Lo Giudice A, et al. World J Mens Health. 2024 Jan;42:e9. https://doi.org/10.5534/wjmh.230106

Introduction: The importance of erectile dysfunction (ED) diagnosis and treatment has been highlighted since the early 2000s. However, nearly 20 years after the first phosphodiesterase 5 inhibitor (PDE5i) was marketed, underdiagnosis and undertreatment of ED in the primary health care setting may still be present. Aim: To assess the relative frequency of patients who are medically treated for ED before referral to specialized urology care. The secondary objectives were to evaluate possible reasons for non-treatment prior to referral and other signs of undertreatment, namely cardiovascular risk assessment and antihypertensive treatment. Methods: 200 male patients referred for ED to specialist urology care by general practitioners were screened after consent between January 2016–December 2018. A full standardized medical and sexual history were taken. Previous medical treatment of ED, namely pharmacologic name and dosages, and cardiovascular risk factors were noted. Main Outcome Measures: Of the 115 included patients, only 33.9% of patients had already taken PDE5i before referral, and none had taken alprostadil by intracavernous route. Results: The mean patient age was 58.68 ± 10.01 years old. Only 45.2% had been prescribed the highest dose of PD5i. From the remaining untreated patients, only 19.7% had ≥3 cardiovascular risk factors, including 5.6% of patients who also presented moderate-to-severe stable or unstable angina requiring a stress test or cardiology assessment before treatment. Regarding the 54 patients with medical history of arterial hypertension, 43.4% and 30.2% were treated for hypertension with a diuretic and a beta blocker, respectively. Conclusion: More focus on the primary healthcare continuous medical education regarding sexual dysfunction, namely ED, is needed because major undertreatment of ED is still present because low prescription of PD5i before referral is noted.

Introduction: Specialized diagnostic evaluation of erectile dysfunction (ED) may require an intracavernous injection test (IIT) or penile duplex ultrasound (PDU). Aim: Our primary objective was to compare the prognostic value of IIT and PDU for treatment efficacy and patient satisfaction with first-line sildenafil citrate. Methods: After 200 patients were screened, a total of 77 patients with ED had a standardized PDU by a blinded third party, and peak systolic velocity (PSV), end diastolic flow (EDF), and resistive index (RI) in timely intervals were recorded. The erection hardness score (EHS) was used to score erection rigidity during the test and was also noted. Patients also completed a briefed International Index of Erectile Function (IIEF-5) questionnaire and were started on open-label 100 mg sildenafil citrate at baseline. The IIEF-5 and erectile dysfunction inventory of treatment satisfaction (EDITS) questionnaires were repeated and completed at 6 months’ follow-up. Improvement, cure, and satisfaction were defined as an increase of 4 points in IIEF-5 with an IIEF-5 score higher than 21 points and EDITS score higher than 50, respectively. Receiver operating characteristic curves were drawn and the area under the curve (AUC) was calculated and compared. Main Outcome Measure: EHS did not have a different or larger AUC than PSV, EDF, and RI for improvement, cure, and satisfaction with sildenafil citrate. Results: The patient’s mean age was 58.76 ± 10.27 years and almost half of the patients had moderate ED according to the IIEF-5 (42.8%). Improvement, cure, and satisfaction were high among participants (77.9%, 64.9%, and 67.5%, respectively). The erection rigidity EHS also showed an excellent-to-good ability to predict improvement, cure, and patient satisfaction (AUC = 0.921, 0.873, and 0.898, respectively) with sildenafil citrate. Clinical Implications: There is no point in performing more than an IIT when a specialized diagnostic evaluation is required for diagnostic or medico-legal reasons because PDU is time-consuming and requires both hardware and ultrasound skills with no added prognostic value. Strengths and Limitations: This is the first prospective study to directly compare IIT with PDU, and validated disease-specific questionnaires were used to assess both clinical efficacy and satisfaction. Moreover, the PDU was performed by a blinded third party. However, this was a single-center study and the population included was small. Conclusion: PDU parameters add no prognostic value to determining erection rigidity during a standard IIT. Erection rigidity during IIT, as assessed with the EHS, suffices as a prognostic tool.