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Abstract
Erectile dysfunction has constituted a major concern to different categories of health caring staff over centuries. Erectile dysfunction (impotence) is the inability to obtain and sustain an erection adequate for sexual intercourse. This is a common problem and the prevalence increases with age. It is important to distinguish erectile dysfunction from ejaculatory disorders including premature ejaculation and ejaculatory failure. Erection supposes a process regulated by hormonal and neuro-vascular mechanisms on both cerebral and peripheral levels.
A careful history, including a drug history, will usually differentiate organic from psychogenic impotence. Organic impotence generally has a gradual, insidious onset with progressive worsening until no erection is obtained. Psychogenic impotence is more likely to have an abrupt onset. This is often related to a distinct precipitating event (e.g. a psychologically traumatic episode of sexual failure). The impotence is often inconsistent, occurring only in certain situations. Nevertheless, organic impotence usually invokes a secondary psychological overlay which may complicate evaluation of the etiology. Evidence of possible causative factors (e.g. diabetes, pituitary disease, lipid disorders, vascular or neuropathic disease, and androgen deficiency) should be sought systematically. Gonadal status (secondary sexual characteristics, testis size) and visual field defects suggesting pituitary tumor should be assessed. Altered peripheral pulses and neurological reflexes in the legs can be evidence of vascular or neurological disorders.
Few investigations of erectile dysfunction lead to specific interventions, so extensive testing cannot be justified in routine practice. Specific correctable underlying causes such as androgen deficiency or pituitary tumor should be sought, even though they are rare. Serum prolactin, testosterone and luteinising hormone (LH) should be measured and repeated if any is abnormal. If consistently abnormal, further investigations are required. Blood glucose and lipids should be measured. Although treatment of diabetes or hyperlipidaemia may not improve erectile function, they should not be overlooked.
Apart from measurement of penile blood pressure (penile duplex) which may exclude or confirm a vasculogenic basis, other complex investigations are not usually justified. Surgically correctable vascular lesions are rarely found and, even then, surgical outcomes are functionally very disappointing. Sleep studies with or without determination of nocturnal penile tumescence are not usually justified clinically. They add information which usually does not influence management.
The management of erectile dysfunction begins with the identification of organic comorbidities and psychosexual dysfunctions; both should be appropriately treated. The currently available therapies that should be considered for the treatment of erectile dysfunction include the following: oral phosphodiesterase type 5 (PDE5) inhibitors, intra-urethral alprostadil, intracavernous vasoactive drug injection, vacuum constriction devices, and penile prosthesis implantation. These appropriate treatment options should be applied in a stepwise fashion with increasing invasiveness and risk balanced against the likelihood of efficacy.
In our thesis we have tackled that category of patients who were not responding to sildenafil after two trials with 100 mg dose. We had followed up the response to three categories of intracavernosal injections up to six months; using papaverine, prostaglandin E1 and Trimix (combination of papaverine, phentolamine and prostaglandin E1) on fifty four patients who were considered sildenafil non responders. We had found the great improvement and very good compliance of both prostaglandins and trimix with favor to trimix that had less side effects and much comparable less cost. This was on two main groups of patients those with history of DM and the other category of those patients who had history of radical pelvic surgery. We also recognized that the assessment of patient should depend mainly on the subjective evaluation of patient through the international index of erectile function questionnaire of the 5 module (IIEF-5) plus the objective evaluation by monitoring the response to ICI visually by the degree and duration of erection. Saving the penile duplex studies and hormonal profile; to those with more clinically related problems.