Sperling Herbert, Lümmen Gerd, Schneider Tim, Rübben Herbert
Urologische Klinik am Universitätsklinikum Essen, Germany.
Herz. 2003 Jun;28(4):314-24. doi: 10.1007/s00059-003-2472-1.
Erectile dysfunction is a medical condition that influences the sexual life of millions of men and women worldwide. Due to a large number of currently available drugs, the therapy of erectile dysfunction has changed profoundly during the last decades. The pharmacologic options are divided into initiators versus conditioners and central- or peripheral-acting drugs. Besides intraurethral and intracavernous application of prostaglandin E(1) (PGE(1), peripheral initiator)--a transdermal application is still in clinical testing--there are drugs for oral application. PGE(1), the vasoactive drug mainly used, was replaced by sildenafil in first-line-therapy. PGE(1), administered intracavernosally or intraurethrally, is highly effective with success rates up to 90%, but the attrition rate due to personal inconvenience remains significant. Yohimbine is known as a central amplifier of erection and is useful in psychogenic and mild organic erectile dysfunction. Apomorphine, a central initiator of erection, amplifies erectile response as a central dopamine agonist in mild and moderate erectile dysfunction and starts acting 15-20 min after sublingual application. The phosphodiesterase type 5 (PDE-5) inhibitors sildenafil, vardenafil, and taldalafil are peripheral conditioners. Sildenafil, the most distributed oral agent worldwide, should be taken orally 60 min before sexual intercourse in combination with sexual stimulation. Sildenafil shows a high efficacy-safety profile with success rates for all etiologies between 50-80%. Paralleling nitrate-containing medication is an absolute contraindication. Vardenafil, another selective PDE-5 inhibitor with potentially higher selectivity and efficacy compared to sildenafil was just approved. The data from the clinical trials show the same adverse events and success rates as sildenafil. Tadalafil, just launched as well, amplifies erectile function for up to 24 h, allowing the patient to engage in sexual activity for this period. Adverse events and success rates resemble those of the other two substances. If medical treatment fails, there are nonpharmacologic options such as the vacuum constriction device and penile implants. The vacuum device is a safe and effective option for well-selected patients. Penile implants, especially the inflatable ones, completely imitate the physiologic erection. Due to recent research, infection rates and mechanical failures were minimized. Therefore penile implant surgery is well accepted by the patients and their partners. Despite this wide variety of options, therapy of erectile dysfunction should be performed in an individually adapted way. The patient's exact history, physical examination, collaboration of medical disciplines and choice of therapy will offer all patients the possibility to achieve or regain a satisfying sexual life.
勃起功能障碍是一种影响全球数百万男性和女性性生活的医学病症。由于目前有大量可用药物，在过去几十年中，勃起功能障碍的治疗发生了深刻变化。药理学选择分为启动剂与调节剂以及中枢或外周作用药物。除了经尿道和海绵体内应用前列腺素E(1)（PGE(1)，外周启动剂）——经皮应用仍在临床试验中——还有口服药物。PGE(1)，主要使用的血管活性药物，在一线治疗中已被西地那非取代。经海绵体内或经尿道给药的PGE(1)非常有效，成功率高达90%，但由于个人不便导致的脱落率仍然很高。育亨宾被认为是勃起的中枢增强剂，对心因性和轻度器质性勃起功能障碍有用。阿扑吗啡，一种勃起的中枢启动剂，作为中枢多巴胺激动剂在轻度和中度勃起功能障碍中增强勃起反应，舌下给药后15 - 20分钟开始起效。5型磷酸二酯酶（PDE - 5）抑制剂西地那非、伐地那非和他达拉非是外周调节剂。西地那非是全球分布最广的口服药物，应在性交前60分钟口服并结合性刺激。西地那非显示出高疗效 - 安全性特征，所有病因的成功率在50 - 80%之间。与含硝酸盐药物同时使用是绝对禁忌。伐地那非，另一种选择性PDE - 5抑制剂，与西地那非相比可能具有更高的选择性和疗效，刚刚获批。临床试验数据显示其不良事件和成功率与西地那非相同。同样刚刚上市的他达拉非可增强勃起功能长达24小时，使患者在此期间能够进行性活动。不良事件和成功率与其他两种药物相似。如果药物治疗失败，还有非药物选择，如真空收缩装置和阴茎植入物。真空装置对精心挑选的患者是一种安全有效的选择。阴茎植入物，尤其是可充气的那种，完全模仿生理性勃起。由于最近的研究，感染率和机械故障已降至最低。因此阴茎植入手术很受患者及其伴侣的接受。尽管有各种各样的选择，但勃起功能障碍的治疗应以个体化适应的方式进行。患者的确切病史、体格检查、医学学科的协作以及治疗选择将为所有患者提供实现或恢复满意性生活的可能性。
