Their results demonstrated that study group animals
developed pockets of adipocytes throughout the caver-
nosal smooth muscle matrix. Mechanically, it is
conceivable that this tissue would interfere with
compression of the subtunical vasculature (necessary
for maintenance of cavernosal blood for an erection)
and predispose the patient to venous leak, margin-
alizing the effectiveness of any of the aforementioned
These observations were put into clinical context by
et al
who conducted a randomized,
controlled trial of testosterone and demand-dose
sildenafil versus sildenafil alone for previous PDE-5
inhibitor non-responders. Subjects were followed with
serial IIEF scores. Perhaps not surprisingly, patients
receiving testosterone repletion sustained a dramatic
improvement in response to sildenafil (as assessed by
IIEF scores) versus the control group. Patients were
followed for only 12 weeks, although the difference in
IIEF scores was only significant at 4-week follow-up
despite a qualitative difference being observed at all
follow-up points. The authors remark that this may be
related to the placebo effect within the control group.
Perhaps, it is also related to the small sample size and
the baseline function of these subjects.
Admittedly, the clinical evidence supporting the
role of testosterone for erectile function is in its
infancy. However, the early evidence is convincing
and small clinical benefits are complemented by
molecular rationale. In fact, a dose-dependant relation-
ship between erectile function and testosterone has
been suggested, where a critical threshold has been
postulated to govern adverse erectile function out-
This would imply that normal variations
in testosterone, and perhaps even levels below the
lower limit of normal, might not compromise erectile
Regardless, the impact of testosterone on quality
of life in men is well established.
We choose to
include testosterone replacement in our EP protocol
for two important reasons: (1) the scientific rationale
that testosterone is key component of erectile
function and (2) the overall quality of life improve-
ments are likely to drive sexual interest and
compliance with other components of the program.
The combination of these factors justifies the role
of testosterone in post-RP EP. However, concern
regarding testosterone supplementation for men
after RP remains controversial.
Sexual function assessment tools for
As the sophistication of ED management has
evolved, the need to better characterize and define
gradients of erectile function has been critical to
advance therapeutic strategies. Additionally, the
focus of practitioners has evolved from a narrow
scope (for example erectile function) to a more
general approach to optimize sexual function (for
example satisfaction). Even more recent has been
the recognition that the sexual partners and health
of the relationship impact outcomes for these
patients. Perhaps not surprisingly, female sexual
dysfunction has been shown to correlate with male
sexual dysfunction, particularly after RP.
more, female sexual function has been reported to
improve in prospective studies in which men with
ED were treated.
Female partner age has even
been found to correlate inversely with the ability for
post-RP patients to achieve natural erections after
One study has uncovered a potential
role for female sexual function as a predictor of
We present a list of
some of the tools available to clinician to understand
baseline sexual function and track the progress of
patients (and partners) over therapy. A summary of
these tools is also presented in Table 1.
Relationship Assessment Scale
The relationship assessment scale assesses overall
relationship satisfaction with a seven-item measure
of general relationship satisfaction. The relationship
assessment scale has been used in a wide range of
patient populations. Interestingly, it has been speci-
fically used in men with ED.
Questions are
answered on a five-point Likert scale, with higher
scores indicating greater satisfaction.
For men
Erection Hardness Score
This single question scoring system has been
validated for the assessment of erection hardness.
The erection hardness score has demonstrated good
test–retest reliability and has correlated well against
the pre-specified domains of the IIEF and quality of
erection questionnaire.
International Index of Erectile Function
The IIEF is probably the most highly regarded tool
for comprehensively assessing erectile function. The
survey is a 15-item questionnaire that measures
participants’ responses on a five- and six-point
Likert scale.
The tool is broken up into five
distinct factors: erectile function, orgasmic function,
sexual desire, intercourse satisfaction and overall
sexual satisfaction. Significant (
changes between baseline and post-treatment scores
were identified across all five of the aforementioned
domains in the treatment responder cohort as
compared with the non-responder cohort in the vali-
dation study. A five-item version of the IIEF (IIEF-5
or SHIM) has been introduced and enables a slight
more rapid assessment of male sexual health.
Review and treatment protocol: erectile preservation for RP patients
DJ Moskovic
et al
International Journal of Impotence Research