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CLINICAL UPDATE
Managing erectile dysfunction and Peyronie’s disease By Dr Shane La Bianca, Urologist, Murdoch Erectile dysfunction (ED) is common as males age. Unusual below age 30 (estimated <10%). it may affect more than 75% of men over the age of 70. Peyronie’s disease (PD) prevalence varies (210%) greatly between populations studied, most likely reflecting variations between social views on self-reporting and clinical detection methodology. Only 10-20% of PD cases resolve spontaneously.
Treatments
ED and PD have similar aetiologies. Both are associated with cardiovascular co-morbidities: diabetes, obesity, hypertension, dyslipidaemia, smoking, low testosterone and pelvic/prostate surgery. Penile trauma is reported in around 10% of cases.
Additional oral agents such as curcumin and colchicine may be of use in early PD (painful inflammatory phase) but dosing is complex. Acetyl L-Carnitine and Pentoxifylline (another PDEi) may also improve curvature, decrease plaque formation and improve erectile function. All these oral therapies are supported by level two evidence at best.
The underlying pathophysiologic mechanism for PD plaque is poorly understood. Plaque formation may relate to trauma or repetitive microvascular injury to the (semi-) erect penis. The pathophysiology of PD is likely multifactorial – genetic predisposition, trauma, tissue inflammation and aberrant wound healing all contributing.
Phosphodiesterase-5 inhibitors (PDE5i) are a safe option for all men with ED or PD, except those with symptomatic angina. A trial of daily 5-7.5mg Tadalafil should be considered in both conditions as initial therapy to improve baseline erectile function. L-Arginine is a useful adjunct to PDE5i, acting via nitric oxide dependant pathways.
Patient evaluation requires a comprehensive clinical history focused on disease status (acute or chronic), ED nature (e.g. lack of response to stimulation, loss during penetration, penile curvature, change over time, prior treatments) and other medical co-morbidities that might affect treatment options and outcomes. Physical examination includes the genitals, circumcision status, PD plaque size and location, assessment of the degree of penile deformity based on digital photography (dorsal and lateral views) and assessment of peripheral pulses.
Penile traction therapy may have some benefits in PD (level three evidence) in terms of correcting penile pain, curvature and improving corporal elasticity and erectile response. It should be used in combination with oral therapies and for at least six months. Low intensity Shock Wave Therapy (LiSWT) is not supported by recently published trials. Intralesional therapy with collagenase is effective (level two evidence), but not available here. Despite no large-volume or highlevel evidence-based data to suggest the best treatment option in PD, surgery offers the most rapid and reliable outcome addressing advanced aspects of PD, such as extensive plaque, severe ED and complex penile deformities. Author competing interests- nil
OBESITY MANAGEMENT (and COVID-19) Obesity in this era of Covid-19 carries an even greater risk with an increase in hospital and ICU admissions. Weight management is more important than ever and, as always, we are here to help with a number of surgical and medical options tailored to the individual. We are able to see patients either in person at our rooms at Subiaco, Murdoch, Booragoon or Mandurah, or via Telehealth.
FOR ENQUIRIES/BOOKINGS: Ph (08) 9332 0066 Fax (08) 9463 6202 Mob 0401 809 255 (Dr Chandraratna) Mob 0413 149 758 (Dr Gong) Mob 0404 758 539 (Dr Kiyingi)
Modifying risk factors is critical to addressing ED. Both conditions can compromise sexual function and quality of life. Distress over symptoms, penile appearance, and erectile function must be considered.
MEDICAL FORUM | MEN 'S HEALTH ISSUE
JULY 2020 | 33
