Guidelines on Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation K. Hatzimouratidis (Chair), |. Eardley, F. Giuliano, I. Moncada, A. Salonia Associationright improve reeponae to a PDESI [49, 120-121]. Modification of other ik factors may also be beneficial as iscussed in section 34.4.2. Fow data suggest that some pationts might respond better to cne FDESI than to nother [122], Although these diferences might be explained by variation in drug pharmacokinetics they do raise the possibilty that, despite an identical mode ef action, switching to diferent PDESI might bs helpful. Mereaver, mainly patients with severe ED, ithas been suggested to combine tadalafil daily dosing with shert acting PDE! (such as sdenefi) without any signfcant increase in terms of side-effects [123]. It drug treatment fai, then patiants should be offered an altemative therapy such as inracavernosal injection ‘therapy or use of a vacuum erection device (VED). A452 Vacuum erection devices _VEDs provide passive engorgement ofthe corpora cavernosa, together with a constictr ring placed atthe bate of the pen to retain blood within the ecrpora. Published data report that efficacy. in terme of erections satisfactory for intercourse. is as high 2s 80%, regardless ofthe cause of ED and satistactin rates range botwoen 275% and 84% [184, 135], Most man who discontinue use of VEDs do so within 3 months. Long-term Use of VEDs decreases to 50-04% after? years [126], The commonest adverse events inctade pain, inability 10 cjeculate, patechiae, buking, and numbness, which occur in < 30% of pationts [135]. Serious adverse ovents (ckin necrosis) can be avoided if patients ramave the constiction ring within 30 min. VEDs are contraindicated in patients with biaecing disorders er on anticoagulant therspy. VEDs may be the treatment of choice in well informed older patents wit infrequent sexual nterccures and comorbidity requiting non-nvasive, drug-ttes management of ED [134, 135. SASS Shockwave therapy Recently, the use oflow-inteneity extracorpereal shock wave therapy (I-SWT) was proposed 2s a novel ‘restment for ED [197] inthe fst randomised, doube-bind, sham-controlld study, t was demonstrated thet LU-SWT ad a positive short-term clinical and physilogical elect on the EF of men iho respond to PDESIs [198], Moreover, there sre preirinary data showing improvement in penile haemodynamics and endothelial function, 2s well as IIEF-EF demain score in severe ED patients who are poor responders to PDESIs (130, 140} (Curent data are sil initec and clear recermendations cannat be given. SA46 — Second-lin therapy Patients not responding to oral drugs may be offered intracavemousinjctions. Success rte is high €5%) [141,142]. ntracavemous administration of vasoactive drugs was the frst medical treatment for ED more than. 20 years ago [143,144] 9A.46.1 Intracavernus injections 3A46.1.1 Alprostadil “Alprostacl(CaverjectM, Edon/Viria TM} was the fist and only drug approved for intracavemous treatment of ED [143, 144] ntracavercus alprostadil is most eficacious as monatherapy at a dose of §-40 pg (oft, 40 19 dose is not registered in every Europeen country). The erection appears after 5-15 min and lasts accorcing ‘tothe dose nected. An office-traning programms is required forth patient to lean the eamect meetin process. In cases of limited manual dexter, the technique may be taught to their partners. The use of en futomatic escape that acids a vow ofthe nosis can resohs fase of pile puncture and simpfcs the technique. Efficacy rates for intracavernous alprostadil of >707 fis Beni fauna inl genisrallEDIPOpUSHGrD _ aswell as in patient subgroups (e.g. diabetes or CVD), with reported seual activity aftor 84% of the injections. _and satisfaction rates of 87-83.5% in patients and 86-90.3% in partners [143, 144} Complications of intracavernous alprostailinclude penile pain (60% of patients reperted pain but pain reported only after 115% of total injections, prolonged erections (5%), pripiam (1%), and fibrosis (236) [143-15]. Pain is usually set- lirited after prolonged use. I can be alleviated with the action of sodium bicarbonate orlocal anaesthesia [143,144, 146]. Cavernosal fibrosis (om a small hematoma) usually clears within a few months ser temporary Giscontzuation cf the injection program. However, tunical fibrosis suggests early onset of Peyronie's disease and may indicate stopping intracavernosal injections indefinitely. Systomic sid-offects are uncommon. The ‘most commen ia mild hypotension, especialy whan using higher doses. Contraingicatione include men with abhistory of hypersonsitviy to alprastadi, mon at risk of priapism and men with bleating disorders. Despite “these favourable data, drop-out rates of 41-68% have been described for ntracavemous pharmacotherapy (143, 144, 147,148], with most drop-outs occurring within the fet 2-3 month. In a comparative study, siprostac monotherapy had the lowest discontinuation rate (27.5%) compared to overall drug combinations (67.690), with an atti rate after the fret few months of therapy of 10% per year Reasons fer discontinuation included dese fora permanent modality of therapy (209%) lack ofa suitable partner 20%), poor response (238) (especially among early drop-out patients), fear of needles (23%), fear of complications (22%), and lack of spontaneity (21%). Careful counseling of patients during the ofce-training phase 2s well as close follow-up 18 MULE SEXUAL DYSRINCTION - UPDATE MARCH 2015