Nicola Mondaini

Disfunzione erettile (DE) e’ un

SINTOMO DSM-IV: “persistente o ricorrente incapacità di ottenere o

mantenere una erezione peniena adeguata per il completamento della attività sessuale”

DSM-IV, American Psychiatric Association, 1994

NIH Consensus Development Panel on Impotence: “incapacità

di ottenere e/o mantenere un’erezione sufficiente a consentire

un rapporto sessuale soddisfacente”

NIH Consensus Development Panel on Impotence,

JAMA, 270:83, 1993

EAU Guidelines

ED treatment – EAU Guidelines

DISTURBI AREA PELVICA

Assessment of the Impact of Sildenafil Citrate on Lower Urinary Tract Symptoms

in Men with Erectile DysfunctionJohn P. Mulhall MD,*, Patricia Guhring RN, BSN, Marilyn Parker MD, Carin Hopps MD

48 men with comorbid ED and LUTS:

•mean improvement in the EF domain score was 7 points (P = 0.01).

•mean improvement in the IPSS score was 4.6 points (P = 0.013)

•mean improvement in quality of life (QOL) score was 1.4 points (P = 0.025)

2002

2006

2007

112 men with ED:

• Treatment with sildenafil appears to improve urinary symptoms.

• There was a significant inverse relationship between the baseline

IPSS and sexual function scores after treatment.

280 men with LUTS/BPH with or without ED:

• Tadalafil 5 mg

• Improvement in IPSS score (both irritative and obstructive)

• No change in uroflowmetry

Eur Urol 2011PDE5-Is

11 STUDIES, Urology, January 2011

4 STUDIES, BJU Int, April 2011

5 STUDIES, Eur Urol, June 2011

508

Citation identified in electronic search

106

Studies retrieved for detailed evaluation

12

Studies included in sistematic review

7 PDE5-Is alone (A)

1 Sildenafil

4 Tadalafil

1Vardenafil

1 UK-369,003

5 PDE5-Is + α-blockers (B)

2 Sildenafil

2 Tadalafil

1 Vardenafil

Phosphodiesterase type 5, PDE5

Phosphodiesterase type 5 inhibitors, PDE5-I

sildenafil, tadalafil, vardenafil, udenafil

lower urinary tract symptoms, LUTS

benign prostatic hyperplasia, BPH

PubMed,

Embase,

Cochrane Library

Efficacy

Subjective: IPSS, BII,

Objective: Qmax, Qave, PVR

Safety

Drugs interaction (Alpha-blockers)

AEs

IPSS

Mean difference in IPSS: -2,8 (Gacci) to -2,6 (Liu)

Reduction of both irritative (storage) and obstructive (voiding) LUTS

Timing: 4 weeks (3/4) – 12 weeks (1/4): (lasting 12 months)

Dose dependent

Regression of Age on Difference in means

Age

Diffe

renc

e in

mea

ns

55,01 56,08 57,15 58,21 59,28 60,35 61,42 62,49 63,55 64,62 65,69

-1,00

-1,50

-2,00

-2,50

-3,00

-3,50

-4,00

-4,50

-5,00

-5,50

-6,00

Regression of BMI on Difference in means

BMI

Diffe

renc

e in

mea

ns

26,72 26,92 27,13 27,33 27,53 27,73 27,93 28,13 28,33 28,54 28,74

-1,00

-1,50

-2,00

-2,50

-3,00

-3,50

-4,00

-4,50

-5,00

-5,50

-6,00

Regression of IPSS on Difference in means

IPSS

Diffe

renc

e in

mea

ns

16,50 16,86 17,22 17,58 17,94 18,30 18,66 19,02 19,38 19,74 20,10

-1,00

-1,50

-2,00

-2,50

-3,00

-3,50

-4,00

-4,50

-5,00

-5,50

-6,00

Best candidate for PDE5-Is

Young men

Low BMI

Severe LUTS

Mc Vary 2007

Stief 2008

Porst 2009

PDE5-Is alone: +5,5 IIEF

PDE5-Is + α-blocker: +3,6 IIEF

IIEF

BPH

Without ED

BPH

With ED

-2,60

-2,57

Mean change in

IPSS score

Liu, Urology 2011

Qmax

No decrease in Qmax

Improvement related to Qmax at baseline

Mean change < 1mL/sec

Similar results accross different drugs

Adverse Events

Gacci et al. Eur Urol 2012

Gacci et al. Eur Urol 2012

Take home message

• PDE5-Is for LUTS/BPH:

– Safe: ↓ AEs

– Effective: ↑ IPSS (Irr./Obstr.) and IIEF; Qmax?

• PDE5-Is: Which drug and dosage?

– Tadalafil: Strong litterature / Dose finding / Low AEs

– Tadalafil 5 mg a day

– Lasting for 12 months or more?

– Continous or intermittent?

DE PSICOGENA,EP e ANSIA da

PRESTAZIONE

L’erezione è il risultato finale del rilasciamento della muscolatura liscia delle trabecole

(sinusoidi) e delle arterie elicine a livello dei corpi cavernosi

SIMPATICO

contrazione - flaccidità

PARASIMPATICO

rilasciamento - erezione

Definizione

“Si definisce precoce l’eiaculazione che,

con frequenza ricorrente o persistente,

viene raggiunta con minima stimolazione

prima o poco dopo la penetrazione, e prima

che la persona lo desideri, in assenza di

capacità di controllo volontario, e che

determina disagio nella persona affetta e

nella sua partner”

2nd International Consultation on Sexual and Erectile Dysfunctions

Orgasm

Premature

ejaculation

A, NA

Ansia da prestazione

INDURATIO PENIS PLASTICA o

MALATTIA DI LA PEYRONIE

TRIADE:

INCURVAMENTO

DOLORE

DISFUNZIONE ERETTILE

Peyronie’s disease guidelines – AUA

2015

24www.auanet.org/education/guidelines/peyronies-disease 2015

TRAUMA GENITALI:

PRIAPISMO

Priapismo e deformazioni anatomiche del pene

Pazienti che hanno erezioni che durano

4 ore o più devono essere informati di cercare immediata assistenza medica.

Se il priapismo non viene trattato immediatamente, può causare un danno al

tessuto del pene e una perdita permanente di potenza.

CIALIS deve essere impiegato con cautela nei pazienti con deformazioni

anatomiche del pene (es. angolazione, fibrosi cavernosa o malattia di

Peyronie) o nei pazienti che presentano patologie che possono predisporre al

priapismo (come l’anemia falciforme, il mieloma multiplo o la leucemia).

La terapia daily della DE

Obesity

Metabolic syndrome

Dyslipidemia

Hypertension

Ejaculatory disorders

Sexual orientation

ED duration

Genitorial plans

Life Style

Smoking

Use of recreational drugs

Cost

ED Aetiology

Prostatic diseases

Spinal Cord Injury

Diabetes

Endocrine disorders

Depression

Intrapsychic component

Age

Food and alcohol

intake

Partner

needs/requirements

/habits

Patient’s relational

experience and

expectations

Side effects

Previous treatment

used for ED

Frequency

Concomitant

therapies

Cardiac diseases

ED Patients

PDE5i

ITEMS NOT SIGNIFICANT

ITEMS SIGNIFICANT PDE5I CHOICE

Corona G, Mondaini N, Ungar A, Razzoli E, Rossi A, Fusco F.

Phosphodiesterase type 5 (PDE5) inhibitors

in erectile dysfunction: the proper drug

for the proper patient. J Sex Med. 2011

Dec;8(12):3418-32