Erectile dysfunction: new advice for vulnerable group

THE first evidence-based Australian clinical guidelines on the management of erectile dysfunction (ED) are a timely reminder of the standard of care for this vulnerable patient group amid the advertising saturation of online men’s health platforms this spring season. soccer finals.

Posted in MJAThe guidelines have been developed by a panel of experts appointed as representatives of the Urological Society of Australia and New Zealand and the Australian sexual health medicine chapter for the Royal Australasian College of Physicians.

Erectile dysfunction affects up to a third of Australian men and is defined as the persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to allow satisfactory sexual activity, occurring for at least 3 months.

The guidelines note that, in Australia, most cases of erectile dysfunction are identified and managed by GPs, with referrals to specialists for men who have an incomplete response or require further investigation and treatment.

“This shared care model…reflects the optimal utilization of health care resources and recognizes that general practitioners play an important role in primary care,” the guidelines state.

The main recommendations of the guidelines are:

  • a complete clinical history and a personalized physical examination are essential;
  • laboratory tests should include fasting glucose, lipid profile, and total testosterone level;
  • specialized diagnostic tests are recommended in selected cases and the patient should be counseled accordingly;
  • lifestyle changes and optimization of existing medical conditions should accompany all treatment regimens for ED;
  • oral phosphodiesterase type 5 (PDE5i) inhibitor is an effective first-line medical therapy;
  • a penile prosthesis implant may be considered in men who are medically refractory or unable to tolerate the side effects of medical therapy; Y
  • Pro-erectile regenerative therapy remains largely experimental.

Guidelines co-author Professor Eric Chung, professor of surgery at the University of Queensland, said an important message from the guidelines was the importance of cardiometabolic screening in patients with erectile dysfunction to stratify cardiovascular risk and identify hidden heart disease. .

“ED shares many of the same epidemiological and cardiovascular disease (CVD) risk factors studies have shown that people with CVD are more likely to have severe erectile dysfunction and drug-refractory treatment,” said Professor Chung. Vision+.

“Furthermore, the presence of erectile dysfunction itself serves as an important marker for future CVD, and studies have shown that the severity of erectile dysfunction correlates with increased CVD mortality and death overall.”

Lifestyle interventions were critical, and existing standard therapies for erectile dysfunction were often effective and safe after cardiovascular risk stratification, he said.

For those who failed medical therapy (oral and injectable medications), a penile prosthesis implant was a safe, effective and long-lasting treatment option, he said.

“Penile prosthetic implants have been around for almost 50 years and there are three major companies in Australia that market these types of devices,” he said. “Up to one in four men with erectile dysfunction will likely require a penile prosthesis implant as definitive treatment.”

Professor Chung warned that there was “a lot of hype and false advertising about treating erectile dysfunction”.

In 2015, published Australia’s first clinical report to study of low-intensity extracorporeal shock wave therapy in ED, a promising form of regenerative therapy that aims to promote endothelial revascularization. He has also published the only paper that examines shock waves beyond 5 years, as well as an Asia-Pacific guide in shock wave therapy.

Still, Professor Chung said: “There is so much information that we still don’t fully know about this type of therapy, including the types of machines, the correct shockwave setting and long-term safety.

“While regenerative therapy might work in the carefully selected group of men with erectile dysfunction, much data is lacking and it should only be offered in clinical trials, where there should be no exchange of monetary payment, and after careful informed consent.” . he said.

Professor Chung said patients should also be warned about using online men’s health platforms that offer erectile dysfunction treatments.

“They often take advantage of vulnerable men and charge a significant amount of money,” he said. Professor Chung said that, in his opinion, “some of these companies sometimes practice dangerous medicine and do not properly refer patients who need further evaluation, such as cardiovascular checks.”

However, the guidelines’ co-author, Dr. Christopher Love, a urologic and prosthetic surgeon in Victoria, said he believed some of the new online men’s health platforms were “not a bad place to start” for men with dysfunction. erectile.

Dr. Love is the medical adviser for one such platform and approves of the templates used in phone consultations by the site’s doctors, which he said include a basic cardiovascular risk assessment.

“At first, many men just need to talk to someone and understand performance anxiety, and maybe start some first-line oral therapy,” he said. “Many patients like the anonymity of not having to discuss sexual dysfunction with the GP they have known since they were 4 years old.”

He stressed the importance of proper cardiovascular risk assessment of patients with erectile dysfunction, saying, “Erectile dysfunction should be considered as an early warning sign of potential heart disease.”

Dr. Love said that, like the other guideline authors, he was concerned about “commercial clinics” offering shock wave therapy and other regenerative treatments, such as platelet-rich plasma injections, at significant cost to patients. patients but with little or no proven benefit.

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