Practice Guidelines
AUA Updates Guidelines on Management of Erectile Dysfunction
The American Urological Association (AUA) has updated its 1996 recommendations on the treatment of erectile dysfunction (ED). The updated guidelines are available online at http://www.auanet.org/guidelines/edmgmt.cfm.
Diagnostic Evaluation
A typical evaluation for ED should be conducted in person and should include a thorough sexual, medical, and psychosocial history, focusing on conditions such as cardiovascular disease (e.g., hypertension, atherosclerosis, hyperlipidemia), diabetes, depression, alcoholism, premature ejaculation, increased latency associated with age, psychosexual relationships, and other conditions that might be contraindications for certain drug therapies. Other risk factors for ED that may be discovered include smoking; pelvic, perianal, or penile trauma; neurologic disease; endocrinopathy; obesity; pelvic radiation therapy; Peyronie's disease; and prescription or illicit drug use. During the evaluation, special attention should be paid to defining the problem and clearly distinguishing ED from problems with ejaculation or orgasm, as well as establishing the chronology and severity of symptoms.
After the initial examination, a physical examination should be performed, focusing on the abdomen, penis, testicles, secondary sexual characteristics, and lower extremity pulses. A rectal examination, vascular and neurologic assessment, determination of prostate-specific antigen and testosterone levels, and monitoring of nocturnal erections may be indicated in some patients.
Comorbidities
ED results from a combination of vascular, neurologic, hormonal, and psychologic factors. Conditions that affect the arterial or venous systems have a negative effect on erectile function. Diabetes, heart disease, and hypertension increase the risk of ED, and management of these conditions may prevent the development of ED. Minimal evidence also suggests that maintaining ideal body weight, not smoking, and exercising regularly may prevent or reverse ED.
Many patients with ED also have cardiovascular disease. High-risk patients (e.g., those with unstable or refractory angina, uncontrolled hypertension, left ventricular dysfunction or congestive heart failure, myocardial infarction [MI] or a cardiovascular event in the past two weeks, high-risk arrhythmias, cardiomyopathy, or moderate to severe valvular disease) should not receive treatment for ED until their cardiac condition has stabilized because of increased risk of MI during sexual activity.
Initial Management
Education, support, and reassurance may be enough to restore sexual function in some patients. In other patients, different ED therapies should be tried with increasing invasiveness. The choice of treatment should be made jointly by the physician, patient, and the patient's partner.
Treatment
The review panel considered the following nonsurgical therapies for ED: phosphodiesterase type 5 (PDE5) inhibitors, alprostadil (Caverject, Prostin VR) intraurethral suppositories, intracavernous injection, vacuum constriction devices, and herbal therapies.
pde5 inhibitors
The AUA recommends that PDE5 inhibitors be offered as the first-line therapy for ED unless contraindicated. The three PDE5 inhibitors studied (i.e., sildenafil [Viagra], tadalafil [Cialis], and vardenafil [Levitra]) are metabolized by the liver, and dosage should be adjusted for patients with altered hepatic function. The side effects of all three medications include facial flushing, nasal congestion, headache, and dyspepsia. Sildenafil and vardenafil may cause visual side effects. A limited number a patients taking tadalafil report back pain. Vardenafil may cause mild prolongation of QT interval; caution should be used when prescribing this agent for patients with a history of QT prolongation or those taking medications that prolong the QT interval.
Many men being treated for ED also are taking medication for treatment of hypertension or lower urinary tract symptoms. PDE5 inhibitors interact with beta blockers, a class of drugs commonly used to treat hypertension and lower urinary tract symptoms. Vardenafil should not be used by any patient taking any other medication with alpha blocker activity. Any dose of tadalafil and 50- and 100-mg doses of sildenafil should be administered with caution to patients taking alpha blockers.
Patients taking PDE5 inhibitors should not take organic nitrates concomitantly. No safe interval between the use of nitrates and PDE5 has been determined, but it is suggested that a 24-hour interval be used for sildenafil and a 48-hour interval be used for tadalafil.
It is important that physicians monitor the effectiveness, side effects, and health changes in patients using PDE5 inhibitors. This can be done at the time of prescription renewal. Patients who do not respond to PDE5 inhibitors may have modifiable risk factors such as hormonal abnormalities, food or drug interactions, incorrect dosing, lack of adequate sexual stimulation, heavy alcohol use, or relationship problems with their partner. Patients who do not respond to PDE5 inhibitors should be informed of the risks and benefits of other therapies.
alprostadil intraurethral suppositories
The panel recommends that the first dose of alprostadil intraurethral suppositories be administered under a physician's supervision because hypotension has been reported in approximately 3 percent of patients. Studies show that alprostadil combined with PDE5 inhibitors or a penile constriction device is more effective than the use of alprostadil alone.
intracavernous vasoactive drug injection therapy
Intracavernous injection therapy is invasive, but it is the most effective nonsurgical treatment for ED. The most widely used drugs for this therapy are alprostadil, papaverine (Pavabid), and phentolamine. The initial dose of all intracavernous injection medications should be administered in the presence of a physician to instruct the patient on proper technique, determine the most effective dose, and monitor the patient for side effects. It is important to watch for priapism in patients taking intracavernous injection therapy. Priapism can cause corporal tissue damage but, if caught early, usually can be reversed with nonsurgical measures.
vacuum constriction devices
Vacuum constriction devices are a low-cost treatment appropriate for some patients with ED. To avoid injury to the penis, only devices that contain a vacuum limiter should be used. Vacuum constriction devices are available with or without a prescription.
topical therapies
Topical therapies for the treatment of ED are not currently approved by the U.S. Food and Drug Administration. Limited studies show that topical application of vasoactive drugs does not appear to be significantly more effective than intraurethral alprostadil.
treatments not recommended by the aua
Trazodone (Desyrel), testosterone (in patients with normal serum testosterone levels), and yohimbine and other herbal therapies are not recommended for treatment of ED.
surgical therapies
Penile Prosthesis Implantation. The panel limited its discussion to inflatable penile prostheses. Patients considering prosthesis should be informed of the types of prostheses available, possible side effects, differences between the pre- and postprosthetic penis, and the potential reduction in effectiveness of other ED treatments if the device is removed.
Inflatable penile prostheses can result in complications such as pump displacement and autoinflation; the five-year mechanical failure rate ranges from 6 to 16 percent. To reduce the risk of infection, one available inflatable device has an antibiotic coating, and the other has a hydrophilic coating. A lockout valve recently was added to some models to prevent autoinflation.
Magnetic resonance imaging (MRI) can be used to evaluate the status of a penile implant, but MRI is contraindicated in patients with ferromagnetic implants.
The surgery to implant the device should not be performed if the patient has a systemic, cutaneous, or urinary tract infection. Gram-negative and gram-positive antibiotics should be administered before surgery. The operative area should be shaved immediately before surgery, and a thorough skin preparation should be performed. General, spinal, or epidural anesthesia usually is performed.
Vascular Surgery. The AUA panel does not recommend penile venous reconstructive surgery (surgeries performed to limit the venous outflow of the penis). Penile arterial reconstructive surgery remains controversial. The panel consensus is that a large study of penile arterial reconstructive surgery must be performed to determine its effectiveness. Arterial reconstructive surgery is an option only in healthy men with recently acquired ED secondary to a focal arterial occlusion who do not have any evidence of generalized vascular disease.
Practice Guideline Briefs
AAP Recommendations for Treating Children After a Disaster
The American Academy of Pediatrics (AAP) has released a clinical report recommending a course of action in treating children who have experienced or witnessed a disaster. The full report, "Psychosocial Implications of Disaster or Terrorism on Children: A Guide for the Pediatrician," was published in the September 2005 issue of Pediatrics and is available on the AAP Web site at http://pediatrics.aappublications.org/cgi/content/full/116/3/787.
The report outlines several studies that were conducted after the Sept. 11, 2001, terrorist attacks in New York and Washington, D.C. Three months after the attacks, some children were deeply dependent on parents for emotional and psychological support. The studies found that parents' moods and behaviors after traumatic events may add to a child's fears. Parents also may not recognize symptoms of their child's stress.
After a disaster, children may experience a range of symptoms, from mild stress reactions to more severe cases of post-traumatic stress disorder (PTSD). A child with adverse stress reactions lasting longer than one month after a disaster may be at higher risk of developing PTSD or violent behaviors later in life. Boys generally display higher rates of symptoms and require more time to recover than girls. Shy, fearful, or poorly supported children are at greater risk of developing negative mental reactions after trauma. Children with indirect exposure to a disaster on television also face the same risk as those witnessing it directly.
Physicians treating children after a traumatic event should be aware of patients who are at risk of adverse reactions or the development of symptoms of PTSD, and they should educate and counsel parents about the range of normal emotional and behavioral reactions of children to disaster. Physicians should help parents recognize the potential deleterious effects of indirect disaster exposure from news media and educate them about the importance of helping children understand information at a developmentally appropriate level.
Physicians should screen for anxiety in all patient encounters after a disaster. A simple question and expression of concern is an effective, brief intervention. For many children with supportive families, peers, and teachers, the reaction to traumatic experience resolves in a few months. A follow-up screening four to six months after the disaster would be appropriate to identify children with continuing symptoms who may need referral for additional services.
CDC Report on Vaccination Coverage in Children
The Centers for Disease Control and Prevention (CDC) reported increases from 2003 to 2004 in vaccination coverage among children 19 to 35 months of age for the combined vaccine series 4:3:1, 4:3:1:3:3, and 4:3:1:3:3:1 (see box) as well as for the recently implemented varicella and pneumococcal conjugate vaccines (National, State, and Urban Area Vaccination Coverage Among Children Aged 19-35 Months-United States, 2004 MMWR 2005;54:717-21). For the first time, coverage for the 4:3:1:3:3 series exceeded the Healthy People 2010 goal of 80 percent, although it varied substantially among states and urban areas, ranging from 68 percent in Nevada to 89 percent in Massachusetts.
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4:3:1:3:3:1 Vaccine Series |
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4 or more doses of diphtheria (D), tetanus toxoid (TT), and pertussis vaccines; D and TT; and D, TT, and any acellular pertussis vaccine |
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3 or more doses of poliovirus vaccine |
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1 or more doses of any measles-containing vaccine |
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3 or more doses of Haemophilus influenzae type b vaccine |
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3 or more doses of hepatitis B vaccine |
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1 or more doses of varicella vaccine |
The report states that coverage levels are notable given the supply shortage of several vaccines between 2001 and 2004. Recurrence of shortages is likely, therefore strategies for managing supply and continued monitoring are needed.
Breast Cancer Screening and Socioeconomic Status
The Centers for Disease Control and Prevention (CDC) has released a report on breast cancer screening for women in 35 major metropolitan areas in 2000 and 2002. Data for the report were collected from surveillance surveys and the 2000 U.S. Census. The findings were published in the October 7, 2005, edition of Morbidity and Morality Weekly Report and can be accessed online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5439a2.htm.
More than 250,000 women 18 years and older were interviewed to determine general demographic status and were asked if they had ever had a mammogram. Those who answered yes were asked the date of their last mammogram. Analyses for this report focused on women 40 years or older. Of these women, 9.6 percent had household incomes of less than $15,000 per year, and 23.7 percent had incomes of $15,000 to $34,999 per year. Overall, 78.5 percent reported having a mammogram during the two years preceding the study. Among women who reported annual household incomes of less than $15,000, 68.4 percent received a mammogram in the preceding two years; 75.3 percent of women with household incomes of $15,000 to $34,999 and 82.5 percent of women with household incomes of more than $50,000 had received a mammogram in the preceding two years. Women who did not complete high school or were never married and women who had no health insurance had lower mammography rates than those who were college graduates or had married, or who had health insurance.
The report shows that women with household incomes of less than $15,000 per year were less likely to have had a breast cancer screening test in the past two years than wealthier women, especially those living in affluent areas. Women with less education also were less likely to have had a mammogram.
The CDC suggests that women not eligible for Medicaid who do not have employer-sponsored health care may receive breast and cervical cancer screening through the CDC's National Breast and Cervical Cancer Early Detection Program (http://www.cdc.gov/cancer/nbccedp).
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| Copyright © 2006 by the American
Academy of Family Physicians. |
