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AUA 2020

AUA 2020: Guidelines Based Medical Management & Treatment of Erectile Dysfunction

(UroToday.com) Physician assistant Ken Mitchell, MPAS, PA-C, provided an in-depth review of the AUA 2018 Erectile Dysfunction (ED) Guideline Statement at the virtual AUA 2020 conference, adding clinical “pearls” for the APP.1  The AUA ED guideline is an evidence-based document that reviews evaluation, diagnosis, treatment, with an algorithm for clinical decision making.  The ED guideline is based on shared-decision making where the patient and clinician work together to determine the best course of therapy, based on risks benefits and the patients’ desired outcome (goals).  The ED guideline recommends the use of a validated questionnaire, the Sexual Health Inventory for Men (SHIM) for assessing erectile function.2 

At my practice, Penn Urology, we have all male patients complete this questionnaire irrespective of their presenting diagnosis or chief complaint. In addition, the guideline also recommends that the evaluation of men with ED includes an assessment of testosterone (T), especially if the man has symptoms of testosterone deficiency (TD).  There are two questionnaires to test TD: Androgen Deficiency in the Aging Male (ADAM)7 and Quantitative Androgen Deficiency in the Aging Male (qADAM). The ED guideline recommends morning draw of blood total T-levels (Moderate Recommendation; Evidence Level: Grade C). Mr. Mitchell spoke at length about risk factors associated with ED and other conditions and comorbidities (e.g. diabetes, underlying cardiovascular disease (CVD). He also stressed the need for involvement of mental health professionals to address performance anxiety, a major complaint of men with ED, and for counseling on sexual relationships.  

ED treatment:

1. Phosphodiesterase 5 Inhibitors (PDE5i): the guideline strongly recommends (Evidence Level: Grade B) their use for the following:

  • Prescribe to men post RP or RT, although early use may not improve spontaneous, unassisted erectile function. However, small dose of a daily PDE5i (tadalafil 5mg) is often part of a urology practice protocol and is part of our protocol in these men. (Evidence Level: Grade C)
  • Men with ED and TD may benefit by a combination of T therapy and a PDE5i (Evidence Level: Grade B)

2. Vacuum erection device (VED)

  • Moderate recommendation for use of a VED (Evidence Level: Grade C). Many recommend men start using a VED immediately post-radical prostatectomy.

3. Intraurethral (IU) alprostadil

  • Only a conditional recommendation. The speaker relayed that some men complain that this urethral suppository may not totally dissolve and falls out of the urethral during intercourse, causing a burning sensation.

4. Intracavernosal injections (ICI)

  • Moderate recommendations for ICI by informing patients of benefits and risks/burdens.
  • A “clinical principle” was that men must have in-person injection instructions and demonstration

5. Penile Prosthesis Implant

  • A strong recommendation for informing men about the option of a penile implant although evidence level is only a “C”
  • Counseling around expectations should be part of the pre-operative plan
  • Contraindications include the presence of systemic, cutaneous or UTIs

Physician assistant, Ken Mitchell, presented what the AUA ED guideline does not recommend:

1. Penile venous surgery

2. Low-intensity extracorporeal shock wave therapy is considered investigational

  • Benefits do not outweigh the risks or benefits
  • Only some evidence for short-term efficacy as RCTs varied in methodology and outcomes did not report a return to normal erectile function.
  • Expensive

3. Stem cell intracavernosal therapy and platelet‐rich plasma (PRP) therapy are considered investigational

Mr. Mitchell discussed the underlying non-physiological issue with ED in men: the male brain.  He noted there are predatory “ED and Low-T shot clinics” who prey on the male desire to achieve adequate sexual function and the societal view of “manhood.” As many of these are online programs, they are an “arms-length” approach, minimizing the person’s shame and embarrassment as it is an anonymous service.  But the speaker felt that many of these companies are predatory in nature, trying to sell the concept that “manhood can be restored” without appropriate evaluation. 

He noted the most common underlying mechanism for ED is vascular.  There is a known relationship between ED & CVD and other independent risk factors (e.g. age, smoking, diabetes, hypertension, obesity, etc) are seen in many men with ED. Symptoms of ED may precede a CV event by up to 5 years.  When ED is present in younger men, it predicts a marked increase (up to 50‐ fold) in the risk of future cardiac events.  The increasing number of men with CVD risk factors is paralleled by the worldwide increase in the prevalence of ED. So it is important that men with ED have a thorough evaluation of the etiology of ED and possible CV risk. The AUA ED guideline is a must-read for urologic APPs.

Presented by: Kenneth A. Mitchell, MPAS, PA-C, Assistant Professor, Meharry Medical College, Nashville, TN 
Written by:  Diane Newman, DNP, ANP-BC, Adjunct Professor of Urology in Surgery, Perelman School of Medicine, University of Pennsylvania and Co-Director of the Penn Center for Continence and Pelvic Health

References: 

  1. Burnett et al. Erectile Dysfunction: AUA Guideline. J Urol. 2018 Sep;200(3):633-641. doi: 10.1016/j.juro.2018.05.004
  2. Cappelleri, J., Rosen, R. The Sexual Health Inventory for Men (SHIM): a 5‐year review of research and clinical experience. Int J Impot Res 2005, 17, 307–319 (2005)
  3. Inman et al: A population‐based, longitudinal study of erectile dysfunction and future coronary artery disease. Mayo Clin Proc 2009; 84: 108.
  4. Irwin GM.  Erectile Dysfunction.  Prim Care. 2019 Jun;46(2):249-255. doi: 10.1016/j.pop.2019.02.006.
  5. Katsiki et al. Erectile dysfunction and coronary heart disease. Curr Opin Cardiol. 2015 Jul;30(4):416-21. doi: 10.1097/HCO.0000000000000174.
  6. Miner et al. Baseline Data From the TRiUS Registry: Symptoms and Comorbidities of Testosterone Deficiency. 2011 May;123(3):17-27.   doi: 10.3810/pgm.2011.05.2280.
  7. Mohamed et al. The quantitative ADAM questionnaire: a new tool in quantifying the severity of hypogonadism. Int J Impot Res. 2010;22(1):20–4.
  8. Mulhall et al.. Evaluation and Management of Testosterone Deficiency: AUA Guideline.  J Urol. 2018 Aug;200(2):423-432. doi: 10.1016/j.juro.2018.03.115.
  9. Nehra  et al. Diagnosis and treatment of erectile dysfunction for reduction of cardiovascular risk. J Urol. 2013 Jun;189(6):2031-8. doi: 10.1016/j.juro.2012.12.107.
  10. Osondu et al. The relationship of erectile dysfunction and subclinical cardiovascular disease: A systematic review and meta-analysis. Vasc Med. 2018 Feb;23(1):9-20. doi: 10.1177/1358863X17725809.
  11. Rosen et al. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Dysfunction (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11:319-326. http://www.nature.com.