Professional Documents
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Definition
Erectile dysfunction is a multidimensional but common male sexual dysfunction that involves an alteration in any of the
components of the erectile response, including organic, relational and psychological.
Faysal A. Yafi, Wayne J. G. et al. 2016
Pathophysiology
Epidemiology
1. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J
Urol. 1994;151:54–61.
2. Age-related changes in general and sexual health in middle-aged and older men: results from the European Male Ageing Study (EMAS).Corona G, Lee DM, Forti G, O'Connor DB, Maggi
M, O'Neill TW, Pendleton N, Bartfai G, Boonen S, Casanueva FF, Finn JD, Giwercman A, Han TS, Huhtaniemi IT, Kula K, Lean ME, Punab M, Silman AJ, Vanderschueren D, Wu FC, EMAS
Study Group. J Sex Med. 2010 Apr; 7(4 Pt 1):1362-80.
Patophysiology
Classification
• Blood pressure
• Cardiac, thyroid, testicular, prostate examination
• Penile anatomical abnormalities
• Gynecomastia
• Exercise treadmill test (if cardiac risk factors are present)
• BMI calculation or waist circumference measurment
Young patients with a history of pelvic or perineal trauma (who could benefit from
potentially curative vascular surgery.)
Patients with penile deformities which might require surgical correction (e.g., Peyronie’s
disease, congenital curvature).
Patients with complex psychiatric or psychosexual disorders.
Patients with complex endocrine disorders.
At the request of the patient or his partner.
Medico-legal reasons (e.g., implantation of penile prosthesis, sexual abuse).
• Include specific diagnostic tests in the initial evaluation of ED in the presence of the
indicated conditions
First-Line
Treat underlying disease
Life style modification
PDE5I
Vacuum Erection Device
Intraurethral Alprostadil
Shockwave therapy
Second-Line
Intracavernous Injection
Third-Line
Penile prostheses
Oral Pharmacotherapy
PDE5-I drug
Sildenafil
Tadalafil
Valdenafil
Avanafil
Avanafil1,2
Latest PDE5I, available in 2013
Recommended starting dose 100 mg, 15 – 30 Dosage Successful Placebo
minutes before sexual intercourse Sexual
Maximum dosing frequency once a day Intercourse
50 mg 47% 28%
Mean percentage of successful intercourse
100 mg 58% 28%
1. Wang, R., et al. Selectivity of avanafil, a PDE5 inhibitor for the treatment of erectile dysfunction: implications for clinical safety and improved tolerability. J Sex Med, 2012.
9: 2122. https://www.ncbi.nlm.nih.gov/pubmed/22759639
2. Goldstein, I., et al. A randomized, double-blind, placebo-controlled evaluation of the safety and efficacy of avanafil in subjects with erectile dysfunction. J Sex Med, 2012.
9: 1122. https://www.ncbi.nlm.nih.gov/pubmed/22248153
PDE5 Inhibitor
Cardiovascular Safety
Sildenafil, Tadalafil, Vardenafil no increase in myocardial infarction rate
It is CONTRAINDICATED in
Patient suffered from myocardial infarction, stroke, life threatening arrythmia within the LAST 6 MONTHS
Resting hypotension < 90/50 mmHg or hypertension >170/100 mmHg
Unstable angina, Angina with sexual intercourse or CHF NYHA IV
Nitrates result in cGMP accumulation and unpredictable blood pressure drop. If patient taken PDE5I,
develop angina, nitrate should be postponed base of PDE5I drugs half-life.
Co-administrative with other anti hypertensive agent, considered safe
Interaction with alpha-blocker orthostatic hypotension
Topical/intraurethral Alprostadil
Vasoactive agent, topical route (300 ug) or
medicated pellet (500 ug) via urethral meatus
Intercourse achieved in 30-65.9% patients
Provides alternative treatment for intracavernous
injection patients, who prefer less invasive even
though it is less-efficacious treatment
Adverse effect
Local pain
Penile erythema
Dizziness / hypotension
UTI
Shockwave therapy
Low-intensity extracorporeal shockwave therapy
EAU recent studies showed that LI-SWT could improve the IIEF and Erection Hardness
Score of mild ED patient.
Still unclear for definitive recommendation
Penile prostheses
Patient who failed pharmacotherapy and prefer a permanent solution
2 classes of implant
Inflatable
Semi-rigid
2 surgical approaches
Penoscrotal
(+) Excellent exposure, avoid dorsal nerve injury, direct visualization of pump placement
(-) Blind reservoir placement or need to do separate incision to insert reservoir under direct vision
Infrapubic
(+) Insert reservoir under direct vision
(-) risk of dorsal nerve injury when inserted the pump
Complication
Mechanical failure
infection