madman
Super Moderator
Introduction: Erectile dysfunction (ED) is a common condition affecting more than 3 million men in the United States every year. Given the prevalence of severe comorbidities associated with ED, the clinician must take a thorough history and conduct a diagnostic exam accordingly. The clinician should consider that every man who presents with ED is unique with regards to his symptoms, degree of stress, associated health conditions, sexual relationship quality, and sociocultural context. The clinician determines an appropriate treatment plan that is aligned with the patient’s and his partner’s priorities and values, adopting a shared decision-making process. The clinician must possess sufficient knowledge of all available treatment modalities and be able to offer to all treatment options that are not contraindicated, regardless of invasiveness or irreversibility, as potential first-line treatments.
Materials and methods: Current medical and surgical treatment options in ED, including novel and innovative therapeutic options, were reviewed.
Results: There are a variety of treatment options for the management of ED, both medical and surgical. The most commonly considered medical treatment option is phosphodiesterase type 5 inhibitors (PDE5i), which has been proven successful in up to 65% of men with ED. Other treatment options, such as vacuum erection device or intracavernosal injection therapy using vasodilator medications, should be considered in men who have contraindications or are non-responders to PDE5i. Surgical treatment of ED using penile implants has undergone multiple improvements over the years with low device failure and infection risks providing an effective and satisfying treatment alternative. Other therapies, such as penile vascular surgery, extracorporeal shock wave therapy, and intracavernosal stem cell therapies, are novel and should be considered investigational due to lack of evidence supporting their long term safety and efficacy.
Conclusions: The management of ED requires considerations of all aspects of the patient’s health and involvement of the patient and his partner in the decisionmaking process. Patients should be informed of all available treatment options and be able to choose the option that is most aligned with their condition, goals, and risk tolerance. There are medical and surgical therapeutic options available in the management of ED, all supported with the best level of evidence. Novel therapeutic options are promising; however, randomized controlled trials with long term follow up periods and larger sample sizes are needed to support their safety and efficacy.
*Oral PDE5i
*Intraurethral alprostadil
*Intracavernosal injection
*Penile prosthesis implantation
*Penile vascular surgery
*Extracorporeal shock wave therapy
*Intracavernosal stem cell therapy
*Platelet-rich plasma and other therapies
Conclusion
In clinical practice, the majority of patients with ED are placed on oral treatment with PDE5i as initial therapy. However, improving overall health with lifestyle modification and treatment of underlying comorbidities may alone enhance erectile function. The clinician should discuss all possible choices during the initial visit, regardless of its invasiveness, considering the patient’s health literacy and sociocultural background. Shared decision making between clinician, patient, and partner plays a vital role in promoting treatment adherence. Before starting PDE5i, the clinician should provide instructions to maximize benefits and efficacy. Dose titration is essential to achieve the best efficiency with minimal adverse events. Referral to mental health professionals should not be overlooked; performance anxiety and communication between partners need to be addressed to achieve full success.
Treatments such as transurethral alprostadil, ICI, or VED should be offered in case that PDE5i fails or there are contraindications to use of such medication. In-office injection tests should be utilized before initiating therapies like transurethral alprostadil or ICI to establish an effective dose and monitor adverse effects. In-office trials also help patients gain confidence with technique and facilitate adherence. If non-surgical options fail, penile prosthesis implantation should be discussed. The clinician should review the short and long term expectations of penile prosthesis implantation with the patient and his partner in-depth due to the irreversible consequence of surgery.
There have been many emerging therapies developed for ED treatment over the last decade. Some of these innovative and novel therapies, such as SCT, gene therapy, and PRP, may indeed replace or regenerate the endothelial, neuronal, and smooth muscle cells in the penis. However, the long term implications of these therapies are unknown. Well-designed randomized controlled studies adopting standardized protocols and including larger study populations are needed. An algorithm for the management principles of patients presenting with ED is described in Figure 1.
On another note, new pharmacologic agents targeting underlying pathophysiologies such as guanylate cyclase activators, NO donors, and RhoA/Rho-kinase inhibitors are promising therapies based on preclinical studies. Improvements in novel surgical techniques using tissue transplants and new device-based treatments such as novel drug or drug delivery systems may be implemented as ED therapies in the future.
Materials and methods: Current medical and surgical treatment options in ED, including novel and innovative therapeutic options, were reviewed.
Results: There are a variety of treatment options for the management of ED, both medical and surgical. The most commonly considered medical treatment option is phosphodiesterase type 5 inhibitors (PDE5i), which has been proven successful in up to 65% of men with ED. Other treatment options, such as vacuum erection device or intracavernosal injection therapy using vasodilator medications, should be considered in men who have contraindications or are non-responders to PDE5i. Surgical treatment of ED using penile implants has undergone multiple improvements over the years with low device failure and infection risks providing an effective and satisfying treatment alternative. Other therapies, such as penile vascular surgery, extracorporeal shock wave therapy, and intracavernosal stem cell therapies, are novel and should be considered investigational due to lack of evidence supporting their long term safety and efficacy.
Conclusions: The management of ED requires considerations of all aspects of the patient’s health and involvement of the patient and his partner in the decisionmaking process. Patients should be informed of all available treatment options and be able to choose the option that is most aligned with their condition, goals, and risk tolerance. There are medical and surgical therapeutic options available in the management of ED, all supported with the best level of evidence. Novel therapeutic options are promising; however, randomized controlled trials with long term follow up periods and larger sample sizes are needed to support their safety and efficacy.
*Oral PDE5i
*Intraurethral alprostadil
*Intracavernosal injection
*Penile prosthesis implantation
*Penile vascular surgery
*Extracorporeal shock wave therapy
*Intracavernosal stem cell therapy
*Platelet-rich plasma and other therapies
Conclusion
In clinical practice, the majority of patients with ED are placed on oral treatment with PDE5i as initial therapy. However, improving overall health with lifestyle modification and treatment of underlying comorbidities may alone enhance erectile function. The clinician should discuss all possible choices during the initial visit, regardless of its invasiveness, considering the patient’s health literacy and sociocultural background. Shared decision making between clinician, patient, and partner plays a vital role in promoting treatment adherence. Before starting PDE5i, the clinician should provide instructions to maximize benefits and efficacy. Dose titration is essential to achieve the best efficiency with minimal adverse events. Referral to mental health professionals should not be overlooked; performance anxiety and communication between partners need to be addressed to achieve full success.
Treatments such as transurethral alprostadil, ICI, or VED should be offered in case that PDE5i fails or there are contraindications to use of such medication. In-office injection tests should be utilized before initiating therapies like transurethral alprostadil or ICI to establish an effective dose and monitor adverse effects. In-office trials also help patients gain confidence with technique and facilitate adherence. If non-surgical options fail, penile prosthesis implantation should be discussed. The clinician should review the short and long term expectations of penile prosthesis implantation with the patient and his partner in-depth due to the irreversible consequence of surgery.
There have been many emerging therapies developed for ED treatment over the last decade. Some of these innovative and novel therapies, such as SCT, gene therapy, and PRP, may indeed replace or regenerate the endothelial, neuronal, and smooth muscle cells in the penis. However, the long term implications of these therapies are unknown. Well-designed randomized controlled studies adopting standardized protocols and including larger study populations are needed. An algorithm for the management principles of patients presenting with ED is described in Figure 1.
On another note, new pharmacologic agents targeting underlying pathophysiologies such as guanylate cyclase activators, NO donors, and RhoA/Rho-kinase inhibitors are promising therapies based on preclinical studies. Improvements in novel surgical techniques using tissue transplants and new device-based treatments such as novel drug or drug delivery systems may be implemented as ED therapies in the future.
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