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<blockquote data-quote="madman" data-source="post: 203725" data-attributes="member: 13851"><p><strong>3.2.4.3. Dynamic duplex US of the penis. </strong></p><p></p><p><em><strong>Dynamic duplex US of the penis is a test specifically aimed to study the hemodynamic pathophysiology of erectile function [125]. </strong></em>Therefore, in clinical practice, it is usually applied in those conditions where a potential vasculogenic etiology of ED (eg, diabetes mellitus, renal transplantation, multiple concomitant CV risk factors, and/or overt peripheral vascular disease, poor responders to oral therapy, etc.) is suspected [3]. <strong><em>Recent data have suggested that duplex scanning as a hemodynamic study may be better at tailoring therapy for ED, such as for low-intensity shockwave therapy (LI-SWT) and for diagnosing vasculogenic ED [126]. </em></strong>A further vascular investigation is unnecessary if a duplex US examination is normal.</p><p></p><p></p><p></p><p><strong>3.2.5. Treatment of ED </strong></p><p><strong></strong></p><p><strong><em>ED can be treated successfully with a number of therapeutic options, but it cannot be cured.</em> <em>The only exceptions are psychogenic ED, post-traumatic arteriogenic ED in young patients, and hormonal causes (eg, hypogonadism) [3,120], which can potentially be cured with specific treatments.</em> </strong>Most men with ED will be treated with therapeutic options that are not cause specific. <strong><em>Based on the currently available evidence and the consensus of the panel, a novel comprehensive therapeutic and decision-making algorithm for treating ED has been presented (Fig. 4).</em></strong> This novel treatment algorithm was discussed extensively within the guideline panel as an alternative to the traditional three-level concept, in order to better tailor personalized therapy to individual patients, according to invasiveness, tolerability, and effectiveness of the different therapeutic options, along with patients’ needs and expectations. In this context, patients should be counseled fully with respect to all available treatment modalities.</p><p></p><p>ED may be associated with modifiable or reversible risk factors, including lifestyle or drug-related factors [3]. These factors may be modified either before or at the same time as specific therapies are used. Likewise, ED may be associated with concomitant and underlying conditions (such as endocrine disorders and metabolic disorders—eg, diabetes, and some CV problems—eg, hypertension), which should always be well controlled as the first step of any ED treatment [129]. Major clinical potential benefits of lifestyle changes may be achieved in men with specific comorbid CV or metabolic disorders, such as diabetes or hypertension [129]. Educational intervention is often the first approach to sexual dysfunction and consists of informing patients about the psychological processes involved in the individual’s sexual response, in ways they can understand. This first-level approach was shown to favor sexual satisfaction in men with ED [130].</p><p></p><p></p><p></p><p></p><p><strong>3.2.5.4. Low-intensity shockwave therapy. </strong></p><p></p><p><em><strong>The use of LI-SWT has increasingly been proposed as a treatment for vasculogenic ED over the last decade [142], is the only currently marketed treatment that might offer a cure, which is the most desired outcome for most men suffering from ED [126].</strong></em><strong><em> Overall, several single-arm trials have shown a benefit of LI-SWT in patient-reported erectile function scores, but data from prospective randomized trials are conflicting, and</em></strong> <strong><em><u>many questions remain to be answered especially because of the heterogeneity in shockwave generators (ie, electrohydraulic, electromagnetic, piezoelectric, and electro-pneumatic), type of shockwaves delivered (ie, focused, linear, semi focused, and unfocused), set-up parameters (eg, energy flux density and number of pulses per session), and treatment protocols (ie, duration of the treatment course, number of sessions per week, the total number of shockwave pulses delivered, and penile sites of application)</u> [143].</em></strong> <em><strong><u>As a whole, most of the studies suggest that LI-SWT can significantly increase the IIEF and EHS, especially in patients with mild vasculogenic ED, although this improvement appears modest </u>[126];</strong></em> indeed, a pooled data analysis of RCTs has shown a mean IIEF-EF score improvement from baseline ranging from 2 to 4 points [126]. Moreover, few studies have shown an improvement in terms of penile hemodynamic parameters after LI-SWT, with a meta-analysis showing a mean peak systolic velocity improvement of 4.12 (95% confidence interval: 2.3–5.9) after treatment [143], but the clinical meaning of this improvement remains unclear [143]. Likewise, data suggest that LI-SWT could ameliorate erection quality even in patients with severe ED who are either nonresponders or inadequate responders to PDE5Is [144,145], thus reducing the immediate need for more invasive treatments. Further clarity is also needed in defining treatment protocols that can result in greater clinical benefits [146]. <strong><em>As a whole, according to the available data and the novel treatment decision algorithm, LI-SWT may be offered to patients with vasculogenic ED, although they should be counseled fully before treatment.</em></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>Table 8 – Recommendations for the treatment of erectile dysfunction</strong></p><p>[ATTACH=full]15206[/ATTACH]</p><p>[ATTACH=full]15207[/ATTACH]</p><p>[ATTACH=full]15208[/ATTACH]</p><p></p><p></p><p><strong><u>Recommendations</u></strong></p><p><strong></strong></p><p><strong><em>*Use LI-SWT in patients with mild vasculogenic ED or as an alternative first-line therapy in well-informed patients who do not wish to have or are not suitable for oral vasoactive therapy or those who desire a curable option. Use LI-SWT in vasculogenic ED patients who are poor responders to PDE5Is.</em></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong><u>Strength rating</u></strong></p><p><strong></strong></p><p><strong><em>*Weak</em></strong></p></blockquote><p></p>
[QUOTE="madman, post: 203725, member: 13851"] [B]3.2.4.3. Dynamic duplex US of the penis. [/B] [I][B]Dynamic duplex US of the penis is a test specifically aimed to study the hemodynamic pathophysiology of erectile function [125]. [/B][/I]Therefore, in clinical practice, it is usually applied in those conditions where a potential vasculogenic etiology of ED (eg, diabetes mellitus, renal transplantation, multiple concomitant CV risk factors, and/or overt peripheral vascular disease, poor responders to oral therapy, etc.) is suspected [3]. [B][I]Recent data have suggested that duplex scanning as a hemodynamic study may be better at tailoring therapy for ED, such as for low-intensity shockwave therapy (LI-SWT) and for diagnosing vasculogenic ED [126]. [/I][/B]A further vascular investigation is unnecessary if a duplex US examination is normal. [B]3.2.5. Treatment of ED [I]ED can be treated successfully with a number of therapeutic options, but it cannot be cured.[/I] [I]The only exceptions are psychogenic ED, post-traumatic arteriogenic ED in young patients, and hormonal causes (eg, hypogonadism) [3,120], which can potentially be cured with specific treatments.[/I][U] [/U][/B]Most men with ED will be treated with therapeutic options that are not cause specific. [B][I]Based on the currently available evidence and the consensus of the panel, a novel comprehensive therapeutic and decision-making algorithm for treating ED has been presented (Fig. 4).[/I][/B] This novel treatment algorithm was discussed extensively within the guideline panel as an alternative to the traditional three-level concept, in order to better tailor personalized therapy to individual patients, according to invasiveness, tolerability, and effectiveness of the different therapeutic options, along with patients’ needs and expectations. In this context, patients should be counseled fully with respect to all available treatment modalities. ED may be associated with modifiable or reversible risk factors, including lifestyle or drug-related factors [3]. These factors may be modified either before or at the same time as specific therapies are used. Likewise, ED may be associated with concomitant and underlying conditions (such as endocrine disorders and metabolic disorders—eg, diabetes, and some CV problems—eg, hypertension), which should always be well controlled as the first step of any ED treatment [129]. Major clinical potential benefits of lifestyle changes may be achieved in men with specific comorbid CV or metabolic disorders, such as diabetes or hypertension [129]. Educational intervention is often the first approach to sexual dysfunction and consists of informing patients about the psychological processes involved in the individual’s sexual response, in ways they can understand. This first-level approach was shown to favor sexual satisfaction in men with ED [130]. [B]3.2.5.4. Low-intensity shockwave therapy. [/B] [I][B]The use of LI-SWT has increasingly been proposed as a treatment for vasculogenic ED over the last decade [142], is the only currently marketed treatment that might offer a cure, which is the most desired outcome for most men suffering from ED [126].[/B][/I][B][I] Overall, several single-arm trials have shown a benefit of LI-SWT in patient-reported erectile function scores, but data from prospective randomized trials are conflicting, and[/I][/B] [B][I][U]many questions remain to be answered especially because of the heterogeneity in shockwave generators (ie, electrohydraulic, electromagnetic, piezoelectric, and electro-pneumatic), type of shockwaves delivered (ie, focused, linear, semi focused, and unfocused), set-up parameters (eg, energy flux density and number of pulses per session), and treatment protocols (ie, duration of the treatment course, number of sessions per week, the total number of shockwave pulses delivered, and penile sites of application)[/U] [143].[/I][/B] [I][B][U]As a whole, most of the studies suggest that LI-SWT can significantly increase the IIEF and EHS, especially in patients with mild vasculogenic ED, although this improvement appears modest [/U][126];[/B][/I] indeed, a pooled data analysis of RCTs has shown a mean IIEF-EF score improvement from baseline ranging from 2 to 4 points [126]. Moreover, few studies have shown an improvement in terms of penile hemodynamic parameters after LI-SWT, with a meta-analysis showing a mean peak systolic velocity improvement of 4.12 (95% confidence interval: 2.3–5.9) after treatment [143], but the clinical meaning of this improvement remains unclear [143]. Likewise, data suggest that LI-SWT could ameliorate erection quality even in patients with severe ED who are either nonresponders or inadequate responders to PDE5Is [144,145], thus reducing the immediate need for more invasive treatments. Further clarity is also needed in defining treatment protocols that can result in greater clinical benefits [146]. [B][I]As a whole, according to the available data and the novel treatment decision algorithm, LI-SWT may be offered to patients with vasculogenic ED, although they should be counseled fully before treatment.[/I] Table 8 – Recommendations for the treatment of erectile dysfunction[/B] [ATTACH type="full"]15206[/ATTACH] [ATTACH type="full"]15207[/ATTACH] [ATTACH type="full"]15208[/ATTACH] [B][U]Recommendations[/U] [I]*Use LI-SWT in patients with mild vasculogenic ED or as an alternative first-line therapy in well-informed patients who do not wish to have or are not suitable for oral vasoactive therapy or those who desire a curable option. Use LI-SWT in vasculogenic ED patients who are poor responders to PDE5Is.[/I] [U]Strength rating[/U] [I]*Weak[/I][/B] [/QUOTE]
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