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Second-line therapy

Intracavernosal injection or intraurethral therapy can be used according to the patient's wishes.

Intracavernosal injection

Several drugs have been proposed for intracavernosal injection, alone or in combination (prostaglandin E1, phentolamine-vasointestinal polypeptide, phentolamine-papaverine, maxislititrimx); however, only two are approved by the FDA- alprostadil sterile powder and alprostadil alfadex (22). Patient comfort and education are essential elements of the practice of intracavernosal injection therapy. The use of an automatic special pen

that avoids the needle view can resolve the fear of penile puncture.

Injection therapy is effective in most cases of ED, but it is contraindicated in men with a history of hypersensitivity to the drug employed and in men at risk of priapism. It is not advised in men with limited manual dexterity but their partners may be taught the technique. Intracavernosal therapy is effective in 60-90% of cases. The erection appears after 5-15 min and lasts according to the dose injected. Side-effects include prolonged erections or priapism, penile pain and fibrosis.

After 4 hrs of erection, patients are advised to consult the doctor to avoid any damage to the intracavernous muscle, which would provoke permanent impotence. A 19-gauge needle is used to aspirate blood and therefore to decrease the intracavernous pressure. This simple method is usually sufficient to make the penis flaccid. However, if the penis becomes rigid again after this, phenylephrine intracavernous injection at a dose starting at 200 ug every 5 minutes and increasing to 500 ug if necessary is required. The risk of having a prolonged erection during following subsequent injections cannot be predicted. When this problem occurs, the dose is usually reduced for the next injection. The patient must be carefully observed for systemic effects of the treatment used.

Intraurethral therapy

Prostaglandin E1 may be administered intraurethrally in the form of a semi-solid pellet. A band placed at the base of the penis seems to improve the resulting rigidity. About 70% of patients have been satisfied or very satisfied. Even the administrated route seems to be less invasive (23). Side-effects include penile pain and hypotension, and the clinical success rate is lower than that achieved with intracavernosal therapy (23).

3.3 Third-line therapy

Prosthesis

For patients who fail pharmacological therapy or who prefer a permanent solution to their problem, surgical implantation of a prosthesis may be considered. Two types of prosthesis exist: malleable and inflatable. The inflatable penile prosthesis provides not only a more cosmetic erection but also a more satisfying one. Penile growth is usually better with an inflatable rather than a semi-rigid erection, although the former is associated with an increased rate of mechanical failure and complications. There is also a difference in price; the inflatable prosthesis is much more expensive. In several countries, patients are reimbursed for the cost of the prosthesis, but an organic cause has to be determined for the ED and the patient has to undergo a complete impotence assessment.

Prosthetic infection is the most problematic complication following surgery as the combination of infection and a foreign body requires removal of the prosthesis. The patients most commonly affected by infection problems are diabetics (24).

Exact intra-operative length measurement is mandatory. If the device is too long, post-operative pain and eventually prosthesis erosion may result. If too short a device is used, the 'concorde' deformity with leaking of the glans during intercourse may occur, and lateral perforation may result.

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