurologic patients that can lead to ED. The assessment of NED in these patients is generally evolving with the application of evoked potentials technology in the test of somatic and autonomic nerves and functional magnetic resonance imaging. With the electrophysiological examinations, neurogenic causes can be determined. These tools allow the categorization of neurologic lesions and assess the patient's prognosis. The first-line treatment for NED is phosphodiesterase inhibitors. Second-line treatments include intracavernous and intraurethral vasoactive injections. Third-line treatments are penile prostheses. The efficacy and safety of each treatment modality depend on the specific neurologic condition. This review discusses the physiology, pathophysiology, diagnosis, and treatment of ED in multiple peripheral and central neurologic conditions, as well as for future research.
INTRODUCTION
Erectile dysfunction (ED) is common (affecting 10-20 million men in the USA) and multifactorial disease due to organic and/or psychological factors that strongly impair the quality of life in man. During the past decade, many advances in the understanding of the pathophysiology of ED have been made and new therapeutic strategies have become available (1). ED is the inability to achieve or maintain an erection that is sufficient for satisfactory sexual performance and affects a considerable proportion of men at least occasionally. The severity of ED is often described as mild, moderate, or severe according to the five-item International Index of Erectile Function (IIEF-5) questionnaire, with a score of 1-7 indicating severe ED, 8-11 moderate ED, 12-16 mild-moderate ED, 17-21 mild ED and 22-25 no ED (2). Risk factors for ED are numerous, with patients over 40 years old demonstrating a significant association between ED and cardiovascular risk factors including hypertension, dyslipidemia, diabetes mellitus (DM), coronary artery disease, and metabolic syndrome (3). Organic causes are responsible for about 60% to 90% of all causes of ED. The most frequent pathologies involved are vasculogenic. The most common etiologies are due to low blood inflow (large vessel atherosclerosis), DM, endocrinologic disorders, neurogenic, trauma, penile disease, iatrogenic, and drugs. It was estimated that 10-19% of the organic ED are neurogenic. The main causes are intracerebral (Parkinson's disease, cerebrovascular disease, stroke, encephalitis, or temporal lobe epilepsy) or spinal cord etiologies (trauma, multiple sclerosis, myelodysplasia). Peripheral nerves are also affected in alcoholic neuropathy, diabetic neuropathy, after surgery (radical pelvic surgery), and trauma (4). The first distinction of ED that should be established is psychogenic from organic.
Clues to suggest a psychogenic etiology include sudden onset, good quality spontaneous or self-stimulated erections, major life events, or previous psychological problems. Conversely, gradual onset, lack of tumescence, and normal libido are more suggestive of an organic etiology (5). Identification of ED can be made through questionnaires or a complete medical and sexual history. Anamnesis and laboratory tests are sufficient in most cases to identify ED and to manage the treatment. Supplementary tests are used in special cases or where confirmation of an etiological diagnosis is required (6). The current standard of care for ED consists of lifestyle changes such as management of diet, diabetes, hypertension, and weight loss, along with pharmacotherapies. The current gold standard treatment is the use of phosphodiesterase 5 inhibitors (PDE5i) (7). PDE5i are the most effective oral drugs for the treatment of ED, including ED associated with DM, spinal cord injury, and antidepressants. Intraurethral and intracavernosal injections (ICI), vacuum pump devices, and surgically implanted penile prostheses are alternative therapeutic options when PDE5i fail. Testosterone supplementation in men with hypogonadism improves ED and libido (8). More invasive options exist for patients who do not respond to PDE-5i therapy or in whom it is contraindicated. Alprostadil (prostaglandin E1) causes smooth muscle relaxation and subsequent vasodilation by acting on adenylate cyclase to increase the intracellular cyclic adenosine monophosphate (cAMP) concentration.
Prostaglandin E1 may be administered intraurethral, where it is absorbed and transported throughout the erectile bodies. Vasoactive drugs may also be injected intracavernosal. Such therapy represents an important second-line therapy for ED. It is the most effective pharmacologic treatment but has a high dropout rate because of the associated pain (9). Penile prostheses are the only surgical therapy option maintaining its significance as a cure for ED. There are convincing long-term results with a high degree of patient and partner satisfaction, high patient acceptance, and good functional durability of the mostly three-piece inflatable devices (10).
In patients where pharmacological therapy is unhelpful or contraindicated, another option is the surgical approach. Penile vascular surgery is suitable only for healthy men with acquired ED due to isolated stenosis of extra-penile arteries without any kind of generalized vascular disease. Penile prosthesis implant is recognized, at present, as the most effective option to obtain an artificial erection satisfactory for sexual intercourse in those patients in which the pharmacological approach is contraindicated or ineffective (11). We performed a narrative review to discuss the physiology, pathophysiology, diagnosis, and treatment of ED in multiple peripheral and central neurologic conditions. We also presented the novel therapies for ED in some neurologic diseases.
*Erectile dysfunction (ED) in patients with spinal cord injury
*Erectile dysfunction (ED) in patients with Cerebrovascular accident
*Erectile dysfunction(ED) in patients with Parkinson’s disease
*Erectile dysfunction (ED) in patients with multiple sclerosis
*Erectile dysfunction (ED) in patients with epilepsy
*Erectile dysfunction (ED) in patients with Herniated disc
*Erectile dysfunction (ED) in patients with multiple system atrophy
*Erectile dysfunction (ED) in patients with peripheral neuropathy
CONCLUSIONS
Sexual and function are important factors contributing to the quality of life in patients with neurologic disease. Neurogenic ED is a complex problem. Sexual functioning should be regularly evaluated during a long-term rehabilitation program and any existing ED should be included in the treatment plan. New drugs and treatment options may help to improve the treatment and quality of life of patients with neurologic conditions.
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