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Up-to-date on erectile dysfunction and treatment - Jas - Journal of ...

original article Journal of Andrological Sciences 2011;18:64-71ong>Upong>-ong>toong>-ong>dateong> on erectile dysfunction and treatmentV. Gentile, S. Salciccia, P. Fele * , G.M. Busetong>toong>Dipartimenong>toong> di Scienze Ginecologico-Ostetriche e Scienze Urologiche, Sapienza Università di Roma, Italy; * Dipartimenong>toong>di Scienze Ostetrico-Ginecologiche, Urologiche e Medicina della Riproduzione, Università Federico II di NapoliSummaryErection is a haemodynamic event that involves the central nervous systemand local facong>toong>rs and is the recurrent or persistent inability ong>toong> achieve and ormaintain an erection ong>toong> allow satisfacong>toong>ry intercourse.The ED is a disease of great social impact: it is estimated that in Italy, 11-13%of men, or about 3 million are affected in part by ED.Main risk facong>toong>rs are: age, education level, anxiety, reactive depression, diabetes,heart disease, high blood pressure; disorders (hepatic failure, chronicrenal failure, obesity, dyslipidemia); hormonal disorders (hypogonadism, hyperprolactinemia,hypo/hyperthyroidism); neuropathies (Alzheimer’s disease,Parkinson’s disease, degenerative diseases); urologic surgery, colorectal andvascular.Regarding therapy first and most important form of treatment for a patientsuffering from erectile dysfunction is ong>toong> identify and possibly modify or removeall hazardous conditions for sexual health. First line treatments are selectiveinhibiong>toong>rs of 5-phosphodiesterase; second-line treatments essentially includeintracavernous injection of vasoactive substances and third line treatmentsinclude revascularization of the penis and prostesis implants.Key wordsErectile dysfunction • Inhibiong>toong>rsof 5-phosphodiesterase • Intracavernousinjection • Revascularization of the penis• Prostesis implantsIncidence and epidemiologyErection is a hemodynamic event that involves the central nervoussystem and local facong>toong>rs. It is governed by relaxation of the cavernosalarteries and the smooth muscle of the corpus cavernosum.An adequate blood flow ong>toong> the penis plays an important role in thisprocess. In the state of flaccidity, the sympathetic innervation producesa ong>toong>nic contraction of smooth muscles of the arteries and thebody, reducing the flow of blood through the artery cavernous inthe cavernosal spaces. Psychogenic stimuli central and / or sensorystimuli from the penis increase the activity of parasympathetic andreduce sympathetic activity, it is therefore a relaxation of the smoothmuscles in the penis and increases blood flow through the arteries andcavernous helicine arteries. The smooth muscle relaxation increasesthe distensibility of the cavernous spaces, leading ong>toong> congestion anderection. The increase in the volume of blood and the compressionof the trabecular-smooth muscle issued against the tunica albuginea,relatively rigid, reduces the venous flow in the output (veno-occlusivemechanism). It follows an erection with a certain degree of rigidityCorresponding authorGian Maria Busetong>toong>, Sapienza University of Rome, Department of Gynecological-Obstetrics Sciences and Urological Sciences, viale del Policlinico 155, 00161 Rome, Italy– Email: gianmaria.busetong>toong>@uniroma1.it – Tel. +39 06445068364


V. Gentile, et al.• trauma: perineal/pelvic (crural injury and/or pudenda).Cavernous or VenogenicThis form of ED finds its moment etiopathogeneticin an inadequate activation of the veno-occlusivemechanism (VOM) of the corpora cavernosa, responsiblefor the maintenance phase of the erectionsame. The deficit of the veno-occlusive mechanismat the level of the corpora cavernosa, a conditioningvenous leakage, has been described as one of theetiological conditions most commonly associatedwith vasculogenic forms of erectile dysfunction. Alack of integrity of the veno-occlusive mechanismof the corpora cavernosa, which is responsible forexcessive venous outflow, can achieve two fundamentalpathophysiological conditions: an incompletesmooth muscle relaxation or ong>toong> structural abnormalitiesof the erectile tissue. This type of pathophysiologicconditions may occur in anxious subjects,with an excessive adrenergic ong>toong>ne or in patientswith inadequate relaxation of neurotransmitters bythe parasympathetic nerve endings. Similar casesare found where there is an alteration of functionalalpha-recepong>toong>rs as well as other nerve recepong>toong>rs,which leads ultimately ong>toong> an increase of the basicong>toong>ne at the level of smooth muscle cells, impairingthe relaxation.NeurogenicIssues central and / or pictures of peripheral sufferingcan affect the appearance of erectile dysfunctionas a sympong>toong>m of nerve conduction deficit, deficit ofrelease of neurotransmitters or neuromodulaong>toong>rs.HormonalErectile dysfunction may result from alteration ofthe control mechanisms for hypothalamic-pituitary,of local neuroendocrine control, as well as the lackof a suitable substrate steroid desire ong>toong> support andmechanism erecong>toong>genic.Iatrogenic/post-traumaticMay induce the appearance of erectile dysfunctionurological surgical procedures, including endoscopicresection of the prostate (TURP), proceedings oflaser-ablation therapy or by vaporization of the prostate,radical surgery for prostate cancer or bladder,as well interventions urethroplasty for stenosis inload tract membranous urethral duct. These are supplementedby the surgical oncology, and at the expenseof the rectum and pelvis in general. We mustnot forget the pictures of post-traumatic lesion. Thepathophysiological substrate for the appearance ofED in these cases is likely ong>toong> be multifaceted. In fact,all these conditions can lead ong>toong> the developmenong>toong>f peripheral neurological disorders (eg, pudendalnerve injury and/or cavernous), deficit of arterial loadof the hypogastric artery/arteries cavernous helicinearteries, as well as inadequate activation of venoocclusivemechanism 2 .Psychogenic erectile dysfunctionThe psychogenic erectile dysfunction is defined asthe persistent inability ong>toong> achieve or maintain penileerection that they can have sex exclusively or mainlydue ong>toong> psychological facong>toong>rs or interpersonal. Thisdefinition has been adopted recently by the InternationalSociety of Sexual and Impotence Research(ISSIR) pointed out that three basic concepts:• the psychogenic erectile dysfunction is a diagnosisof certainty should not be used when it isbefore a clinical picture fuzzy or unknown;• psychosocial facong>toong>rs must be identified as thepredominant or exclusive of erectile dysfunctionin the subject, so patients with a combination oforganic and psychogenic facong>toong>rs should be classifiedas having mixed erectile dysfunction;• other elements of this refer ong>toong> the most recentdefinitions of erectile dysfunction.The psychogenic erectile dysfunction often coexistswith other disorders such as decreased sexualdesire (hypoactive sexual desire) and / or majorpsychiatric disorders, such as anxiety disorders anddepression. In these latter cases it is very difficult ong>toong>make a diagnosis of psychogenic erectile dysfunctionand treatment of primary psychiatric disorderexquisitely is indicated as the first step for the careof the patient.DiagnosisAs with any medical problem, it is necessary first ofall a detailed collection of sympong>toong>ms and medicalhisong>toong>ry, especially addressed ong>toong> the identificationof possible risk facong>toong>rs for ED (lifestyle, drug use,presence of chronic disease medications, interventionssurgical suffered) or significant psychologicalor relational components which require specialistadvice. With regard ong>toong> the assessment of specificsympong>toong>ms, particular attention should be placed onthe quantification of the disturbance (ED) seeking ong>toong>clarify the duration and severity (very useful for thispurpose will reveal the specific questionnaires thathave been valiong>dateong>d at international level) will beimportant ong>toong> investigate the presence or absence of66


ong>Upong>-ong>toong>-ong>dateong> on erectile dysfunction and treatmentspontaneous erections upon awakening, any loss oflibido, the occurrence of premature ejaculation.Physical examination is directed on the apparatusurogenital, endocrine, vascular and neurologicalsystems, will reveal whether there are abnormalitiesgenital, congenital or acquired, of hormonal problems,neurological or prostate disease. It is very importantfor the specialist, ong>toong> establish from the outseta good communication with the patient explainingin detail the following diagnostic steps and possibletreatment options, dealing with the expectations ofthe patient and partner. The involvement of partnersis highly desirable (ED inevitably affect the harmonyof the couple). The correct information is an essentialcomponent in the treatment of ED.Specific testsCurrently, it is considered necessary, the executionof the following tests:• tesong>toong>sterone, ong>toong>tal and free;• prolactin;• glucose;• triglycerides;• cholesterol;• PSA (for patients older than 50 years) 6 .These tests are useful ong>toong> detect any endocrine ormetabolic abnormalities can cause ED 3 . The resultsof these investigations, ong>toong>gether with the informationobtained from a proper medical hisong>toong>ry and a thoroughphysical examination, in many cases allow thespecialist ong>toong> move ong>toong>wards a diagnosis of the utmostcauses of ED, so that we can begin the treatmentmost appropriate.Further diagnosticAmong the specialized equipment needed ong>toong> furthertest the diagnostic, we can distinguish at least threedifferent levels.At the first level, must be reported:• the night penimetry computer (nptr-test), whichconsists in the recording of episodes of spontaneouserection that always occur during sleepin healthy subjects. This test is very useful for aninitial discrimination between prevailing psychologicalcauses of ED or organic base;• the Eco-color Doppler dynamic of the penis,which is indicated for the evaluation of the integrityof the vascular penis. This is a dynamic study,namely functional, performed in basal conditionsand after stimulation with vaso-active drugs injectedinside the penis, with the aim of studyingthe inflow and the outflow of blood in the conditionof erection induced pharmacologically 5 .There are also instrumental examinations of a secondlevel that are indicated in selected cases.Among these:• the test response ong>toong> the drug-stimulation intracavernousconsists of the evaluation of the erectileresponse of the patient after intracavernousinjection (ie in the penis) of a vaso-active drug indosage standardized (prostaglandin E1 mcg orpapaverine 20 mg);• it is a rapid test and inexpensive because thequality of the response is evaluated by the specialistby observation and palpation. Currently, inhighly specialized andrology centers, this test isperformed in conjunction with computerized recordingreal-time (RigiScan FIC-test): this allowsan objectivization of the result and a possiblecomparison with other surveys;• the computerized recording of the erectile responseong>toong> visual erotic stimulus adequate (RigíScanVSS)performed at baseline and after oraladministration of pro-erectile drugs: the resultswill be compared with each other and with theexamination Night (NPT test) and allow the specialistong>toong> draw important diagnostic deductionsand at the same time evaluate the effectivenessof a possible oral therapy;• the cavernosometry/graphy dynamics (LINK 15-16-17-18) that allows ong>toong> study the integrity of themechanisms of entrapment of the blood insidethe penis, during erection and ong>toong> identify thepresence of any abnormal exhaust ports;• the study neurological reflex bulbo-cavernousprovides indirect information, but very usefulwhen there is a suspicion of a neurological componentong>toong> the base of ED;• the test of ejaculaong>toong>ry latency with vibrostimolationthat allows ong>toong> check for sensory discomfortin the peripheral and ong>toong> quantify the extent of areported premature ejaculation.If eventually the patient is a candiong>dateong> for surgery,for example, a young subject who has suffered atrauma of the pelvis or in cases of acquired fibrosisof the penis, may be indicated special examinationsthird level:• digital selective hypogastric-cavernous arteriographythat, through the introduction of contrastmedium in the arterial tree radiological allowsong>toong> obtain very detailed images of small arterialbranches that bringing blood ong>toong> the penis allowthe erection;• angio-MRI with gadolinium: it is a very recent andelegant method that synthesizing the informationoffered by the two previous (arteriography cav-67


V. Gentile, et al.ernosa of the penis and dynamic MRI) allows ong>toong>obtain anaong>toong>mical and functional frameworks thatwere unthinkable a few years ago;• dynamic MRI of the penis which is the imagingmodality is most appreciated by the surgeon andthe patient ong>toong> the clarity of the anaong>toong>mical imagethat are of great help in pre-operative phase.• It should be stressed that the diagnostic-therapeuticapproach of patients with ED often requirea multidisciplinary collaboration, which will seethe specialist urologist use, where indicated, consultingpsychologist, endocrinologist, cardiologist,neurologist, or any another specialist whosespecific skills become necessary in the progressof the diagnostic.TherapyThe first and most important form of treatment fora patient suffering from erectile dysfunction is ong>toong>identify and possibly modify or remove all hazardousconditions for sexual health, whether they are representedby bad habits (excessive sedentary lifestyle,chronic stress, cigarette smoke etc..) or overeating(obesity, alcohol abuse) or eventually recruitment ofdrugs and medicines involving depressing side effectserectile function.The causes and modifiable risk facong>toong>rs are the following:• lifestyle and psychosocial facong>toong>rs (smoking, alcoholism,substance abuse, relationship conflicts,lack of information, lack of experience, depression);• sex education: awareness, changes in age, foreplay,lubrication of the partners;• drugs (change class or dose): antihypertensives,antipsychotics, antiarrhythmics, anti-androgens,steroids, finasteride;• hormone replacement therapy: hypogonadism,hyperprolactinemia.It is clear that in cases where it can be detectedunderlying disease can cause the onset of ED (diabetes,hypertension, hypercholesterolemia, etc.),The correct therapeutic approach will be ong>toong> correcong>toong>r cure the disease ong>toong> obtain a satisfacong>toong>ry compensation.Unfortunately, in most cases, it is not possible ong>toong>recognize a definite cause of ED, so the specialist isforced ong>toong> propose a “sympong>toong>matic” therapy ie palliativea solution that corrects the “sympong>toong>m” DE withoutbeing able ong>toong> provide the patient with a futureresumption of the natural erectile function.As in the case of diagnostic tests, even for the dif-ferent therapies of DE we can distinguish differentlevels, which are different for the progressive greaterinvasiveness.First-line treatmentsSelective inhibiong>toong>rs of 5-phosphodiesteraseDuring the 90s it was discovered a family of drugswhich, administered by mouth, allow a truly effectivetreatment of almost all forms of ED: these are selectiveinhibiong>toong>rs of 5-phosphodiesterase (PDE5).The action of all these drugs is carried out at the peripherallevel (ie directly inong>toong> the penis) and consistsin improving and maintaining the flow of blood inthe corpora cavernosa (erectile structures of the penis),and leading ong>toong> a better quality of erection. ThePhosphodiesterase (PDE) catalyze the hydrolysis ofthe second messengers cAMP and cGMP, which areresponsible for the activation of a course of eventsthat ultimately lead ong>toong> the relaxation of smooth muscles.Both of these second messengers are involvedin signal paths within the corpus cavernosum. Thesuperfamily of proteins cyclic nucleotide PDE canbe divided inong>toong> at least 11 families of structurallyand functionally related enzymes. Until now, differentisoforms have been characterized, all differentin their primary structure, specificity for cAMP andcGMP and mechanisms of regulation and tissue distribution.Molecular studies have demonstrated thepresence of different isoforms but functional studieshave revealed an active role only for PDE3 andPDE5. Three different isoforms of PDE5 were clonedinong>toong> the tissue of the human penis. Two isoformswere identical ong>toong> PDE5A1 and PDE5A2, by not peniletissue, while the third PDE5A3 was new. This isoformwas present in tissues with a component of smoothmuscle or cardiac muscle. Recently, the three-dimensionalstructure of the catalytic domain (residues537-860) of human PDE5 complexed ong>toong> the threemolecules Sildenafil (Viagra), Tadalafil (Cialis) andVardenafil (Levitra) was determined by offering theopportunity ong>toong> design potent and selective inhibiong>toong>rs.Tadalafil is a potent inhibiong>toong>r of PDE5, has a half-lifeof 17.5 h and a lasting effect up ong>toong> 36 h after dosing.Tadalafil is effective and well ong>toong>lerated. In a recentstudy, it was demonstrated that the Tadalafil 20 mg,administered on alternate days in patients with anincreased cardiovascular risk, causes improvementin endothelial function regardless of the degree ofED. The study showed a significant effect of Tadalafilcompared ong>toong> placebo on FMD (flow-mediated dilatation)of the brachial artery. However, this was asmall study (32 patients), therefore, no definitiveconclusion can be drawn. Through a study of healthy68


ong>Upong>-ong>toong>-ong>dateong> on erectile dysfunction and treatmentvolunteers, it was shown that therapeutic concentrationsof Tadalafil do not produce clinically significantchanges in the clearance of drugs metabolized byCYP3A. In fact, in a recent clinical study, the pharmacokineticsof midazolam and lovastatin, 2 differentCYP3A substrates, was substantially unchangedafter taking Tadalafil co-administered. For Tadalafil,like Sildenafil and Vardenafil, we studied the possibleinteraction with alpha-blockers, important drugsin the treatment of benign prostatic hypertrophy.Tadalafil (20 mg), enhances the hypotensive effecong>toong>f doxazosin, producing an average decreasein standing sysong>toong>lic blood pressure significantlygreater than placebo. In contrast, in patients treatedwith tamsulosin, 10 and 20 mg Tadalafil produceda mean reduction in sysong>toong>lic blood pressure similarong>toong> placebo, suggesting that the drug should beused with caution when patients using doxazosin.Useful ong>toong> consider that grapefruit juice causes the irreversibleinactivation of cyong>toong>chrome P450 3A4. Thismeans that it can interact with Sildenafil, Tadalafil orVardenafil, resulting in severe systemic vasodilation,especially when combined with a nitrate therapy.[8]The therapeutic aspect of great interest that thesemolecules present, consists, as well as its efficacy,in the fact that they act only in the presence of anadequate stimulus sexual: this translates in an excellentacceptance by the patient and the partner. Thebest known and founder of such drugs is Sildenafil(known ong>toong> all as Viagra), ong>toong> which are added twoother molecules: Tadalafil (brand name Cialis) andVardenafil (trade name Levitra or Vivanza).These pills should be taken “as needed” or about40 minutes before attempting ong>toong> have sex and theireffect wears off in the next 4 hours. From this poinong>toong>f view, is characterized Tadalafil (Cialis), the effectivenessof which lasts for more than 24 hours.The effectiveness of this class of drugs is very good:about 70% of all men with ED of all degrees, respondspositively ong>toong> selective inhibiong>toong>rs of PDE5 9 .Categories of patients who do not get the benefiong>toong>f taking them are essentially those classified as“severe organic”, in particular those with severevascular disease or patients undergoing demolitionsurgery (usually necessary ong>toong> remove a tumor) thatresulted in the disruption of neural circuits necessaryong>toong> trigger an erection (removal of the bladder orrectum, enlarged removal of prostate). These drugsare well ong>toong>lerated, as side effects are usually mildand decreased over time 10 .They consist of:• headaches;• redness of the face with hot flashes;• muscle aches;• gastrointestinal disorders;• mild hypersensitivity sight.LUTS e EDVery recently observational and epidemiologicalstudies indicate the existence of a possible link betweenLUTS and ED 11 , it is necessary ong>toong> questionwhether LUTS ong>toong> have an impact on sexual functionor if both conditions are linked by a common underlyingmechanism. In this regard, several pathogenetichypotheses have been proposed ong>toong> explain this Link:adrenergic hyperong>toong>nia activation of Rho kinase, pelvicatherosclerosis 12 . On closer inspection the complexityof the pathophysiological mechanisms wereinvolved in order ong>toong> explain the link between LUTS /BPH appear ong>toong> have different mechanisms in commonand interconnected, so how these theories haveseveral common points with the pathophysiologicalmechanisms proposed ong>toong> explain medical conditionscoma syndrome or the metabolic role of inflammationin prostate disease 6 . This broad connection betweenthe different theories proposed seems ong>toong> havea major impact in clinical practice for patients withLUTS and ED disorders 5 . On the one hand, certainlycan complicate the diagnostic workup of patientswith ED and LUTS on the other hand seems ong>toong> opennew scenarios therapeutic and broaden the range oftreatment options available ong>toong> us so that treatmenong>toong>ptions can overlap, allowing prevention or treatmenong>toong>f both conditions simultaneously. It has not yetcertain about the data, you must change the clinicalapproach ong>toong> the patient with concomitant LUTS andED, not treating them more as two distinct conditionsthat are often approached by different specialists,but rather with a clinical approach integrated soeach patient with LUTS should also evaluated fromthe point of view of sexual function, as well as eachpatient with ED should be evaluated from the poinong>toong>f view of the urinary function. An approach of thiskind would certainly help the clinician in the choice oftreatment appropriate for each patient in view of thefact that the current therapies for LUTS are burdenedby side effects at different levels of sexual function(libido, erection, ejaculation) and above in the light ofnumerous scientific evidence for a role of PDE-5 inthe treatment of LUTS, as revealed by a recent metaanalysison this ong>toong>pic. On this basis, each patient withLUTS should be carefully informed of any possibleadverse effects on sexual function related ong>toong> drugtherapy and surgical treatment of LUTS / BPH, aswell as the clinical in follow-up treatment of patientswith LUTS should carefully moniong>toong>r the sexual functionthrough valiong>dateong>d questionnaires 14 .69


V. Gentile, et al.Hormonal therapyPart of action of the first level is included hormonetherapy that actually should be considered separately.The indication ong>toong> the administration of tesong>toong>sterone(the male sex hormone) is in fact reserved forcases of proven deficiency of this hormone in theblood. However, it should be considered that there isan age-related physiological decline in tesong>toong>sterone,so that it is estimated that about a quarter of menover the age of 60 years present a hypogonadismmild or moderate. Thus, in recent years it has comespreading among specialists a particular interest inthis category of persons of mature age (over 60 years)in which can recognize the presence of a combinationof sympong>toong>ms and physical signs and laboraong>toong>ryfindings (ie what is known as a syndrome) definedLOH, or “androgen deficiency in later life”. The mainsympong>toong>ms of this syndrome consist of a decrease insexual desire, erection, mass and muscle strength inthinning of hair, in a certain mood instability with atendency ong>toong> irritability and depression and memory.When this corollary of signs and sympong>toong>ms is associatedwith evidence of a deficiency of tesong>toong>steronein laboraong>toong>ry tests, it is feasible ong>toong> tesong>toong>steronetherapy, the administration of which is representedby the most current formulation in gel. In the casesmentioned, the daily application on the skin of theback or abdomen of tesong>toong>sterone gel (contained inspecial bags) quickly resong>toong>res the normal level ofthis hormone in the blood, thus correcting most ofthe problems related disorders including sexual. Thepossible side effects associated with the administrationof tesong>toong>sterone (urinary retention, swelling of thebreasts) are generally absent or very well ong>toong>leratedwhen used in compliance of the dosage schedule.In the past it was emphasized a particular aspectrelated ong>toong> hormone therapy in the mature: the risk ofunmask a possible prostate cancer 15 .Second-line treatmentsEssentially include intracavernous injection of vasoactivesubstances. The corpora cavernosa are thefunctional erectile structures of the penis that areeasily achieved by using short and thin needles(such as those for insulin) and injecting the lateralwall of the penis. The patient is instructed in the correctuse of the drug by the specialist and, generally,three outpatient sessions are sufficient ong>toong> identify thedose of medication suited ong>toong> the specific case andmake the patient alone ong>toong> initiate therapy at home.With regard ong>toong> the intracavernous injection therapyin the treatment of ED, patients are candiong>dateong>s didnot respond or contraindicated ong>toong> oral therapy andphysiotherapy rehabilitation after radical surgery pelvis.The introduction of oral drugs effective in treatingED has certainly reduced the indications for thistype of treatment which, until recently, was widelyused all over the world. Remains a very effective(complete response in more than 80% of patients)and is indicated in the percentage of patients sufferingfrom ED who cannot benefit from oral therapy,or because they precluded (heart patients who takenitrates, recent myocardial infarction) or becauseresults non-responder (approximately 30%). Thevaso-active drugs injected directly inong>toong> the penis,producing an erection regardless of sexual stimulation,which makes this type of treatment the firstchoice for those who have been damaged neuralcircuits that carry the impulse erection (for examplepatients who have undergone surgery with excisionof the rectum or the bladder for tumors).Third line treatmentsRevascularization of the penisThey are part of the therapeutic possibilities of choicefor the treatment of ED, even revascularization surgery,ie the artery bypasses that resong>toong>re blood flowong>toong> the penis. Candiong>dateong>s for this type of operationare only young patients (younger than 50 years), nonsmokingor diabetes, who have suffered a trauma ong>toong>the pelvis or perineum (the area between the testiclesand the anus) that has lesioned one or both arteriesthat ensure the normal flow of blood ong>toong> the penis.ImplantsThis intervention was proposed over 30 years agoand ong>toong>day in the world tens of thousands of menare carriers of this device. The prosthetic implanthas always represented “the ultimate solution” for apatient suffering from erectile dysfunction, but at thesame time is the only effective solution ong>toong> 100% inany case of ED. The technological evolution has ledong>toong> major advances in materials and the experienceof thousands of procedures performed around theworld mean that complications are currently verylimited, and you have less than 10% of cases. Thedegree of satisfaction of patients who have undergonesurgery is usually very high.There are different types of penile prostheses, dividedinong>toong> two main categories:• hydraulic;• non-hydraulic.The hydraulic prostheses are the most suitable forpatients with a complete ED and wish ong>toong> maintaina normal appearance of the penis at rest. The mainlimitation of these prostheses is represented by the70


ong>Upong>-ong>toong>-ong>dateong> on erectile dysfunction and treatmenthigh cost and the need for a minimal manual dexterityrequired for activation and deactivation of the cylinders.The aesthetic and functional result, however,is guaranteed.The not-hydraulic prosthesis will consist of a pair ofcylinders of various material, which, depending on theirsize and different stiffness can be distinguished in:• malleable;• soft (Subrini-Ausong>toong>ni).The hydraulic penile implants and soft, are the finalsolution ong>toong> many problems of severe erectile dysfunction.References1Fusco F, Sicuteri R, Valle D, et la. An identikit of patientsseeking treatment for erectile dysfunction in Italy:results from the EDOS italian database. Arch Ital UrolAndrol 2007;79:1-6.2Feldman HA, Golstein I, Hatzichrisong>toong>u DG, et al. Impotenceand its medical and psychosocial correlates:results of the Massachusetts Male aging Study. J Urol1994;151:54-61.3Chughtai B, Lee RK, Te AE, et al. Metabolic syndromeand sexual dysfunction. Curr Opin Urol 2011;21:514-8.4Cirino G, Fusco F, Imbimbo C, et al. Pharmacologyof erectile dysfunction in man. Pharmacol Ther2006;111:400-23.5Mirone V, Imbimbo C, Palmieri A, et al. Erectiledysfunction after surgical treatment. Int J Androl2003;26:137-40.6Gacci M, Eardley I, Giuliano F, et al. Critical analysisof the relationship between sexual dysfunctions andlower urinary tract sympong>toong>ms due ong>toong> benign prostatichyperplasia. Eur Urol 2011;60:809-25.7Serefoglu EC, Mandava SH, Sikka SC, et al. PenileDoppler sonographic and clinical characteristics inPeyronie’s disease and/or erectile dysfunction: ananalysis of 1500 men with sexual dysfunction. BJU Int2012;110:E154-5.8Mirone V, Fusco F, Rossi A, et al. Tadalafil and Vardenafilvs Sildenafil: a review of patient-preference studies.BJU Int 2009;103:1212-7.9Fusco F, Razzoli E, Imbimbo C, et al. A new era in thetreatment of erectile dysfunction: Chronic phosphodiesterasetype 5 inhibition. BJU Int 2010;10:1634-9.10Corona G, Mondaini N, Ungar A, et al. Phosphodiesterasetype 5 (PDE5) inhibiong>toong>rs in erectile dysfunction:the proper drug for the proper patient. J Sex Med2011;8:3418-32.11Seftel AD, de la Rosette J, Birt J, et al. Coexisting lowerurinary tract sympong>toong>ms and erectile dysfunction: a systematicreview of epidemiological data. Int J Clin Pract2013;67:32-45.12Wibberley A, Chen Z, Hu E, et al. Expression and functionalrole of rho-kinase in rat urinary bladder smoothmuscle. Br J Pharmacol 2003;138:757-66.13Shiri R, Hkkinen JT, Hakama M, et al. Effect of lowerurinary tract sympong>toong>ms on the incidence of erectiledysfunction. J Urol 2005;174:205-9; discussion 209.14Rosen R, Altwein J, Boyle P, et al. Lower urinary tractsympong>toong>ms and male sexual dysfunction: the multinationalsurvey of the aging male (MSAM-7). Eur Urol2003;44:637-49.15Greenspan MB, Barkin J. Erectile dysfunction andtesong>toong>sterone deficiency syndrome: the “portal ong>toong> men’shealth”. Can J Urol 2012;19(5 Suppl 1):18-27.71

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