3rd Annual Jefferson Urology Symposium: Men’s Health Forum

© The Canadian Journal of Urology TM : International Supplement, August 2020 29 The medical and surgical treatment of erectile dysfunction: a review and update Given the highprevalence of EDand the highnumber of severe co-morbidities associated with it, the clinician must be able to conduct a validdiagnostic examandoffer available treatment options to patients. Aguideline has been published by theAmericanUrologicalAssociation (AUA) last updated in 2018 to provide a clinical strategy for the clinicians in the diagnosis and management of ED. 8 Basedon theAUAguideline for ED,menpresenting with symptoms of EDshouldundergoa completehistory and physical examination. Validated questionnaires such as the International Index of Erectile Function (IIEF), ErectionHardness Scale (EHS), andSexual Health Inventory for Men (SHIM) are recommended to assess the severity of ED, to measure treatment effectiveness, and to guide future management. However, none of these questionnaires is valid for sexually inactive men. Laboratory tests such as fasting blood glucose, lipid profile, urinalysis, complete blood count, TSH, and serum testosterone can be done at the initial visit if the patient has an underlying condition. Using the shared decision-making process as a cornerstone for care, all patients along with their partners, if possible, should be informed of all treatment modalities that are not contraindicated, regardless of invasiveness or irreversibility, as potential first-line treatments. For each treatment option, the clinician should ensure that the man and his partner have a full understanding of the benefits and risks/ burdens associated with that choice. Additionally, the clinician needs to be aware of the health literacy of the patient, as well as social, cultural, religious factors. Every man who presents with ED is unique based on his symptoms, degree of stress, associated health conditions, relationship quality, and sociocultural context. All treatment options that are not medically contraindicated should be considered; however, the clinician evaluating all these issues should determine an appropriate treatment that is aligned with the man and his partner’s priorities and values. Additionally, ED occurs in a complex psychosocial context related to masculinity and sexuality. The patient should be strongly advised to receive psychotherapy or psychosexual counseling to promote treatment adherence, reduce performance anxiety, and integrate treatments into a sexual relationship. This current article aims to conduct a review of current medical and surgical treatment options, as well as novel and innovative therapeutic options in ED. Current treatment modalities for ED EDhas been significantly associatedwithgeneral health status. Lifestyle modifications such as weight loss, physical exercise, a healthy diet, smoking cessation, and reducing alcohol intake should be discussed with any man with ED. Lifestyle modifications show their effect via amelioration of endothelial dysfunction by inducing NO production, decrease in oxidative stress, reduced insulin resistance and lowering inflammatory state associated with metabolic diseases. 9 In addition to lifestyle modifications, the AUA guideline acknowledges noninvasive and invasive treatment options, including oral phosphodiesterase type 5 inhibitors (PDE5i), vacuum erection devices (VED), intracavernosal injections (ICI), intraurethral suppositories, and penile prostheses for ED. PDE5i are usually suggested by clinicians as first-line therapy due to their clinical efficacies and safety profiles. However, any of these treatment options can be chosen as first- line therapy by patients. Additional testing and specialist referral are typically options reserved for cases where initial treatments failed. Other indications for specialist referral include: (1) younger patients with a history of pelvic or perineal trauma, (2) patients with significant penile deformity, (3) complicated endocrinopathies, (4) complicated psychiatric or psychosexual disorders, (5) need for vascular or neurosurgical intervention, and (6) medicolegal reasons. Novel approaches to treat ED, including but not limited to extracorporeal shock wave therapy (ESWT), penile vascular surgeries, stem cell therapies (SCT), and platelet-rich plasma (PRP), have shown promising initial results and may become more commonly suggested by clinicians for ED treatment. Oral PDE5i Oral PDE5i, including sildenafil, tadalafil, vardenafil, and avanafil, have been preferred as first-line therapy by clinicians due to their clinical efficacies and safety profiles. Up to 65%of menwho are taking PDE5i show a good response after initial treatment. 10,11 However, the underlying pathophysiology of ED, such as post radical prostatectomy or radiation, and co-morbidities such as diabetes can decrease the success rate of PDE5i. 12-15 Nitric oxide (NO) increases the cGMP levels in corpus cavernosum smooth muscle cells following reflexogenic or psychogenic stimulation resulting in penile erection by smooth muscle relaxation. PDE5i prevent cGMP degradation by inhibiting the PDE5 enzyme and keeping cGMP levels high. 16 It is important to highlight that PDE5i are not effective without the induction of penile erection viaNO release. PDE5i do not work sufficiently in diabetic neuropathy or cavernous nerve damage frompelvic surgeries, such