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TREATMENT

The first objective of every doctor is to cure the medical condition. Therefore, the primary goal in the management strategy for a patient with ED is to determine the aetiology of the disease and treat it when possible, and not to treat the symptom alone. It is clear that ED may be associated with modifiable or reversible factors, including lifestyle or drug-related factors, that may be modified prior to or in conjunction with the employment of specific therapeutic operations.

Testosterone deficiency is potentially reversible and is a result of primary testicular failure or secondary to pituitary/hypothalamic causes (12). Patients with hormone abnormalities need to take the advice of an endocrinologist. Testosterone replacement therapy is effective, but can only be used when other possible endocrinological causes for the testicular failure have been excluded. Testosterone replacement therapy is contraindicated in men with a history of prostate carcinoma or with symptoms of prostatism. Prior to initiating testosterone replacement, a digital rectal examination and serum PSA test should be performed. Patients receiving androgen therapy should be monitored for clinical response as well as the development of hepatic or prostatic disease (12). However, it should be mentioned that this treatment is not always effective in the management of ED associated with hypogonadism.

In young patients with pelvic or perineal trauma, a surgical penile revascularization erection procedure is often associated with good results; there is a 60-70% long-term success rate (5). The lesion must be demonstrated by duplex sound and confirmed by penile pharmaco-arteriography. A corporeal veno-occlusive dysfunction must be excluded by pharmaco-cavernosometry.

When no specific therapies for ED are required, a strategic approach should be followed. Again the patient and his partner, when possible, must be informed on the route of administration, the invasiveness, the

cost and the reversibility of the treatment. In other cases, such as older patients without traumatic lesions or in patients with secondary cavernovenous leakage, vascular surgery is no longer recommended due to poor results at long-term follow-up.

3.1 First-line therapy

Oral therapy

Sildenafil citrate (Viagra) and Apomorphine (Uprima) are currently the only oral drugs available on the market

with proven efficacy and safety for the treatment of ED.

Sildenafil is an oral drug, effective after 60 min. in the presence of sexual stimulation. The most common side effects include headaches, flushing, dyspepsia and nasal congestion. It causes small decreases in systolic and diastolic blood pressure, although clinically significant hypotension is rare. For that reason, it is formally contraindicated in patients who take long-acting nitrates or who use short-acting, nitrate-containing medications (17). It may be hazardous to prescribe Sildenafil in patients with:

• Active coronary ischaemia

• Congestive heart failure and borderline low blood pressure

• Borderline low cardiac volume status

• A complicated multi-drug antihypertensive programme

• Drug therapy that can prolong the half-life of Sildenafil

The dosages are 25, 50 and 100 mg. The starting dose should be 50 mg regardless of the aetiology of ED and adapted according to the success and side-effects; however, patients with liver/renal failure and those aged over 65 years should be given 25 mg. After 24 weeks of treatment in a dose-response study, improved erections were reported by 56%, 77% and 84% of the men taking 25, 50 and 100 mg of Sildenafil, respectively, compared with 25% by those taking placebo (4).

Sildenafil is a potent and selective inhibitor of cyclic GMP (cGMP), specifically phosphodiesterase type 5, the predominant isoform of the enzyme found in the human penis, resulting in smooth muscle relaxation, vasodilatation and penile erection (4).

Apomorphine sublingual (18) is a dopamine agonist that acts through enhancing pre-erectile stimuli through the hypothalamic neural pathways. The sublingual formula produces a fast acting circulating plasma concentration resulting in the quick onset of action; producing an erection in a median response time of 18-19 minutes. The dosages are 2 and 3 mg.

Uprima 2 mg resulted in a 1,66 fold increase and 3 mg resulted in a 2,2 fold increase in the percentage of attempts presenting an erection firm enough for intercourse from baseline. It is well-tolerated and there seems to be no interaction with other medications, food and alcohol.

Oral phentolamine (19) and other phosphodiesterase inhibitors, are under investigation.

It must be emphasized that the physician should warn the patient that sexual intercourse is considered to be a vigorous physical activity, which increases heart rate as well as cardiac work. Physicians should assess the cardiac fitness of patients prior to treating ED.

Vacuum device

A vacuum device could be used in patients in stable relationships in whom the mechanism of ED is easily understood (20). It is also better accepted in older patients. The device applies a negative pressure to the penis, thus drawing venous blood into the penis, which is then retained by the application of a visible constricting band at the base of the penis. The adverse effects associated with vacuum therapy are penile pain, numbness and delayed ejaculation.

Psychosexual therapy

For patients with a significant psychological problem, psychosexual therapy may be given either alone or in combination with another therapeutic approach. Psychosexual therapy takes time and has been associated with variable results (21).

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