Caverject

Erectile dysfunction (ED), also known as impotence, can manifest in several ways. It can be charfcaadP acterized by the consistent and complete inability to achieve erection, the inability to achieve erection firm enough to engage in sexual activity such as penetration, or the ability to sustain erection for a satisfactory period. A lack of sexual desire and an inability to ejaculate may also be seen.1 Erectile dysfunction may be mild, moderate, or severe. Mild ED can be defined as failing in two out of 10 attempts at achieving a satisfactory erection; with severe ED there maybe 10 such failures out of 10. Because the definition of the disorder is so broad, it is difficult to estimate the number of men with ED, but according to the National Institutes of Health, between 15 million and 30 million American men are afflicted with it.1

Since the Food and Drug Administration (FDA) approval of sildenafil (Viagra) in 1998, millions of men in the United States have sought treatment for the disorder. Many other treatments for ED are available, from psychotherapy to vacuum constriction devices (VCDs). But despite the prevalence of the problem and the fact that many clinical trials have been conducted, recent studies suggest that clinicians still do not pay enough attention to sexual health, failing to properly evaluate, educate, counsel, and follow-up with their patients.2 They seldom assess patients' sexual partners and too infrequently consider alternatives to drug therapy. In addition, most providers are inadequately prepared to address sexual functioning and few routinely inquire about it.2,3

A consensus panel met in September 2001, at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in Newark to develop provider guidelines for the management of ED and other sexual disorders in men and women. The panel included registered nurses, nurse practitioners, physician assistants, diabetes educators, and physicians. A broad range of specialties was represented, including urology, cardiology, endocrinology, diabetology, psychiatry, family medicine, and rehabilitation medicine. All participants had significant clinical and professional experience in sexual health medicine and ED management, and most were published in peer-reviewed journals on this topic. The panel's recommendations were published by Albaugh and colleagues under the title "Health Care Clinicians in Sexual Health Medicine: Focus on Erectile Dysfunction" in the August 2002 issue of Urologic Nursing.

The model the consensus panel proposed for the management of ED includes:

* identification

* assessment and diagnosis

* intervention, counseling, and education

* follow-up.

The use of this model requires respect for the sexual and emotional needs of the patient, as well as an understanding of the role sexuality plays in general health. Erectile dysfunction should be addressed seriously because it can be a marker or symptom of an underlying medical or psychological disorder, it may be a side effect of a necessary medication that causes discontinuation of use, and it may have a devastating effect on the quality of a patient's life.4 In addition, some patients may seek treatment from unqualified sources, such as prescription services available on the Internet. For these reasons, the panel strongly recommends that sexual function be routinely and sensitively assessed in all patients at risk for ED. Although the principles of care incorporated into the panel's recommendations can be applied to other sexual problems of both men and women, this article focuses on the management of ED.

* Pathophysiology and Treatment: An Overview Causes and Effects

Erectile dysfunction can result from poor physical health, psychological health, or both. The principal risk factors are diabetes mellitus, heart disease, hypertension, and prostatic hypertrophy.5'6 Medications for hypertension, cardiovascular disease, and depression also may cause or exacerbate ED, and there is strong evidence suggesting that cigarette smoking and heart disease contribute to the disorder. The Massachusetts Male Aging Study, an ongoing epidemiologic study of health and aging in men that began in 1987, reveals a 99% age-adjusted probability of the incidence of ED in smokers treated for heart disease.7 Other risk factors include excessive alcohol consumption, bicycling more than 3 hours a week, and a sedentary lifestyle.7-9

There are three basic categories of ED:

* The failure to initiate the nerve impulse required to generate erection, which can be psychogenic, endocrinologie, or neurogenic in origin

* A failure to fill (arteriogenic in origin)

* A failure to store (venoocclusive in origin)

Failure to initiate implies either central or peripheral inhibition of, or inability to activate, the autonomie response that allows parasympathetic and sympathetic innervation of erectile tissue. Conditions that contribute to failure to initiate this nerve impulse include psychological factors such as stress, anxiety, fear, and aversion; and physical conditions such as hypogonadism (both hypogonadotropic and hypergonadotropic), lumbosacral radiculopathy, multiple sclerosis, and spinal cord injury.

Failure to fill indicates an impaired arterial inflow, leading to decreased perfusion pressure in the hypogastric, pudendal, and cavernous arteries after autonomic nerve activation. Arterial occlusion can be secondary to either atherosclerotic disorders (risk increases with age, diabetes mellitus, heart disease, hypertension, cigarette smoking, and low levels of high density lipoprotein cholesterol) or trauma (such as pelvic fracture or blunt perineal trauma from bicycling).

Failure to store means an impaired venous outflow, leading to an inability to trap blood in the erectile tissue. The impairment may be secondary to insufficient relaxation of corporeal smooth muscle (a possible side effect of medication, such as any adrenergic agonist, or a consequence of psychological stress) or to replacement fibrosis of corporeal smooth muscle (as a result of atherosclerosis caused by priapism or blunt perineal or penile trauma).

These categories are not mutually exclusive and in many patients, ED results from a combination of factors. In patients younger than 40 years of age, ED is more likely to have psychogenic or traumatic causes; older patients are more likely to be affected by diabetic and atherosclerotic factors.6 Psychogenic factors, however, should be considered in all cases.

Treatment Options

In addition to oral medication, intracavernous injections (alprostadil [Caverject]), intraurethral suppositories, VCDs, and various surgical interventions are available. Also, sexual counseling should be recommended if the patient so desires or if there is indication of mental health factors. A patient is seldom informed of all available treatments or of the risks and benefits associated with each, possibly because of the provider's lack of knowledge or the patient's embarrassment. If the clinician does assess sexual health, factors such as smoking and exercising are rarely addressed, despite evidence of their significance in the etiology and treatment of ED.10

Sexual partners of patients with ED often have concerns that aren't addressed by providers. Some men don't have a sexual partner, and this should be noted as well; the patient may want to change the mode of treatment if he enters into a sexual relationship. This panel recommends a strong emphasis on the education and counseling of both patients and their partners.

* Identification of the Problem

Assessment for the presence of ED entailing direct inquiry about sexual function should be routine in the care of middle-aged and elderly men, but it is especially recommended after surgery in that population." Clinicians may choose to give their patients a questionnaire to complete or conduct an interview with the patient alone or with his partner.9,11 For example, it's not uncommon for men with diabetes to have erectile problems. If a clinician asks a patient with diabetes whether he has ED and the answer is no, she should encourage him to inform her if the disorder develops.

The Sexual Health Inventory for Men (SHIM) is a brief, validated scale for the identification of ED, the presence and severity of which may be determined according to its scoring system (see Figure: "Sexual Health Inventory for Men"). The SHIM consists of five questions about sexual activity and erectile capacity.9 The panel recommends the routine use of either the SHIM or another such questionnaire on the first visit (many clinicians have developed their own instruments) to identify ED and determine its degree.

* Assessment and Diagnosis

Assessment and diagnosis begin with a comprehensive sexual, medical, and psychosocial history, in addition to the SHIM, during the interview. The goals are the identification of ED and the determination of its severity and frequency, as well as the contributing factors. Is ED the primary or sole complaint, or are other aspects of the sexual response cycle involved (libido, orgasm)? While taking a patient's history, the clinician should note prescription and nonprescription drug use, identify factors such as high levels of stress and problems in personal relationships, and determine the incidence of sudden changes in sexual functioning that might be attributable to the effects of recent surgery. Certain medications, such as antidepressants and antihypertensives, greatly diminish libido; as many as 60% of men taking antidepressants and at least 20% of those taking antihypertensives experience ED to varying degrees.12 Taking a history is the essence of the evaluation; it most often reveals the cause of the ED and which aspect of the disorder the patient is most concerned about.11

Physical examination should include examination of the genitourinary, endocrine, vascular, and neurologic systems, by which the clinician may be able to confirm poor circulation or Peyronie disease, a painful condition marked by dense tissue around the corpus cavernosum penis. Also, by performing a digital rectal examination, the clinician may detect prostate cancer if she encounters firm nodules that are not painful or a diffusely rubbery, nodular prostate. A neurologic examination such as bulbocavernosus reflex testing, which entails squeezing the head of the penis to induce contraction of the anal sphincter, can be used in cases of neurologic illness such as multiple sclerosis or pelvic or spinal trauma, and may be performed during the digital rectal examination.

Laboratory testing should be performed in all cases to rule out causes of ED such as diabetes, hyperlipidemia, and thyroid conditions. The consensus panel did not recommend one assay over another for assessing androgen status. Reliable assays are available for measuring testosterone levels. Serum prolactin levels should be determined only in selected cases, such as when the serum testosterone level is below 300 ng/dL; a low testosterone level may be attributable to a pituitary tumor in the absence of liver disease, thyroid disease, chronic renal disease, and diabetes.11,13 The following laboratory tests should be performed in patients with established ED:

* Standard serum chemistries, including fasting glucose or glycosylated hemoglobin levels, a complete blood count, and lipid profiles.

* Thyroid-stimulating-hormone (TSH) and free-thyroxine testing (FT4); elevated levels of TSH indicate hypothyroidism, and elevated levels of FT4 indicate hyperthyroidism, which are associated with ED.

* Prostate-specific-antigen testing, depending on the patient's age (screening is performed routinely in men older than 50 years of age, but also in men as young as 40 years of age if there is a family history of prostate cancer or if the patient is African American).

The following tests are specialized, and the panel recommends administering them only in the circumstances indicated:

* Nocturnal penile tumescence and rigidity (NPTR) testing involves the placement of sensors at the base and tip of the penis that record both circumference and circumferential rigidity during sleep over a period of one to three days. Men of all ages normally have erections during the rapid eye movement stages of sleep, and the lack or impairment of them, as measured by NPTR testing, is held to be indicative of a physiologic cause of ED. In contrast, a normal NPTR test result in a man with ED suggests a psychological cause. This self-administered test for use at home is also used in the clinical setting to measure erectile response to sexual stimuli such as erotic videotapes.

While tumescence (increase in girth) and rigidity monitoring does provide useful information, it has limitations, which may include false positives; a patient with restless legs syndrome may have a compromised test response, for example. Improperly applied sensors also may produce faulty results. Although there is no single test that enables providers to determine the precise etiology and degree of ED, NPTR testing provides useful information regarding the rigidity and tumescence in a fairly noninvasive manner.14

* Color Doppler sonography of the penis can be used to detect the peak systolic velocity of the cavernous artery to measure the integrity of arterial inflow during erection.

Patients and partners experiencing difficulties in their relationships can be referred to therapists accredited by the American Association of Sex Educators, Counselors, and Therapists (http://www.aasect.org). Patients with significant cardiac illness, particularly those with a history of angina pectoris or recent myocardial infarction, should be evaluated according to the guidelines established by the Princeton Consensus Panel, published in the Amencan Journal of Cardiology in July 2000, which list cardiac risks associated with sexual activity.15

* Intervention, Counseling, and Education

The panel recommends differing levels of treatment according to the "mechanism of action, degree of invasiveness, ease of administration, reversibility, and relative costs associated with each."11 The treatment options are categorized as first-, second-, or third-line therapies. Patients should proceed from first-line therapies to second- and then third-line options as needed, beginning with education and counseling. A patient does not have to follow the order of the therapies and may choose surgery after counseling or may choose self-injection therapy before trying oral agents. In addition, first-line therapies maybe used concurrently with second-line therapies, but it is generally recommended that patients start with a first-line therapy and move to second-line only if it is not effective or if they are not happy with the option. Third-line therapy is generally used only if the first- and second-line therapies have been ruled out because of inefficacy.

Sexual counseling and education, VCDs, and oral agents, specifically the class known as phosphodiesterase type 5 (PDE5) inhibitors, are first-line treatments for ED.

Education and Counseling

The panel recommends the education and counseling of all patients and their partners before starting medical treatment for ED, the goal of which is to address misconceptions of the disorder. Although patients may be reluctant to attend group meetings on the topic, in the experience of this panel's members, group education can be highly effective in easing the embarrassment often caused by ED.

The acceptance of the condition and the level of distress it causes vary among patients, as may the need for information and the attitude toward treatment. Some patients strongly favor a nonpharmacologic treatment like counseling, and some prefer the most aggressive pharmacologie or surgical treatment; the clinician's job is to determine which one is best.

A patient may have unrealistic expectations of treatment and its outcome-the expectation that successful treatment alone will guarantee him a sexual partner, for example. Among partners, such expectations of treatment are varied as well. Management is more successful if the partner agrees on what to expect from treatment, and he or she should be encouraged to participate in discussions with the patient and clinician. Individual counseling may benefit patients who anticipate discomfort in a group setting where they may not feel free to express concern about whether, for example, they will be able to achieve erection without the aid of medication. Sex counseling also may benefit some patients, allowing both them and their partners to discuss sexual preferences and techniques. Partners should be encouraged to be assertive when discussing sexual preferences and performance. If partners prefer not to perform oral sex, for example, they should make that clear before treatment for ED begins.

The medications most often associated with the onset of ED are agents that have antiandrogenic properties such as the antineoplastic leuprolide (Lupron and others); antiarrhythmics; and certain antidepressants, most notably selective serotonin reuptake inhibitors, such as paroxetine (Paxil). Although some patients respond well to a change or substitution of medication, this strategy is not always recommended. The panel recommends a careful review of treatment options and the patient's preferences for treatment before deciding to alter or substitute medications. Patients who have ED associated with antihypertensive drugs can be encouraged to try to control hypertension through diet and exercise.

As patients become informed about ED and its treatments, they may have questions. Clinicians should be prepared to answer them. The most commonly asked questions include the following:

"Will I actually be cured of ED, or will I be dependent on treatment from now on?"

Oral therapies are effective in a majority of cases but not in all; some patients may not recover full function with oral medication and will need additional treatment. Except surgery, no treatment provides a permanent solution to the disorder. Further, if the ED is secondary to a medical condition such as diabetes, it may be less responsive to treatment as the primary disease progresses.

"If I take medication, must I tell my partner?"

The partner should be informed when a patient is undergoing treatment for ED. Doing so may foster trust and cooperation in the relationship, thereby enhancing treatment.

"Are VCDs and medications safe?"

Generally, ED treatments are safe, but misuse of them can cause adverse effects; clinicians should clearly instruct patients in proper dosage or use.

"Is medication the only treatment other than surgery?"

It is important to inform patients of the second-line treatment options-injectable and intraurethral agents-that can be prescribed to those who do not respond to counseling, medication, or VCDs.

Oral Therapies

The PDE5 inhibitors, (the drug class that includes sildenafil, vardenafil [Levitra], and tadalafil [Cialis]), are minimally invasive compared with surgery or penile insertions, are easy to use, and have relatively short halflives. They cost $8 to $10 per pill. Sildenafil and vardenafil have half-lives between 4 and 5 hours. Sildenafil greater than 25 mg should not be taken within 4 hours of an alpha-blocker. Vardenafil is contraindicated with all alpha-blockers. Tadalafil has a substantially longer half-life of 17.5 hours, allowing for a longer period during which erection can be achieved and is contraindicated with all alpha-blockers except tamsulosin (Flomax) 0.4 mg. All these drugs inhibit PDE5, the primary form of the enzyme found in erectile tissue that is responsible for the breakdown of cyclic guanosine 3',5'-monophosphate, the intracellular second messenger of nitric oxide, the principal vasodilator and neurotransmitter involved in erection. The PDE5 inhibitors enhance smooth muscle relaxation within arteries and arterioles in the corpus cavernosum penis, resulting in increased blood flow and, thus, an erection. All three medications are to be taken only when needed and take effect in 30 to 60 minutes. The PDE5 inhibitors are generally well tolerated. Patients taking nitrates may not be prescribed PDE5 inhibitors because they may be at risk for severe hypotension, myocardial infarction, and shock during sexual activity.11 The most common side effects associated with PDE5 inhibitors are headache, flushing, dyspepsia, and nasal congestion, and there is a slight risk of changes in vision such as perception of a blue hue, sensitivity to brightness, and blurred vision.

A review of clinical trials showed that a majority of men taking sildenafil had success in achieving an erection adequate for sexual intercourse.16

Vacuum constriction devices, among the least invasive and least expensive of the treatment options (a single expense of $300 to $500), were approved by the FDA for over-the-counter sale in 2002. To use a VCD, a plastic tube is placed around the penis and air is pumped out of the chamber, drawing blood into the penis and producing an erection. The erection is maintained by placing one or more tension bands around the base of the penis after it is erect. These may remain in place for as long as 30 minutes, and the device can be used daily. Success with VCDs has been reported at between 70% and 94% in the past decade.17,18 Some patients may find the device cumbersome and prohibitive of spontaneity, or that it produces an unnatural erection.19 Adverse effects associated with this device include pain caused by either the vacuum pressure or the tension band, decreased sensation caused by the band, bruising, and obstructed ejaculation. Many patients who discontinue use of a VCD, however, cite reasons unrelated to the device itself, such as the loss of libido, the return of spontaneous erections, and the loss of a partner.

Second-line Therapies

Injectable and intraurethral agents, the second-line therapy for ED, are more invasive and should be administered only if a patient has experienced adverse effects from or has failed PDE5 therapy. Of course, the choice and success of second-line therapies such as self-injection or penile suppositories also depend on whether the patient is willing to administer them.

Self-injection therapy entails the injection of a vasoactive drug directly into the corpus cavernosum penis to induce smooth muscle relaxation, which in turn induces erection. Various forms of prostaglandins as well as other agents such as papaverine hydrochloride and phentolamine are available for this purpose. Prostaglandin E^sub 1^ is available synthetically as alprostadil. Injection therapy for ED has proven to be effective in most patients, regardless of the etiology of the condition. Men at risk for priapism (a symptom of, among other things, sickle cell disease) or hypercoagulation states, and men taking monoamine oxidase inhibitors for depression should not use injection therapy.

The most common adverse effects of injection therapy are penile pain, groin pain, and hypotension; less common are fibrosis and prolonged erection.

Urethral Suppositories

Alprostadil is also available in suppository form. The patient inserts a small, soft suppository into the urethra with an applicator. Alprostadil causes the penile muscles to relax so that blood flows into it to produce an erection. The patient may gently massage the penis to aid in the dissolution of the suppository; standing upright for a few minutes helps to increase the blood flow to the penis. Successful application results in erection in approximately 15 minutes.21 The initial dose should be administered by a clinician because of the remote chance of syncope; the patient's blood pressure should be monitored and the patient observed for 30 minutes in case light-headedness or dizziness develops.20 More common side effects include burning and irritation in the urethra. Recommended doses range from 250 mcg to 1,000 mcg. The efficacy rates associated with urethral suppositories are only 35% to 50%.22,23

Third-line Therapies

If first- and second-line treatments fail or produce unacceptable adverse effects, or if the patient prefers a permanent solution to ED, surgical implantation of a semirigid penile prosthesis or an inflatable prosthesis, the only irreversible treatment for the disorder, is the only option.

Surgical Treatments

The semirigid penile prosthesis consists of two rods implanted into the corpus cavernosum that can be bent upward for intercourse or downward for concealment. This prosthesis is simple to operate, provides rigidity sufficient for penetration and intercourse, and has no mechanical parts that can fail. The erection with this type of implant is firm but does not produce much tumescence.

The inflatable device consists of two cylinders implanted into the corpus cavernosum, a pump with a deactivation mechanism implanted into the scrotum, and a reservoir for sterile saline solution implanted into the abdomen. Patients usually need approximately 6 weeks to recover from the surgery before engaging in sexual activity.

To achieve an erection with the inflatable device, the patient activates the pump by gently squeezing the pump in the scrotum, transferring saline from the reservoir into the penile cylinders. The deactivation mechanism transfers saline from the cylinders back into the reservoir after sexual activity has ended. Neither type of penile prosthesis affects libido, ejaculation, or orgasm, only providing an erection adequate for penetration and intercourse.26 The failure rate for inflatable penile prostheses is approximately 2.5%.27-29

The inflatable penile prosthesis provides a more natural-looking erection and better concealment than positionable prostheses.

Complications of this surgery are rare, but they include infection, urethral or corporal perforation, prolonged pain, damage or malfunction of the device, and the need for additional surgery. Although this surgery holds less appeal than it once did, some studies report that some patients are highly satisfied with the results.24,25

* Follow-up and Reassessment

The consensus panel strongly recommends a follow-up program to reevaluate the patient's medical and psychosocial status and to discuss possible contraindications to treatment, such as a prescription for nitrates after sildenafil has been prescribed. Questionnaires such as the SHIM can be routinely incorporated into the follow-up visit. Partners should be encouraged to attend the follow-up sessions and should also be included in the review of outcomes and any discussion of treatment alternatives. Some key points that should be emphasized:

Communication and education-Be prepared to answer patients' questions about the difficulties of treatment. Issues such as new relationships, relationship problems, or the absence of sexual attraction to a partner may arise and also should be addressed. Providers should remember to keep patients informed of any new research developments and options in the treatment of ED.

Medication adjustment-The follow-up consultation can be used to discuss the patient's medication dosage, the adverse effects of the medication, and its efficacy. Depending on the type and dosage of medication used and the presence or absence of adverse effects, clinicians could adjust the dosing schedule to achieve the desired outcome. Some patients may not respond at any dosage of a medication and may need to consider alternative treatment; other patients may find that pharmacologic treatment of ED is unsuitable and discontinue it.

Erectile dysfunction is a recognized marker for other symptomatologies and morbidities, and patients should be reevaluated for them at every visit. Lifestyle factors, such as obesity, should be assessed and patients should be encouraged to make necessary changes to their diets and to exercise regularly.

CE Test

Erectile Dysfunction in Primary Care

Instructions:

* Read the article beginning on page 42.

* Take the test, recording your answers in the test answers section (section B) of the CE enrollment form. Each question has only one correct answer.

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Erectile Dysfunction in Primary Care

General Purpose: To provide nurse practitioners with a review of the pathophysiology of erectile dysfunction and to present the management recommendations of the Consensus Panel on Health Care Clinician Management of Erectile Dysfunction. Learning Objectives: After reading the preceding article and taking the following test, you should be able to: 1. Discuss the etiology and pathophysiology of erectile dysfunction; 2. Outline a comprehensive assessment of a patient with erectile dysfunction; 3. Compare and contrast the various treatments of erectile dysfunction.

REFERENCES

1. Erectile dysfunction. National Kidney and Urologic Diseases Information Clearinghouse, National Institutes of Health. 2002. [Web site]. Erectile Dysfunction http://www.niddk.nih.gov/health/urolog/pubs/impotnce/impotnce.htm.

2. Marwick C: Survey says patients expect little physician help on sex. JAMA 1999;281(23):2173-4.

3. Baldwin K, et al: Underreporting of erectile dysfunction among men with unrelated urologie conditions (abstract). J Urol 2000; 163(Suppl 4): 1080.

4. Rosen R: Sexual dysfunction as an obstacle to compliance with antihypertensive therapy. Blood Pressure 1997; 6(Suppl 1):47-51.

5. Jardin A, et al: Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A, et al., editors. Erectile Dysfunction. Plymouth, UK: Health Publications Ltd; 2000. p. 711-26.

6. Rosen R, et al: The process of care model for the evaluation and treatment of erectile dysfunction. Newark, NJ: University of Medicine and Dentistry of New Jersey-Center for Continuing Education; 1998.

7. Feldman HA, et al: Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994;151(1):54-61.

8. Sadovsky R, Custis K: How a primary care physician approaches erectile dysfunction. In: Mulcahy J, editor. Male sexual function. Totowa, NJ: Humana Press, Inc.; 2001. p. 57-77.

9. Rosen RC, et al: Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res 1999;11(6):319-26.

10. Derby CA, et al: Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk? Urology 2000;56(2):302-6.

11. Albaugh J, et al: Health care clinicians in sexual health medicine: focus on erectile dysfunction. Urol Nurs 2002;22(4):217-31; quiz 32.

12. Meuleman EJ: Prevalence of erectile dysfunction: need for treatment? Int J Impot Res 2002;14(Suppl 1):S22-8.

13. Lue TF: Erectile dysfunction. N Engl J Med 2000;342(24):1802-13.

14. Levine LA, Lenting EL: Use of nocturnal penile tumescence and rigidity in the evaluation of male erectile dysfunction. Urol Clin North Am 1995;22 (4):775-88.

15. DeBusk R, et al: Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel. Am J Cardiol2000;86(2):175-81.

16. Fink HA, et al: Sildenafil for male erectile dysfunction: a systematic review and meta-analysis. Arch Intern Med 2002;162(12):1349-60.

17. Vrijhof HJ, Delaere KP: Vacuum constriction devices in erectile dysfunction: acceptance and effectiveness in patients with impotence of organic or mixed aetiology. Br J Urol 1994;74(1):102-5.

18. Turner LA, et al: External vacuum devices in the treatment of erectile dysfunction: a one-year study of sexual and psychosocial impact. J Sex Marital Ther 1991;17(2):81-93.

19. Levine LA, Dimitriou RJ: Vacuum constriction and external erection devices in erectile dysfunction. Urol Clin North Am 2001;28(2):335-41, ix-x.

20. Albaugh J, Lewis JH: Insights into the management of erectile dysfunction: Part I. Urol Nurs 1999; 19(4):241-5; quiz 6-7.

21. Impotence treatments: urethral suppositories (MUSE). Erectile Dysfunction Institute. 2003. [Web site]. http://erectile-dysfunction-impotence.org/Erectile-Dysfunction-Treatment/Urethral-Suppositories.html.

22. Linet OI, Ogrinc FG: Efficacy and safety of intracavernosal alprostadil in men with erectile dysfunction. The Alprostadil Study Group. N Engl J Med 1996; 334 (14):873-7.

23. Shabsigh R, et al: Intracavernous alprostadil alfadex is more efficacious, better tolerated, and preferred over intraurethral alprostadil plus optional actis: a comparative, randomized, crossover, multicenter study. Urology 2000; 55 (1):109-13.

24. Montague DK, Angermeier KW: Penile prosthesis implantation. Urol CHn North Am 2001; 28(2):355-61, x.

25. Govier FE, et al: Mechanical reliability, surgical complications, and patient and partner satisfaction of the modern three-piece inflatable penile prosthesis. Urology 1998; 52(2):282-6.

26. Goldstein I, et al: Safety and efficacy outcome of mentor alpha-1 inflatable penile prosthesis implantation for impotence treatment. J Urol 1997; 157 (3):833-9.

27. Wilson SK, et al: Comparison of mechanical reliability of original and enhanced Mentor Alpha I penile prosthesis. J Urol 1999; 162(3 Pt l):715-8.

28. Carson CC, et al: Efficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: results of a long-term multicenter study. AMS 700CX Study Group. J Urol 2000; 164 (2):376-80.

29. Impotence treatments: penile implants. Erectile Dysfunction Institute. 2003. [Web site]. http://erectilc-dysfunction-impotcnce.org/Erectile-DysfunctionTreatment/Penile-Implants.html.

DISCLOSURE

The authors have disclosed that they have no significant relationship or financial interest in any commercial companies that pertain to this education activity.

Jean H. Lewis, BSN, RN, CNP

Raymond Rosen, PhD

Irwin Goldstein, MD

ABOUT THE AUTHORS

Jean H. Lewis is a Urology Nurse Practitioner and Coordinator of the Erectile Dysfunction Clinic, Veterans Affairs Medical Center Minneapolis, MN. Dr. Raymond C. Rosen is Director of the Program in Human Sexuality, Department of Psychology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ. Dr. Irwin Goldstein is Director of the Sexual Medicine Institute, Boston University, Boston, MA.

Copyright Springhouse Corporation Dec 2004
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