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1. Urological Disorders
Erectile Dysfunction

2. Erectile Dysfunction
• ED: inability of a man to achieve or maintain an erection
sufficient to permit coitus of adequate duration to satisfy
himself and his partner.
• ED becomes increasingly frequent as men age.
• According to the Massachusetts Male Aging Study the
prevalence of ED of any degree is 40% among 40-year-old
men and 70% among 70-year-old men.
• The increase in incidence could be due to physiologic
changes that occur with aging, the onset of chronic
disease states associated with ED, increased medication
use, lifestyle factors, or a combination of the above.

3. Pathophysiology of ED
Normal male sexual function requires
• The ability to achieve & maintain penile erection
• An intact libido
• Ejaculation
• Detumescence

4. • Sympathetic & parasympathetic nerves innervate the penis.
• In the flaccid state, α2-adrenergic receptors mediate tonic
contraction of the arterial & corporal smooth muscles.
• This maintains high penile arterial resistance & a balance
exists b/n blood flow into & out of the corpora.
• With sexual stimulation, nerve impulses from the brain
travel down the spinal cord to the thoracolumbar ganglia.
• A decrease in sympathetic tone & an increase in
parasympathetic activity then occurs, causing a net increase
in blood flow into the erectile tissue.
• Erections may also occur as a result of a sacral nerve reflex
arc while pts are sleeping (nocturnal erections).

5. • Penile tumescence leading to erection depends on the
increased flow of blood into the lacunar network
accompanied by the complete relaxation of the arteries
and corporal smooth muscle.
• The microarchitecture of the corpora is composed of a
mass of smooth muscle (trabecula) which contains a
network of endothelial-lined vessels (lacunar spaces).
• Subsequent compression of the trabecular smooth muscle
against the fibroelastic tunica albuginea causes a passive
closure of the emissary veins and accumulation of blood in
the corpora.

6. • In the presence of a full erection and a competent valve
mechanism, the corpora become noncompressible
cylinders from which blood does not escape.
• The CNS exerts an important influence by either
stimulating or antagonizing spinal pathways that mediate
erectile function and ejaculation.
• The erectile response is mediated by a combination of
central (psychogenic) and peripheral (reflexogenic)
innervation.
• Sensory nerves that originate from receptors in the penile
skin and glans converge to form the dorsal nerve of the
penis, which travels to the S2-S4 dorsal root ganglia via
the pudendal nerve.

7. • Parasympathetic nerve fibers to the penis arise from
neurons in the S2-S4 sacral spinal segments.
• Sympathetic innervation originates from the T-11 to the
L-2 spinal segments and descends through the hypogastric
plexus.
• Neural input to smooth muscle tone is crucial to the
initiation & maintenance of an erection.
• There is also an interaction b/n the corporal smooth
muscle cell & its overlying endothelial cell lining .

8. • Nitric oxide is synthesized from L-arginine by nitric oxide
synthase to act postjunctionally on smooth-muscle cells.
• By enhancing the activity of guanylate cyclase, nitric oxide
increases the production of cGMP.
• In addition to nitric oxide, vasoactive peptides & prostaglandins
(PGE1, PGF2) are synthesized within the cavernosal tissue and
increase cAMP levels.
• Both cAMP & cGMP ultimately lead to a decrease in calcium
conc within smooth muscle cells of the penile arteries & the
sinusoidal spaces, leading to smooth muscle relaxation &
increased blood flow.
• As the sinusoidal spaces become engorged, intracavernosal
pressure increases, subtunical venules are compressed, and the
penis becomes rigid and elongated.
• cGMP is gradually broken down by phosphodiesterase type 5.

9. • Ejaculation is stimulated by the SNS, which results in
contraction of the epididymis, vas deferens, seminal
vesicles & prostate, causing seminal fluid to enter the
urethra.
• Seminal fluid emission is followed by rhythmic
contractions of the bulbocavernosus & ischiocavernosus
muscles, leading to ejaculation.
• Premature ejaculation is usually related to anxiety or a
learned behavior & is amenable to behavioral therapy or
treatment with medications such as SSRIs.
• Retrograde ejaculation results when the internal urethral
sphincter does not close; it may occur in men with DM or
after surgery involving the bladder neck.

10. • Detumescence is mediated by NE from the sympathetic nerves,
endothelin from the vascular surface, and smooth muscle
contraction.
• Sympathetic activity induces smooth muscle contraction of
arterioles & vascular spaces leading to a reduction in blood
inflow, decompression of the sinusoidal spaces, and enhanced
outflow.
• These events increase venous outflow & restore the flaccid
state.
• Venous leak can cause premature detumescence & is caused by
insufficient relaxation of the corporal smooth muscle rather than
a specific anatomic defect.
• Priapism refers to a persistent & painful erection & may be
associated with sickle cell anemia, hypercoagulable states, spinal
cord injury, or injection of vasodilator agents into the penis

11. • Testosterone also plays a significant role in erectile
function.
• Testosterone is responsible for much of a man’s libido.
• Testosterone helps stabilization of intracavernosal levels of
nitric oxide synthase, the enzyme responsible for
triggering the nitric oxide cascade.
• With low serum concentrations, libido declines.

12. • Libido refers to sexual desire & is influenced by a variety of
 visual
 olfactory
 tactile
 auditory
 imaginative
 hormonal stimuli
• Libido can be diminished by hormonal or psychiatric
disorders or by medications.

13. Factors Associated with ED
o Chronic Medical Conditions
– Hypertension
– DM
– Inflammatory conditions of the prostate
– Coronary & peripheral vascular disease
– Neurologic disorders (e.g., Parkinson’s disease & MS)
– Endocrine disorders (hypogonadism & pituitary, adrenal &
thyroid disorders)
– Psychiatric disorders (depression, anxiety & schizophrenia)
– Hyperlipidemia
– Renal failure
– Liver disease
– Penile disease

14. o Surgical Procedures
– Perineal surgery
– Radical prostatectomy
– Vascular surgery
o Lifestyle
– Age
– Smoking
– Excessive alcohol consumption
– Obesity
– Decreased HDL levels
– Poor overall health & reduced physical activity
o Trauma
– Pelvic fractures
– Spinal cord injuries

15. Etiology of ED
• Normal penile erections require the full function of the
vascular, neurologic, and hormonal systems.
• Anything that affects the function of these systems may
lead to ED.
• ED can be classified as organic, psychogenic, or a mixture of
these.
• Organic dysfunction includes abnormalities in the three
systems responsible for a normal erection or may be
medication induced.
• Many of the risk factors for ED are the same as risk factors
for CVDs.

16. • ED becomes increasingly frequent as men age.
• Few men report erection problems before the age of
40, but the percentage of men experiencing ED
increases to 26% in men aged 50 to 59 years and
40% in men aged 60 to 69 years.
• The increase in incidence could be due to
– physiologic changes that occur with aging
– the onset of chronic disease states associated with ED
– increased medication use
– lifestyle factors

17. Vasculogenic
• The most frequent organic cause of ED is a disturbance of
blood flow to and from the penis.
• Atherosclerotic or traumatic arterial disease can decrease
flow to the lacunar spaces, resulting in decreased rigidity
and an increased time to full erection.
• Excessive outflow through the veins, despite adequate
inflow, may also contribute to ED.
• Structural alterations to the fibroelastic components of the
corpora may cause a loss of compliance and an inability to
compress the tunical veins.

18. Neurogenic
• Disorders that affect the sacral spinal cord or the
autonomic fibers to the penis preclude nervous system
relaxation of penile smooth muscle, thus leading to ED.
• Pts with incomplete lesions or injuries to the upper part of
the spinal cord are more likely to retain erectile capabilities
than those with complete lesions or injuries to the lower
part.
• Although 75% of pts with spinal cord injuries have some
erectile capability, only 25% have erections sufficient for
penetration.
• Other neurologic disorders commonly associated with ED
include MS and peripheral neuropathy. The latter is often
due to either diabetes or alcoholism.
• Pelvic surgery may cause ED through disruption of the
autonomic nerve supply.

19. Endocrinologic
• Androgens increase libido, but their exact role in erectile
function remains unclear.
• Individuals with castrate levels of testosterone can achieve
erections from visual or sexual stimuli.
• Nonetheless, normal levels of testosterone appear to be
important for erectile function, particularly in older males.
• Androgen replacement therapy can improve depressed
erectile function when it is secondary to hypogonadism;
however, it is not useful for ED when endogenous
testosterone levels are normal.
• Increased prolactin may decrease libido by suppressing
GnRH, and it also leads to decreased testosterone levels.

20. Diabetic Mellitus
• ED occurs in 35–75% of men with DM.
• Pathologic mechanisms are primarily related to diabetes-
associated vascular & neurologic complications.
• Diabetic macrovascular complications are mainly related
to age, whereas microvascular complications correlate
with the duration of diabetes & the degree of glycemic
control.
• Individuals with DM also have reduced amounts of nitric
oxide synthase in both endothelial & neural tissues.

21. Psychogenic
• Two mechanisms contribute to the inhibition of erections
in psychogenic ED.
– 1. psychogenic stimuli to the sacral cord may inhibit
reflexogenic responses, thereby blocking activation of
vasodilator outflow to the penis.
– 2. excess sympathetic stimulation in an anxious man
may increase penile smooth-muscle tone.
• It occurs in up to 30% of all cases of ED.

22. • The most common causes of psychogenic ED are
– performance anxiety
– depression
– relationship conflict
– loss of attraction
– sexual inhibition
– conflicts over sexual preference
– sexual abuse in childhood
– fear of pregnancy or STDs
• Almost all pts with ED, even when it has a clear-cut
organic basis, develop a psychogenic component as a
reaction to ED.

23. Medication-Related
 Diuretics
Thiazides
Spironolactone
 Antihypertensives
CCBs
Methyldopa
Clonidine
Reserpine
beta-blockers
Guanethidine
 Cardiac / antihyperlipidemics
Digoxin
Gemfibrozil
Clofibrate
 Hormones
Progesterone
Estrogens
Corticosteroids
GnRH agonists
5-Reductase inhibitors
 Cytotoxic agents
Cyclophosphamide
Methotrexate
 Antidepressants
SSRIs
TCADs
Lithium
MAOIs
 Tranquilizers
Butyrophenones
Phenothiazines
 H2 antagonists
Ranitidine
Cimetidine
 Anticholinergics
Disopyramide
Anticonvulsants
 Recreational
Ethanol
Cocaine
Marijuana

24. Approach to the Pt
• A good physician-pt relationship helps to unravel the
possible causes of ED, many of which require discussion of
personal & sometimes embarrassing topics.
• A complete medical & sexual Hx should be taken in an
effort to assess whether the cause of ED is organic,
psychogenic, or multifactorial.
• Initial questions should focus on the onset of symptoms,
the presence and duration of partial erections, and the
progression of ED.
• A Hx of nocturnal or early morning erections is useful for
distinguishing physiologic from psychogenic ED.

25. • Nocturnal erections occur during rapid eye movement sleep and
require intact neurologic and circulatory systems.
• Organic causes of ED are generally characterized by a gradual
and persistent change in rigidity or the inability to sustain
nocturnal, coital, or self-stimulated erections.
• The pt should be questioned about the presence of penile
curvature or pain with coitus.
• It is important to address libido, as decreased sexual drive
and ED are sometimes the earliest signs of endocrine
abnormalities (e.g., increased prolactin, decreased
testosterone levels).
• It is useful to ask whether the problem is confined to coitus
with one or other partners; ED arises not uncommonly in
association with new or extramarital sexual relationships.

26. • Situational ED, as opposed to consistent ED, suggests
psychogenic causes.
• Ejaculation is much less commonly affected than erection,
but questions should be asked about whether ejaculation
is normal, premature, delayed, or absent.
• Relevant risk factors should be identified such as DM, CAD,
or neurologic disorders.
• The pt's surgical Hx should be explored with an emphasis
on bowel, bladder, prostate, or vascular procedures.
• A complete drug Hx is also important.
• Social changes that may precipitate ED are also crucial to
the evaluation (health worries, spousal death, divorce,
relationship difficulties, and financial concerns).

27. • The PE is an essential element in the assessment of ED.
• Signs of hypertension, thyroid, hepatic, hematologic,
cardiovascular, or renal diseases should be sought.
• An assessment should be made of the endocrine and
vascular systems, the external genitalia, and the prostate
gland.
• The penis should be carefully palpated along the corpora
to detect fibrotic plaques.
• Reduced testicular size & loss of secondary sexual
characteristics are suggestive of hypogonadism.
• Neurologic examination should include assessment of anal
sphincter tone, the bulbocavernosus reflex, and testing for
peripheral neuropathy.

28. • Although hyperprolactinemia is uncommon, a serum
prolactin level should be measured, as decreased libido
and/or erectile dysfunction may be the presenting
symptoms of a prolactinoma .
• The serum testosterone level should be measured and, if
low, gonadotropins should be measured to determine
whether hypogonadism is primary (testicular) or secondary
(hypothalamic-pituitary) in origin.
• Serum chemistries, CBC & lipid profiles may be of value, as
they can yield evidence of anemia, DM, hyperlipidemia, or
other systemic diseases associated with ED.
• Determination of serum PSA should be conducted.

29. Presentation
• Embarrassment
• Anxiousness
• Anger
• Marital problems
• Low self confidence
• Full inability to achieve erections
• Ability to achieve partial erections, but not suitable for
intercourse
• Erections sufficient for intercourse, but early detumescence
• The problem may have a slow or acute onset, or may wax and
wane
• ED may be the presenting symptom of other chronic disease
states.

30. Treatment
Desired Outcomes
• ED is not a life-threatening condition, but left untreated it
can be associated with:
 depression
 loss of self-esteem
 poor self-image
 marital discord
• The primary goal of therapy is
– achievement of erections suitable for intercourse and
improvement in pt quality of life.
• The ideal therapy should have minimal side effects, be
convenient to administer, have a quick onset of action, and
have few or no drug interactions.

31. • A wide range of treatment options are available for ED.
 medical devices
 pharmacologic treatments
 lifestyle modification
 Surgery
 psychotherapy
• Most often treatment is initiated with the least invasive
option and then progresses to more invasive options.
• The choice of therapy should be individualized, taking into
account pt & partner preferences, concomitant disease
states, response, administration, cost, tolerability & safety

32. Nonpharmacologic Therapy
Lifestyle Modifications
• A healthy diet (low cholesterol diet)
• Regular physical activity
• Weight reduction
• Smoking cessation
• Reduction in excessive alcohol intake
• Discontinuation of the use of illicit drugs
• Optimal control of DM, hypertension & dyslipidemia
• Discontinue or reduce doses of drugs known to cause ED

33. Psychotherapy
• An appropriate treatment approach for pts with
psychogenic or mixed dysfunction.
• It should address immediate causes of dysfunction, and
if possible the partner should attend sessions.
• Effectiveness is not well documented for organic
dysfunction unless combined with other therapies.
• Advantages : noninvasiveness & partner participation
• Disadvantages: increased cost & time commitment.

34. Vacuum Erection Devices(VEDs)
• Induce erections by creating a vacuum around the penis;
the negative pressure draws blood into the penis by
passively dilating arteries and engorging the corpora
cavernosa.
• The erection is maintained with a constriction band placed
at the base of the penis to reduce venous out flow.
• The constriction band not be in place longer than 30
minutes at a time.
• Effective for all etiologies of ED
• The most effective treatment modalities for ED.
• They have a success rate of greater than 90%
• Considered a first-line non- invasive therapy

35. Disadvantage
• Onset of action is slow at around 30 minutes, which limits
spontaneity.
• Pts and partners may complain of a cold, lifeless,
discolored penis.
• Painful ejaculation or inability to ejaculate
• VEDs are contraindicated in persons with sickle cell disease
• VEDs should be used with caution in pts on oral
anticoagulants or who have bleeding disorders due to the
increased possibility of priapism.

36. Penile Prostheses
• Penile prostheses are semi-rigid malleable or inflatable
rods, which are inserted surgically into the corpus
cavernosa to allow erections .
• The malleable rods are rigid at all times, but may be bent
into position by the pt when desired.
• The inflatable prostheses remain flaccid until the pump
within the scrotum moves fluid from a reservoir to the
cylinders within the penis.
• Detumescence is achieved when the fluid is then
transferred back to the reservoir by activating a release
button.

37. • The most invasive treatment available, so they are only
considered in pts who do not respond to medications or
external devices, or those who have significant adverse
effects from other therapies.
• Pt satisfaction rates can be as high as 80% to 90% with
partner satisfaction rates just slightly lower.
• The primary risks of insertion of prostheses are infection
and device failure (happen in 2% to 3% and 2% to 14% of
pts, respectively).
• Higher infection rates in uncontrolled DM pts, paraplegics
& pts undergoing reimplantation or penile reconstruction.
• Most prostheses can be expected to last from 7 to 10 yrs.

38. Pharmacologic Therapy
1. Phosphodiesterase Type 5 Inhibitors
 Sildenafil (Viagra®)
 Tadalafil (Cialis®)
 Vardenafil (Levitra®)
• Act by selectively inhibiting phosphodiesterase (PDE) type 5, an
enzyme that breaks down cGMP.
• By inhibiting the breakdown of cGMP, smooth muscle relaxation
is induced, leading to an erection.
• However, the PDE inhibitors are only effective in the presence of
sexual stimulation to drive the nitric oxide/cGMP system, making
them facilitators of an erection, not initiators.
• Pts must be informed of the need for sexual stimulation to
induce an erection, as it will not occur spontaneously.

39. • Effectiveness of the three available PDE inhibitors is
comparable, but differences exist in duration of action, and
to a small degree, incidence of S/Es & DIs
• A 50% to 80% response rate depending on the dose of
agent used & the etiology of dysfunction.
• Pts with radical prostatectomy have lower response rates.
• Response rates are also lower in pts with DM, severe nerve
damage, or severe vascular disease.
• Considered first line therapies due to high efficacy rates,
convenience of dosing & minimal severe adverse effects.

40. • The most dramatic difference b/n the three agents is tadalafil’s
extended duration of action, earning it the nick- name “the
weekender drug.”
• Sildenafil and vardenafil have average half-lives of 3 to 4 hrs,
tadalafil’s half life is approximately 18 hrs.
• The extended half-life allows for more spontaneous sexual
activity over a couple of days, but may increase the duration of
adverse effects and likelihood of drug interactions.
• The most common side effects: headache, facial flushing, nasal
congestion, dyspepsia & rarely priapism.
• Vardenafil & sildenafil may also cause difficulty in discriminating
blue from green, bluish tones in vision, or difficulty seeing in dim
light due to cross-reactivity with PDE 6 in the retina.

41. • Non arteritic ischemic optic neuropathy in a small number of pts
(a condition in which blood flow is blocked to the optic nerve).
• If pts experience sudden or decreased vision loss they should call
a health care provider immediately.
• PDE inhibitors can lead to significant hypotension.
• Pts taking nitrates are the most at risk, as they potentiate the
drop in BP.
• All three PDE inhibitors are absolutely contraindicated in pts
taking any form of nitrate.
• Caution should be used when using a PDE inhibitor in pts taking
α-blockers due to an increased risk of hypotension.
• Vardenafil may possibility cause of QT prolongation.
• Six to eight attempts with a medication and specific dose may be
needed before successful intercourse results.

42. 2. Alprostadil
• A prostaglandin E1 analog that induces an erection by
stimulating adenyl cyclase, which leads to an increase in
smooth muscle relaxation, rapid arterial inflow, and
increased penile rigidity.
• Alprostadil is available as an intra cavernosal injection
(Caverject® or Edex®) or a transurethral suppository
(MUSE®, medicated urethral system for erection), but the
injectable form is more effective.
• Both forms are considered more invasive than oral
medications or VEDs, and are second-line therapies.

43. • MUSE consists of a urethral pellet of alprostadil with an
applicator.
• Onset of action is within 5 to 10 min & it is effective for 30 to 60
min.
• Aching in the penis, testicles, legs, and perineum, warmth or
burning sensation in the urethra, minor urethral bleeding or
spotting, priapism, and lightheadedness are possible AEs.
• Partners may experience vaginal burning or itching.
• Disadvantages : lower effectiveness, high cost, adverse effects,
complicated insertion technique, and a contraindication against
use with a pregnant partner unless using a condom.

44. • Injections should be done into one side of the penis
directly into the corpus cavernosum, and then the penis
should be massaged to distribute the drug.
• Because of cross-circulation, both corpora will become
erect when massaging.
• Intracavernosal injections are effective in up to 90% of pts,
but side effects, lack of spontaneity, and fear of needles
limit their widespread use as first line therapy.
• Adverse effects: pain with injection, bleeding or bruising at
the injection site, fibrosis, or priapism.
• Use with caution in pts with sickle cell disease, those on
anticoagulants, or those who have bleeding disorders, due
to an increased risk of priapism and bleeding.

45. 3. Papaverine and Phentolamine
• Papaverine is a non-selective PDE inhibitor that induces an
erection by relaxing smooth muscle and increasing blood
flow.
• Phentolamine is a competitive α-adrenergic receptor
antagonist that increases arterial inflow by opposing
arterial constriction.
• Both drugs are rarely used alone, and are most often
mixed in various conc with alprostadil for increased
effectiveness & to reduce adverse effects with smaller
doses of each medication.

46. 4. Testosterone Supplementation
• Testosterone is only effective in pts with low serum
testosterone levels.
• In pts with hypogonadism, testosterone replacement is the
initial treatment of choice, as it corrects decreased libido,
fatigue, muscle loss, sleep disturbances, and depressed
mood.
• Improvements in ED may occur, but they should not be
expected to occur in all pts.
• The initial trial should be for 3 months. At that time, re-
evaluation and the addition of another ED therapy is
warranted.
• Routes: PO, IM, topical patches or gel, and a buccal tablet.

47. • Injectable esters of testosterone offer the most
inexpensive and effective replacement option.
• Testosterone cypionate and enanthate have the longest
duration of action and are therefore the preferred
agents.
• Drawbacks of parenteral testosterone including the need
to administer deep IM injections every 2 to 4 wks.
• In addition, levels of hormone are well above physiologic
values within the first few days.
• Concentrations then decline and eventually dip below
physiologic levels just before the next dose.
• These extreme changes in concentration lead to mood
swings and a reduced sense of well-being.

48. • Treatment with topical products is attractive to pts due to
convenience, but they tend to be more expensive than the
injections.
• Testosterone patches and gels are administered daily and
result in serum levels within the physiological range during
the 24-hr dosing period.
• Most pts prefer the non-scrotal patch or the gel since the
scrotal patch requires shaving of the area, and the patch has a
tendency to fall off.
• Care must be taken with the use of the gel to wash hands
thoroughly after use and avoid baths or showers within 5 to 6
hrs of application.
• The most common side effects of topical testosterone are
dermatologic reactions caused by the absorption enhancers.

49. • Unfortunately, testosterone has poor oral bioavailability and
undergoes extensive first pass metabolism.
• Alkylated derivatives such as methyltestosterone and
fluoxymesterone have been formulated to compensate for
these problems, but this modification makes them
considerably more hepatotoxic.
• This adverse effect makes oral replacement undesirable and
this route of administration should not be used.
• An alternative to the oral route is the buccal mucoadhesive
system.
• The buccal system adheres to the inside of the mouth and the
testosterone is absorbed through the oral mucosa and
delivered to the systemic circulation.
– There is no first pass effect
– Pts apply a 30 mg tablet to the upper gum BID.

50. • Side effects unique to this dosage form include oral irritation,
bitter taste, and gum edema
• General side effects of testosterone include gynecomastia,
dyslipidemia, polycythemia, and acne.
• Weight gain, hypertension, edema, and exacerbations of CHF
also occur due to sodium retention.
• Before initiating testosterone, the pt should undergo evaluation
for BPH and prostate cancer.
• Routine follow up includes yearly PSA, DRE, hemoglobin, and
LFT in addition to assessment of response.

51. OUTCOME EVALUATION
• Successful therapy for ED results in
– Increase in erections suitable for intercourse
– Improvement in the pt’s QoL
• Satisfaction & effectiveness are evaluated after a 4-week
trial unless the pt initiates follow-up sooner.
• Some therapies such as intracavernosal injections will
require multiple visits over the long term to detect adverse
effects.
• If the initial therapy is not effective, the pt must be further
evaluated to determine if the initial assessment of
comorbid disease states, type of dysfunction, and pt goals
were correct.