Erectile dysfunction

Abstract

Erectile dysfunction (ED) is defined as the persistent inability to attain and maintain an erection with sufficient rigidity to perform satisfactory penetrative sexual activity [1]. ED is strongly associated with age and cardiovascular risk factors. Aside from these factors, ED is a frequent long-term complication of the treatment of prostate cancer (PCa). Various treatment options for PCa currently are available, including radical prostatectomy (RP), external beam radiation (EBRT), brachytherapy (BT), and androgen deprivation therapy (ADT); for most urologists, RP is the preferred treatment option for the majority of men with organ-confined disease [2]. The maintenance of a satisfactory quality of life is the principle concern in almost half of the men who elect treatment for localized PCa [3]. Furthermore, sexual dysfunction has been reported to be an independent determinant of a poorer general health-related quality of life at 2 years after primary treatment for PCa [4]. The development of ED over time is not uniform among different treatment options (Fig. 81.1). While following (nerve-sparing) RP, almost every patient develops ED shortly after the surgery; a recovery of erectile function is seen with nerve regeneration until a plateau in erectile function is reached about 18-24 months after surgery. In non-nerve-sparing RP, the same effect is seen, but recovery is only seen in few patients. Following radiotherapy, a gradual decline in potency is seen following treatment, which continues over a long period of time (reported up till 5 years). This effect may explain why in short-term outcome studies, radiotherapy may be perceived as less harmful to erectile function compared to surgical treatment. The PCa outcomes study, however, showed similar low potency rates in a large cohort of patients treated with RP compared to those treated with EBRT 5 years after initiation of treatment [5]. The difference in evolution of ED following various treatments was also reflected in the fact that health-related quality of life remains stable between 2.6 and 6.2 years after RP, while, in patients treated with BT or EBRT, this continued to decline in the studied interval [6]. Following ADT, there is a rather quick drop in potency which generally persists during the treatment period which is also reflected in a decrease in quality of life during the first year after initiation of ADT [7].