Indian Write- Ups
| Management | |
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| Erectile Dysfunction In Diabetics | |
| Dr. Nilanjan Sengupta MD, Dr. Subhankar Chowdhury, DTM & H, MD, DM, MRCP Dept. of Endocrinology & Metabolism, IPGMER & SSKM Hospital, Kolkata. |
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| Diagnostic intracavernosal injection of vasoactive drugs: The basic premise of the test is that in cases of psychogenic, neurogenic or even mild vasculogenic ED, intracavernosally injected vasodilators are capable of increasing the penile blood flow and thereby eliciting an erectile response, whereas in advanced vasculogenic ED they fail to elicit a response. | |
| The test can be carried out as an office procedure, but in a quiet room with assured privacy. With the help of an insulin syringe, the vasodilator is administered intracavernosally 5 cm away from the glans, unilaterally or bilaterally. The commonly used agent is papaverine (about 30 mg) though phentolamine or prostaglandin E1 (PGE1) can also be used. Some use a combination of the three. | |
| Following injection, the patient should be left alone, instructed to stroke the penis gently and fantasize sexually; audio-visual aids may be used. | |
| Usually, erection is achieved in normal persons within 10-30 mins. The patient must not leave the clinic till he detumesces. If there is no dutumescence by 3 hours intracavernosal adrenaline or passive external drainage of blood may be necessary. | |
| Other tests: Cavernosonography, including pharmacodiagnostic testing and arteriography may be done only in those rare cases where vascular surgery is contemplated. | |
| Neurologic integrity can be evaluated with the help of pudendal nerve latency, sacral and genitocerebral evoke responses and bulbocavernosus reflex latency. | |
| Hormonal studies may have to be done if endocrinopathy is suspected. | |
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| Intracavernosal Pharmacotherapy | |
| Though not approved by the US food and Drug Administration, intracaversonal self injection of papaverine, PGE, or vasoactive intestinal peptide (VIP) prior to intercourse may be helpful in the absence of severe vasculopathy. The disadvantages are the pain of injection, priapism (incidence less that 0.3% of injections) and development of penile fibrotic nodules on repeated and prolonged use. It is recommended not to use more than one injection per day and 3 injections per week. PGE1 is claimed to have less side effects compared to papaverine. | |
| Mechanical Devices | |
| If a person is able to achieve a short-lived erection normally, it can be sustained by application of a constructing band to the base of the penis. | |
| In case of severe ED, a vacuum tumescence device (VTD) may help. A plastic cylinder is placed over the penis and with a mechanically or electrically driven pump a negative pressure is created so as to force blood into the penis. When a full erection is thus achieved, sustenance of the same is effected by slipping a constricting band. | |
| However, VTD may cause pain or discomfort, and ejaculation, haematoma and local circulatory disturbance; many view these devices unaesthetic or antiaphrodisiac. VTD will not be effective in presence of severe atherosclerotic vascular disease. Moreover, it is expensive. | |
| Oral agents: Most of these are investigational and of questionable efficacy and safety. They include L-argininie, a NO precursor, the alpha adrenoceptor antagonists like phentolamine and yohindi, and the antidepressant trazodone. Of particular interest is a specific PDE 5 inhibitor, sildenafil citrate, which has been marketed in USA and has achieved unprecedented popularity in no time. A dose of 50-100 mg of sildenafil (often being dubbed as the “wonder drug” or “sex pill”) taken 60 mins before intercourse can improve penile erection in patients with neurogenic or mild vasculogenic ED. However, safety of the drug has not yet been established beyond doubt and there is every possibility of wanton abuse of the drug. | |
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