Mohit Khera, MD, MBA, MPH, presented “Changing Paradigm in the Diagnosis and Management of Erectile Dysfunction” during the 42nd Annual Ralph E. Hopkins Urology Seminar on February 1, 2023, in Jackson Hole, Wyoming.
How to cite: Khera, Mohit. “Changing Paradigm in the Diagnosis and Management of Erectile Dysfunction.” February 1, 2023. Accessed Jun 2023. https://grandroundsinurology.com/changing-paradigm-in-the-diagnosis-and-management-of-erectile-dysfunction/
Changing Paradigm in the Diagnosis and Management of Erectile Dysfunction – Summary
Mohit Khera, MD, MBA, MPH, Professor of Urology, F. Brantley Scott Chair in Urology, and Director of the Laboratory for Andrology Research at the McNair Medical Institute at Baylor College of Medicine, identifies the paradigm shifts represented in 2018 guidelines for erectile dysfunction (ED), and the current landscape of treating these patients with regenerative therapies.
The 2018 American Urological Association (AUA) ED guidelines focused on shared decision-making as a cornerstone for care. Prior to this, the treatment paradigm for ED was to offer oral ED therapies as first line therapies; urethral suppositories, injectables, and vacuum pumps as second-line therapies; and penile implants and corrective vascular surgery as third-line therapies. In the new model, physicians should first counsel patients on all the options available, clearly laying out the benefits and risks of each, and let them decide what the first-line treatment should be. However, as part of that counseling, physicians should stress the importance of lifestyle changes in improving sexual function that could negate the need for any potentially risky intervention. The same goes for the option of mental health referrals and sex therapy. Another paradigm shift represented in the 2018 guidelines was that of sexual dysfunction as a “couple’s disease,” wherein a patient’s sexual function improves as a result of their partner’s improving, and vice versa. Notably, the treatment algorithm in these guidelines don’t mention testosterone, as testosterone is much more effective in combination with PDE5i than monotherapy. The exception to this rule regarding testosterone is in post-prostatectomy hypogonadal men.
Currently, the focus in this space is addressing the unmet medical need for regenerative therapy. Statistically, the most important consideration for patients when starting ED medication is to be cured. Available medications only provide a temporary fix, and not a cure, so naturally, the highest-reported reason for discontinuing medication is non-effectiveness. Hence the push toward regenerative strategies that would restore erectile function without the need for pills. Born out of this movement was a small study that showed that extracorporeal shockwave therapy had promising results in 20 men with vasculogenic ED. Unfortunately, the news of this small study was sensationalized, leading to the proliferation of “shockwave clinics” that can use non-FDA-regulated machines and home shockwave therapy devices that can leave users disappointed. Dr. Khera advises physicians on the most safe and effective machines and proper treatment protocols for ED shockwave therapy, and to keep in mind that this is still considered investigational.
Another exciting emerging option in this space is stem cell therapy, which currently is being studied in combination with shockwave therapies in animal models. There is some data to suggest mesenchymal stem cells alone can improve cavernous nerve and smooth muscle, as well as decrease corporal fibrosis. However, it is important to note that there are no randomized, placebo-controlled trials for this therapy, and the human trials that do exist are very small. The AUA still considers stem cell therapy for ED as investigational, and physicians should be aware of legal nuances, as well as the feasibility and cost-to-benefit ratio for patients.
Platelet rich plasma (PRP), which is lauded online for its ability to improve sexual function, is relatively easy and inexpensive to make. One randomized, double-blind, placebo-controlled trial has shown improvements in International Index of Erectile Function (IIEF) scores. Unfortunately, clinics often drastically overcharge for PRP injections, and the AUA still considers this therapy experimental.
About The 42nd Annual Ralph E. Hopkins Urology Seminar:
The Ralph E. Hopkins Urology Seminar is a multi-day meeting focused on training urologists in the latest in assessing, diagnosing, and treating urologic conditions in the clinical setting. Updates are provided on urologic cancers, stone disease, urologic reconstruction, female urology, infertility, sexual function, emerging surgical techniques, and general urology. The 42nd iteration of the meeting took place from February 1st to 4th, 2023, in Jackson Hole, Wyoming.
For further educational activities from this conference, visit our collection page.