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MEDLINE Abstracts
Second Therapy
for Erectile Dysfunction
What's new in second-line therapy for erectile dysfunction? Find out in this easy-to-navigate collection of recent MEDLINE abstracts compiled by the editors at Medscape Urology. [Medscape, 1999. © 1999 Medscape, Inc.]
Male ImpotenceErectile dysfunction can be devastating for men and for their partners. A good sexual history and focused physical examination can provide clues as to whether the underlying cause is psychogenic or organic. Diagnostic investigation should be tailored to the clinical picture. Oral medications now represent first-line therapy. Penile injection therapy and vacuum constrictive devices are reasonable choices for men in whom oral therapy fails or is contraindicated. The penile prosthesis provides a reliable long-term solution with high satisfaction rates. Psychotherapy may be indicated. Physicians can have a positive impact on the quality of life of patients by providing a non-judgmental and supportive environment for discussion and management of impotence.
Vacuum Constriction Devices for Erectile Dysfunction: A Long-term,
Prospective Study of Patients With Mild, Moderate, and Severe
DysfunctionObjectives: To evaluate, using a long-term, prospective
study, the satisfaction rate, attrition rate, and follow-up treatment of
well-trained patients using an external vacuum erection device, the Osbon
ErecAid System, in the treatment of mild, moderate, and severe organic erectile
dysfunction.
Methods: One hundred twenty-nine patients were
assessed to determine the severity and cause of their erectile dysfunction.
Patients with organic erectile dysfunction who were interested in the Osbon
ErecAid received the device after thorough training. Patients received a
follow-up questionnaire regarding satisfaction, months of use, reasons for
discontinuing, and further treatment.
Results: Our attrition
rate was 65% overall and was lowest among patients with moderate erectile
dysfunction (55%). All patients with mild dysfunction discontinued use, and a
large number (70%) of patients with complete dysfunction also discontinued use.
Of the patients who discontinued, most stopped treatment early (median 1 month,
mean 4 months) and 63% did not seek further treatment. Thirty-five percent of
patients were satisfied with the device and have continued to use it long term
(mean 37 months).
Conclusions: Our study showed a lower
success rate than previous reports. Patients who were satisfied with the Osbon
ErecAid continued to use it for long periods. Patients who were not satisfied
dropped out very quickly, and many did not seek further treatment. Patients with
moderate erectile dysfunction had a higher rate of success than patients with
mild or severe erectile dysfunction.
The Causes of Patient Dropout From Penile Self-Injection Therapy
for ImpotencePurpose: Penile self-injection therapy, a second line
treatment for erectile dysfunction, is the most efficacious means of
reestablishing functional erections when first line therapies fail and the
patient wants to avoid penile prosthesis implantation. Despite high efficacy
rates, injection therapy has high dropout rates. To our knowledge studies to
date analyzing patient attrition have reviewed small numbers of patients
followed for only short periods. We elucidate the main reasons for patient
dropout in a large penile self-injection program with long-term
followup.
Materials And Methods: A questionnaire was mailed
to 1,424 patients who completed the office training and home use phases of a
penile self-injection program.
Results: The overall
attrition rate was 31% of the 720 men who completed the questionnaire, with a
mean followup of 38 months. The main reasons for dropout were cost of therapy,
patient and partner problems with the concept of penile injection, lack of
partner availability and spontaneous improvement in erections. Lack of efficacy
of therapy was the primary reason for only 1 of 7 dropouts. Furthermore, adverse
effects of penile injections (priapism, penile nodules, pain) appeared to be
only minor contributors to dropout.
Conclusions: To our
knowledge this study is the largest published, single center cohort of patients
treated with injection and followed for an analysis of dropout rates. Based on
study data a reduction in dropout rates may be achieved by keeping the cost of
therapy low, and ensuring patient and partner education as well as continued
support throughout treatment.
Comparison of Mechanical Reliability of Original and Enhanced
Mentor Alpha I Penile ProsthesisPurpose: We report the results of a prospective study of
1,381 Mentor Alpha I penile prostheses implanted to treat impotence, and compare
original and enhanced penile prosthesis mechanical
reliability.
Materials And Methods: The study consisted of
410 original models manufactured before November 1992 and 971 enhanced models
manufactured since December 1992. Implants were further stratified as first time
(virgin) or replacements of a previous implant. Mechanical failure-free survival
rates for the original prosthetic and enhanced models were
compared.
Results: The 5-year survival rate increased from
75.3% for the original to 92.6% for the enhanced model overall (log rank
p<0.0001), and from 75.3 to 93.6%, respectively, for the virgin implants only
(log rank p<0.0001). The estimated failure rate of approximately 5.6% for the
original model was fairly consistent during followup, while the significantly
lower failure rate of 1.3% for the enhanced model was not. The failure rate of
the enhanced model implants was about 0.8% per year during the first 3.5 years
and increased to approximately 3.1% per year
thereafter.
Conclusions: Our results strongly support the
premise that mechanical reliability is superior with the enhanced compared to
the original model.
Reasons for Discontinuing Intracavernous Injection Therapy With
Prostaglandin E1 (Alprostadil)Objectives: To clarify the reasons why experience with
self-injection therapy for erectile dysfunction shows high dropout rates.
METHODS:We studied 86 patients 36 to 76 years old who had been on home treatment
for at least 3 months. Sixty-nine patients (80%) were continuing to use
injections, and 17 (20%) had discontinued the treatment. Patients were evaluated
by interview and clinical examination.
Results: Patients
still in the program used one injection every 2 weeks, and those who had given
up treatment had used one injection in 3 weeks (P = 0.31). They were in the
program for 3927 and 1622 months (P = 0.002), respectively, and had used 50 (95%
confidence interval [CI] 21 to 91) versus 12 (95% CI 4 to 20) injections,
respectively (P<0.0001). Injections producing unsatisfactory penile rigidity,
prolonged erections, hematoma at injection site, corporal fibrosis, secondary
penile deviation, and mean estimated duration of a pharmacoinduced erection
showed no significant differences. Patient satisfaction (P = 0.02), estimated
partner satisfaction (P = 0.02), increase in self-esteem (P = 0.01), and
negligible effort in performing injections (P = 0.001) all showed significantly
better results for those still in the program.
Conclusions:
Reasons for dropout from self-injection therapy are not based on objective side
effects and discomfort. Patients leaving the program are less motivated, less
satisfied with the quality of pharmacoinduced sexuality, consider the effort to
perform injections to be substantial, and have not achieved improved
self-esteem.
Endothelial Cell Transplantation Into the Corpus Cavernosum:
Moving Towards Cell-Based Gene TherapyPurpose: As a first step toward a cell based gene therapy
for erectile dysfunction, we transplanted fluorescently labeled autologous
microvessel endothelial cells (MVEC) into the rat corpus
cavernosum.
Materials and Methods: MVEC were isolated from
the epididymal fat pad, labeled with the membrane intercalating dye PKH 26, and
injected into the corpus cavernosum. Two to 15 days after transplantation the
penises were removed, cryosectioned, and examined under epifluorescent and phase
contrast microscopy.
Results: In 7 consecutive animals
transplanted fluorescent cells were identified in the corpora cavernosa.
Bilateral distribution was noted in each animal, and staining with ED1
determined that the fluorescence was not due to engulfment of the MVEC by
phagocytic cells.
Conclusion: Transplanted endothelial cells
adhere and persist in the corporal sinusoids and provide a rationale for
cell-based gene therapy in the penis.
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