© The Canadian Journal of Urology™; 19(Supplement 1); October 2012
GREENSPAN AND BARKIN
22
Transurethral drugs
MUSE
or the “Medicated Urethral System for
Erections” has been available for many years as a
transurethral installation of an absorbable pellet
containing prostaglandin. It can also stimulate the
rapid onset of an erection in a segment of men. Because
it is a direct effect, it can be safely used in men taking
nitroglycerin agents. There is sometimes a complaint
of urethral burning.
22
Intracorporeal injection therapy.
This modality has
been available since 1983. Patients inject themedication
into the side of the penis 15 minutes before they would
like to have an erection. Trimix, a custom-mademixture
of papaverine, phentolamine, and prostaglandin E1
(
PGE1 or alprostadil), is the most widely used injection
therapy for ED. Other injection therapies include a
bimix (papaverine, phentolamine), which also must
be custom compounded by specialized pharmacies
or alprostadil alone (Caverject, Edex [US]). Potential
complications of penile injection therapy include
prolonged erections and penile fibrosis.
Vacuum pump therapy.
Amechanical device (a plastic
cylinder with a rubber flange-attached to either a
manual or electric pump) is placed over the penis.
When the pump is activated, it creates a vacuum that
draws blood into the penis, which results in penile
engorgement. A ring must then be placed over the
base of the penis to hold the blood in. Complaints
of penile pain and ejaculatory interference from the
ring are common. If a patient chooses this method,
he needs to be counseled about how to use the device,
to maximize his chance of success. Merely telling a
patient to buy the device andwatch the accompanying
video is not recommended.
Penile-implant surgery.
This is the “final frontier”
in the treatment of ED. It actually has the highest
patient/ partner satisfaction rate of any ED treatment,
approaching 90% in most series. Success rates are
higher and infection rates lower (< 2%) when done in
specialized implant centers.
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Measuring response to ED treatment
At regular patient check ups, primary care physicians
need tomeasure bloodglucose and cholesterol levels and
blood pressure, etc. Patients may volunteer information
about their success and satisfaction with ED treatment.
However, to objectively measure a patient’s response to
ED treatment, to facilitate dialogue and diagnosis, and
to evaluate treatment changes, patients can be asked to
fill in a questionnaire such as the International Index of
ErectileFunction (IIEF) questionnaire,
24
the SexualHealth
Inventory forMen (SHIM) questionnaire,
25
or theErection
Hardness Scale (EHS) questionnaire.
26,27
The IIEF is a 15-item, validated questionnaire
addressing erectile function, orgasm, sexual desire,
intercourse satisfaction, and overall satisfaction.
Each modality can be measured separately. The
SHIM consists of the five questions from the IIEF
questionnaire that deal with erectile function. Each
question is scored from 1 to 5. A total score of 22 to 25
indicates normal erectile function, whereas a score of
21
or lower indicates some degree of ED.
TheEHSdescribes four types of erectilequality: penis
larger but not hard; penis hard but not hard enough for
penetration; penis hard enough for penetration but not
completely hard; and penis completely hard and fully
rigid.
Erectile hardness appears to be a very important part
of ED treatment and patient satisfaction, such that the
greater apatient’s satisfactionwith erectionhardness, the
greater his satisfactionwith sexual life, love and romance,
and overall health.
28.
The EHS is a very simple way to
discuss ED treatment goals and responses with patients.
Testosterone deficiency syndrome
What it is
In2000, physicianexperts at theFirstAnnualAndropause
Consensus Meeting recognized that “as men age, a
majority have testosterone levels that are below the
normal range for a young population. This decrease
has clinical implications for the aging male population:
these implications include changes in bone density, body
composition, mood and sexual function andpossibly the
cardiovascular system.”
There is a lack of large, blinded, placebo-controlled
studies for treating below-normal levels of testosterone.
The clinical condition that physicians recognize
and treat has had many names in the past, which is
confusing. The most appropriate name is testosterone
deficiency syndrome (TDS).
As John Kenneth Galbraith said, “The conventional
view saves us from the painful job of thinking.” This
statement can apply to physicians’ views about the
indications, risks, benefits, and potential complications
of therapy for TDS.
The barriers to proper diagnosis andmanagement of
TDS include a lack of physician awareness about how
TDS is associatedwith other diseases (such asmetabolic
syndrome, diabetes, and CVD), a lack of physician
awareness of the ability of testosterone replacement
therapy (TRT) to reduce disease symptoms, and
controversy about the effect of TDS on prostate health.
It is generally accepted that TDS is characterized
by below-normal serum testosterone levels. TDS may
involve changes in testosterone-receptor sensitivity to
