Erectile dysfunction: anatomical parameters, etiology, diagnosis, and therapy

Functional anatomy of the human penis involves various parameters: cavernous tissue, covering integument, prepuce foreskin, corpora cavernosa, corpus spongiosum, glans, facia, arterial supply, venous drainage, lymph drainage, musculature, and nerve supply. Several factors affect the expression/degree of erectile dysfunction (ED) endocrine profile, aging/senescence, demyelinating diseases, and surgery. Risk factors of ED are: age, vascular factors, metabolic diseases (diabetes mellitus), neurologic diseases, and HIV/AIDS. Several drugs are associated with ED: antiandrogenic, anticholinergic, antidepressants, antihypertensive, major tranquilizers, anxiolytics, and certain medicines/metabolites. The International Index of Erectile Function (IIEF) is a multidimensional scale for assessment of erectile dysfunction. The main structures mediating erection are the corpora cavernosa or "erectile bodies," which are fused distally for approximately three-quarters of their length. They separate proximally to fuse with each ischial tuberosity of the pelvis. On their ventral surface lies the corpus spongiosum, which surrounds the urethra. Coital dysfunction is classified into "erectile dysfunction" (psychosexual and endocrine/neuro-endocrine) and "ejaculatory dysfunction" (psychosexual, and genitourinary surgery). Vasculogenic impotence was evaluated by high-resolution ultrasonography and pulsed Doppler spectrum analysis. Cavernosal, alpha-blockade is a technique used to evaluate and treat ED. Another diagnostic procedure for ED involves color floro and spectural Doppler imaging after papaverine-induced erection in impotent men. Color Doppler and duplex ultrasonography are used to evaluate Peyronie's disease. Sildenafil cilrate (Viagra) is an effective therapy of ED in men. Vardenavil is a highly selective phosphodiesterase 5 (PDE5) inhibitor which improved ED. Prostagland E1, vasoactive intestinal polypeptide (VIP), and phentolamine mesylate (administered by autoinjectors) have been applied to treat ED in patients resistant to other intracavernosal agents. Clinical trials were conducted on self-injection of vasoactive drugs, apomorphine SL, and tadalafil in diabetic men. Medical therapy of ED includes: medicated urethral system for erection (MUSE), intravenous pharmacotherapy, arterial revascularization, vacuum devices, two- and three-component inflatable penile prosthesis, semi-rigid penile prosthesis in situ, and inflatable one-piece penile prosthesis. Surgical therapy include procedures to correct Peyronie's penile deformity and penile deformity, procedures to avoid inevitable shortening accompanying Nesbit's disease, and for penile lengthening.     

Long-term efficacy and compliance of MUSE for erectile dysfunction following radical prostatectomy: SHIM (IIEF-5) analysis

Baseline and follow-up data of 54 patients from a single surgical series (1998-2001), who used medicated urethral system for erection (MUSE) for the erectile dysfunction (ED) associated with radical prostatectomy (RP), were obtained. Patients were surveyed using the abridged five-item version of the International Index of Erectile Function (IIEF) questionnaire, commonly referred to as the Sexual Health Inventory of Men (SHIM), to determine presence and severity of ED and efficacy of ED treatment modalities. The mean patient age was 63.7+/-5.6 y and the mean follow-up period was 2.3+/-1.2 y. All patients experienced ED for at least 6 months after their surgery before starting MUSE therapy. Overall, 55% of the patients achieved and maintained erections sufficient for sexual intercourse while on MUSE and 48% continued long-term therapy with a mean use of 2.32+/-1.2 y. The mean presurgery SHIM score in these patients was 19.2+/-1.3, which decreased to 5.2+/-0.5 after surgery and increased to 16.3+/-1.3 after MUSE treatment. A total of 28 patients (52%) discontinued treatment after a mean use of 8+/-1.4 months. The reasons for discontinuation were insufficient erections (n = 16, mean SHIM score of 10.5+/-4.4), switch to other ED therapies (n = 4), natural return of erections (n = 4) and urethral pain and burning (n = 4). Excluding the patients (n = 8) who preferred other therapies and return of natural erections, the compliance to MUSE was 63%. There were no significant differences in the IIEF-5 responses between the patients who had a nerve-sparing technique (n=34) and those who did not (n = 20) or among patients who used different doses (250, 500 or 1000 microg) of MUSE. The results of the current trial indicate that MUSE is a successful treatment option in RP patients with established ED. It appears that a post-treatment SHIM score of > or = 16 defines a successful outcome with MUSE therapy.     

Rehabilitation der erektilen Funktion nach nervenschonender radikaler Prostatektomie

Objective

Despite objective published data regarding rehabilitation of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) the gold-standard treatment is still under debate. The aim of this study was to evaluate the distribution of the different treatment options in Germany.

Patients and methods

Between October 2010 and May 2012 a questionnaire was sent to urologists in outpatient, general and university hospitals and rehabilitation hospitals in Germany. The survey consisted of various questions concerning, e.g. if and what kind of therapy urologists choose to support rehabilitation of EF after nsRP. Further questions dealt with the frequency, duration and optimal start of the chosen therapy.

Results

Currently 188 urologists have completed and returned the questionnaire. The distribution was urologists in hospitals n=79 and outpatient/ambulatory n=106, with 24 % performing surgical treatment and urologists in rehabilitation hospitals n=3. The question about the rehabilitation concept showed 39 different forms of treatment within this group. To increase EF after nsRP PDE5 inhibitors were mostly administered (88 %) with 45 % on request compared to 55 %on a daily or regular basis ≥ 3 times/week. The use of penile injection therapy, medicated urethral system for erection (MUSE) and vacuum constriction devices (VCD) was prescribed by 32 %, 6 % and 30 % of urologists, respectively. Only 14 % of the urologists did not choose any active kind of rehabilitation treatment for EF recovery after nsRP.

Conclusion

Many different therapeutic concepts are currently performed in Germany to increase EF recovery after nsRP. The use of PDE5 inhibitors is the most commonly chosen treatment option. Despite published data regarding effectiveness, the optimal treatment seems to be still unknown.     

他达拉非用于前列腺术后阴茎康复的研究进展

前列腺癌根治性切除术(RP)是治疗绝大多数临床局限性前列腺癌的标准术式,保留神经的NSRRP术式的广泛采用使得RP的疗效得到了显著的提升,但是对RP术后勃起功能的保护仍是泌尿外科的难题。RP术后及早开始阴茎康复可显著改善RP术后勃起功能障碍(ED)对患者的术后生活质量。作为唯一的长效选择性磷酸二酯酶-5抑制剂(PDE5Is),他达拉非在RP术后阴茎康复中的显著疗效在临床试验和基础研究中均得到了证实。本文旨在回顾目前RP术后ED的相关进展,及他达拉非在RP术后阴茎康复中的有效性和安全性证据。     

Penile vascular abnormalities observed long-term after surgical repair of penile fractures.

AIM: To assess the penile vascular system in men long-term after surgical treatment of penile fractures. PATIENTS AND METHODS: During a 15-year period, 36 cases of penile fracture underwent immediate surgical repair at the University of Istanbul, Turkey. At least 1 year after operation, all patients were invited for penile vascular evaluation. 15 patients accepted our call and were enrolled in our study. They were evaluated with detailed medical and sexual history, a serial of serum analyses, and penile color Doppler ultrasonography. RESULTS: By history, 6 of the 36 (16.6%) patients who had undergone surgical repair had erectile dysfunction (ED). The mean interval between surgical intervention for penile fracture and penile vascular evaluation was 3.6 +/- 1.9 (range 1.5-8) years. Evaluation of the penile vascular system of 15 men (mean age 35.7 +/- 17.3, range 21-63 years) revealed normal vascular system in seven (46.7%), while cavernosal insufficiency was observed in four (26.7%) and arterial insufficiency in three (20%) men. The remaining case (6.7%) was diagnosed to have mixed arterial and cavernous insufficiency. Erectile dysfunction in two cases was considered to be in psychogenic origin and vascular in the remaining four. CONCLUSION: Although immediate repair is reported to be the treatment of choice in penile fractures, ED of either a physiological or vascular origin can be encountered as a long-term sequel and deserves to be evaluated in detail.     

Multicenter study of the treatment of erectile dysfunction with transurethral alprostadil (MUSE) in Korea

A Korean multicenter study was conducted to assess the effectiveness of transurethral alprostadil with MUSE in 334 subjects with chronic erectile dysfunction (ED) who were enrolled in 21 clinical centers. Patients with psychogenic impotence comprised about 30% of subjects. Intraurethral alprostadil was titrated in a stepwise fashion in the clinics from 250 to 500 or 1000 mcg based on erectile response and tolerability. The erectile responses were evaluated using an erection assessment scale (score of 1-5). The dose that produced a maximal penile response of score 5 (full rigid erection) or 4 (full tumescence, partial rigidity) was selected for home treatment. Patients who showed partial erection (score of 3) with 1000 mcg were also included in the home-treatment group. In-clinic phase: 198 men (59.3%) had maximal penile responses of score 4 or 5. The rate of maximal responses was not related to patient age, etiology or duration of the ED. A total of 228 (68.3%) men progressed to home treatment. The overall level of comfort of the transurethral alprostadil was rated as uncomfortable or very uncomfortable in 12%. Home phase: During the two-month period of home treatment, 178 (78.1%) men had successful sexual intercourse at least once, and 78.2% of administrations (1976) resulted in successful intercourse. The main causes of drop-out were insufficient erectile response in 27 men (11.8%), adverse reactions (mostly penile or urethral pain) in 7 (3.1%) or both in 7 (3.1%). In conclusion, transurethral alprostadil could be a suitable treatment option for patients with ED regardless of age and etiology of ED. Efficacy in an Asian population (Korea) is comparable to that reported previously in Caucasians.     

阴茎负压吸引治疗PDE5i无效型勃起功能障碍疗效分析(附70例报告)

目的:探讨使用Osbon助勃器阴茎负压治疗磷酸二酯酶抑制剂-5(PDE-5i)无效型勃起功能障碍(ED)患者的有效性和安全性。方法:收集口服PDE-5i无效ED患者70例,年龄25～66(38.9±9.1)岁,指导患者使用Osbon助勃器(美国Timm Medical公司)负压锻炼1个月;负压锻炼结束后,使用紧缩张力环进行性生活治疗,比较负压治疗前和治疗后3个月IIEF-5评分变化,以及患者和性伴侣的满意度,评价负压应用的安全性和有效性。结果:PDE-5i治疗无效的ED患者负压治疗后3个月IIEF-5评分较负压治疗前有显著提高(P<0.05),IIEF-5评分由治疗前(10.2±4.0)分上升到(13.3±4.7)分。负压治疗口服PDE-5i无效ED患者的有效率77.1%(54/70)。负压治疗后PDE-5i无效ED患者及性伴侣性生活满意率分别为64.3%(45/70)和65.7%(46/70)。结论:PDE-5i治疗无效型ED患者行阴茎负压治疗,可显著改善患者勃起功能及夫妻双方性生活满意率,值得临床应用。     

Vasoactive intracavernous pharmacotherapy for the treatment of erectile impotence in men with spinal cord injury

A total of 66 spinal cord injury patients with erectile dysfunction entered a protocol of penile intracavernous pharmacotherapy with papaverine hydrochloride (30 mg. per ml.) or a combination of papaverine (25 mg. per ml.) and phentolamine mesylate (0.83 mg. per ml.) in an attempt to restore erectile function. Of the patients 52 completed the protocol and all achieved transient functional penile erections after administration of the drug. Of the 52 responders 71 per cent currently practice self-injection as a method to restore erectile function. Sustained erections that required irrigation of the cavernous bodies with alpha-adrenergic agents developed in 4 patients and 1 suffered localized intracorporeal induration. If the long-term followup shows that complications remain relatively minor, undoubtedly vasoactive intracavernous pharmacotherapy will have a major role in the restoration of erectile function in the motivated man with spinal cord injury. However, in view of the unknown long-term effects and potential dangers of this approach it is important that patients adhere to a strict drug injection protocol under the supervision of qualified urologists who are familiar with the potential risks and complications.     

自我注射前列腺素E1治疗勃起功能障碍

１９９４年１～１２月，采用自我注射前列腺素Ｅ１方法，治疗不同病因的勃起功能障碍患者６０例。阴茎海绵体注射前列腺素Ｅ１可使６１．７％的患者阴茎完全勃起；仅２６．７％的患者注射药物后，阴茎有轻微胀痛感；无阴茎血肿、异常勃起及海绵体纤维化等副作用。结果提示，前列腺素Ｅ１具有安全、有效和副作用小的特点，优于目前治疗勃起功能障碍的其它海绵体注射药物。     

Erectile dysfunction (ED) is prevalent, bothersome and underdiagnosed in patients consulting urologists for benign prostatic syndrome (BPS)

OBJECTIVES: The aim of the present study was to determine the prevalence of erectile dysfunction (ED) in patients visiting office-based urologists in Germany because of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), and to evaluate the impact of ED on quality of life (QoL) in these patients. METHODS: 500 office-based urologists in Germany were invited to evaluate 20 consecutive patients for erectile dysfunction, who presented because of BPH-related LUTS. Physicians provided information on demographic factors, duration and treatment history of BPH, severity of LUTS, ED risk factors, and assessed the patient for the clinical diagnosis of ED. Patients were asked to complete the German version of the IPSS to measure LUTS severity. ED-patients quantified erectile dysfunction and impact on quality of life with validated German questionnaires (Cologne assessment of male erectile dysfunction KEED, and Qol-Med). RESULTS: Office-based urologists were aware of ED in 37.3% of 8768 patients presenting for LUTS before the study, 14.7% of patients were treated for ED. After the study-related assessment, physicians diagnosed ED in 62.1% of these patients and planned treatment in 46.9%. Severity of LUTS and ED prevalence correlated significantly after age-stratification. The incidence of ED was increased in patients with established ED risk factors. Mean QoL-Med score (best QoL: 100, worst QoL: 0) was 53.8 in patients with ED and 50.1 in ED-patients considering treatment. CONCLUSION: ED is highly prevalent in LUTS patients visiting an office-based urologist and is accompanied by a profound impact on the quality of life. Apparently, even during an urological consultation many ED-patients are hesitant to actively ask for treatment. Sexual issues should become key considerations for physicians managing patients with LUTS, especially since effective and well established oral treatment for ED is available.     

Rationale for combination therapy of intraurethral prostaglandin E(1) and sildenafil in the salvage of erectile dysfunction patients desiring noninvasive therapy

Corpus cavernosum smooth muscle relaxation and hence penile erection are regulated in part by increases in smooth muscle synthesis of the second messengers cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP). The object of this study was to determine 30-month follow-up results in motivated patients desiring noninvasive medical therapy using sildenafil citrate (Viagra) in combination with intraurethral prostaglandin E(1) (PGE(1)) (Medicated Urethral System for Erection [MUSE]). Twenty-eight patients (mean +/- s.d. age, 59 +/-7.3 y; 17 who had undergone radical prostatectomy and 11 who had a diagnosis of organic erectile dysfunction) were included in this study. Detailed history taking and physical examinations were performed and vascular risk factors noted. In these patients, treatment with either 100 mg of sildenafil citrate and/or 1000 microg of MUSE had failed. None of these patients desired intracavernosal injection. Duplex Doppler ultrasonography after redosing was carried out on all patients. Dynamic infusion corpus cavernosography/cavernosometry was obtained in 17 of 28 patients, and combination therapy was initiated using 100 mg of sildenafil citrate orally 60 min before intercourse and 500 microg of MUSE intraurethrally immediately before intercourse. Independently, either 100 mg of sildenafil citrate or 1000 microg of MUSE was not efficacious in inducing an erection sufficient for vaginal penetration in any of the 28 patients. After initiating a combination therapy, at 30 months, all 28 patients were reporting erections sufficient for vaginal penetration, with 3.6 intercourse episodes per month. None of the patients crossed over to intracavernosal therapy or penile prosthesis. During therapy, eight of 28 patients reduced the dose of sildenafil citrate to 50 mg. Combination therapy with MUSE and sildenafil may be more efficacious in the salvage of patients who desire noninvasive therapy but in whom single-treatment modalities fail. Although both cAMP- and cGMP-mediated vasodilation can lead to penile erection, combining therapies that incorporate both pathways may succeed when single therapies fail.     

Current developments in hydraulic penis prostheses

The disappointing long-term results of alternative treatments for erectile dysfunction have led to increasing interest in penile implants. Against this backdrop, the development of reliable penile prostheses which offer easy implantation and excellent function is a challenge to bioengineers and urologists with a special interest in the treatment of erectile dysfunction.     

Combination therapy: medicated urethral system for erection enhances sexual satisfaction in sildenafil citrate failure following nerve-sparing radical prostatectomy

The objective of our study was to assess the effectiveness of combining medicated urethral system for erection (MUSE) with sildenafil citrate in men unsatisfied with the sildenafil alone. Baseline and follow-up data from 23 patients (mean age, 62.5 +/- 5.23 years) unsatisfied with the use of the sildenafil citrate alone for the treatment of erectile dysfunction following nerve-sparing radical prostatectomy (mean use, 4 attempts/100-mg dose) was obtained. All patients started oral sildenafil citrate more than 6 months after radical prostatectomy. Combination therapy was initiated using 100 mg sildenafil citrate orally 1 hour prior to intercourse. Patients used combination therapy for a minimum of 4 attempts prior to assessment with the Sexual Health Inventory of Men (International Index for Erectile Function-5) and visual analog scale to gauge rigidity (0-100). The effect of therapy on the total International Index for Erectile Function (IIEF) score and penile rigidity score was assessed. Of the 23 patients, 4 (17%) had no improvement with the addition of medicated urethral system for erection and discontinued the drug, while 19 (83%) reported improvement with the penile rigidity and sexual satisfaction. The IIEF scores of these 19 patients showed significant improvements in each sexual domain, and the patients reported that erection was sufficient for vaginal penetration 80% of the time. Rigidity scores on a scale of 0-100 with sildenafil alone averaged 38% (23-53) for men and 46% (26-67) for their partners. With the addition of MUSE, scores increased to 76% for men and 62% for their partners. We conclude that the addition of MUSE to sildenafil improved sexual satisfaction and penile rigidity in patients unsatisfied with sildenafil alone.     

Erectile dysfunction after kidney transplantation: our 22 years of experience

AIM: To evaluate the results of treatment of erectile dysfunction (ED) in kidney transplant recipients before and after the advent of sildenafil. MATERIALS AND METHODS: From 1981 through 2002, 971 male patients of mean age 53.4 years received a renal graft. Erectile dysfunction (ED) was investigated in all patients at the first urologic visit posttransplantation. Psycho-sexual support was offered to all patients. Before sildenafil use (1998), our diagnostic approach was complex. From 1998 we tested: serum levels of testosterone, prolactin, and glucose with penile duplex ultrasonography and NPT reserved for selected cases. RESULTS: From 1981 through 1998, 365 male kidney transplant recipients (45%) reported ED. Only 169 patients chose to be treated: 27 responded to psycho-sexual therapy; 3 received testosterone with benefit; 133 had a good results from intracavernosal injection of vasoactive drugs; and 6 received a penile prosthesis. Since 1998, 126 patients reported ED (78.3%). Only 78 chose treatment: 24 patients had a satisfactory response to sildenafil (65% with 50 mg and 35% with 100 mg). PGE1 alone or in combination with papaverine and phentolamine produced a good response in 37 patients; 17 patients did not respond to pharmacotherapy; and 5 received a tricomponent penile prosthesis without complications. The side effects of sildenafil and PGE1 therapy were similar to those reported in the literature. CONCLUSIONS: ED is an important problem in male renal transplant recipients. Cultural resistance to treatment is common. However, treatment with sildenafil citrate and intracavernosal self-injection of PGE1 are well accepted, and prosthetic devices may help in resistant cases.     

An analysis of erectile function after intensity modulated radiation therapy for localized prostate carcinoma

Radiation therapy for prostate cancer can cause erectile dysfunction (ED). Intensity Modulated Radiation Therapy (IMRT) can reduce the amount of radiation to surrounding tissues associated with ED. We characterize the incidence of and factors associated with ED in prostate cancer patients after IMRT at the National Naval Medical Center (NNMC). Patients potent by definition of the Sexual Health Inventory for Men (SHIM) before treatment completed the specific erectile questions of the SHIM after IMRT. Statistical analyses were performed to examine the relationships between several factors and ED. Thirty-two of 45 patients with mean age of 68.2 years (50-86 years) completed the SHIM. The median follow-up was 36.8 months (16-63.6 months) as defined by the time from completion of therapy to reassessment with the SHIM. Eight of 32 patients (25%) had no post-treatment ED (SHIM score 22-25), three of 32 (9%) had mild post-treatment ED (SHIM score 17-21), five of 32 (16%) had mild to moderate ED (SHIM score 12-16), five of 32 (16%) had moderate ED (SHIM score 8-11) and 11 of 32 (34%) had severe post-treatment ED (SHIM score<8). Post-treatment potency was significantly associated with the pre-treatment SHIM score (P=0.001) and history of hypertension (P=0.03). The mean radiation dose to the penile bulb and volume of penile bulb treated were not associated with post-treatment potency (P=0.38, 0.76, respectively). IMRT maintains potency in the majority of patients. This analysis compares favorably in preserving erectile function to previously reported series using conventional external beam radiation therapy techniques. The dose of radiation received by the penile bulb and volume of penile bulb were not associated with post-treatment ED in this analysis.     

Organic, relational and psychological factors in erectile dysfunction in men with diabetes mellitus

INTRODUCTION AND OBJECTIVES: Diabetes mellitus-induced erectile dysfunction (DMED) is thought to be multifactorial in aetiology and to include vascular, neurological, and psychological components. The aim of the present study is to determine the contribution of organic, relational, and intrapsychic components to the pathogenesis of ED in diabetic in comparison with non-diabetic patients. METHODS: We studied a consecutive series of 1027 using SIEDY structured interview. A complete physical examination and a series of metabolic, biochemical, hormonal, psychometric, penile vascular tests and nocturnal penile tumescence and rigidity evaluations were performed. RESULTS: 15% of patient studied were affected by DMED. Diabetic patients with DMED have a greater severity of erectile dysfunction and are more likely to have an organic, rather than an intrapsychic, component. Impaired sexual desire is less frequent in these patients and they had an higher prevalence of hypogonadism than non-diabetic individuals. CONCLUSION: Diabetic patients seeking treatment for erectile dysfunction have a greater severity of disease, less impaired sexual desire, suggesting that the need for medical care in diabetic patients with ED could be even greater than in their non-diabetic counterparts. Considering the higher prevalence of obesity-related decrease of testosterone levels in DMED, an appropriate screening and treatment of hypogonadism might improve the outcome of pharmacotherapy for ED in diabetic patients.     

Nocturnal penile tumescence activity unchanged after long-term intracavernous injection therapy

PURPOSE: Anecdotal evidence suggests that some men have restored erectile function after long-term intracavernous injection therapy for erectile dysfunction. We objectively assessed this phenomenon using nocturnal penile tumescence testing. MATERIALS AND METHODS: In our retrospective study 19 men with a mean age of 53.5 years who had organic erectile dysfunction underwent nocturnal penile tumescence testing before and after prostaglandin E1 based intracavernous injection at least 6 months in duration. The nocturnal penile tumescence parameters measured included the number of erectile episodes, base and tip tumescence, and percent of time with rigidity greater than 70% at the penile base and tip. A 5-item questionnaire was given to all patients after the intracavernous injection period to assess subjective changes in erectile quality. RESULTS: Mean time on intracavernous injection was 2.42 years and mean injection frequency was 3.74 times monthly. Prostaglandin E1 only, and combined prostaglandin E1, phentolamine and papaverine were used in 7 and 9 cases, respectively. Nine patients believed that unaided erection improved after intracavernous injection and 6 achieved intercourse without injection who were unable to do so before injection. No statistically significant changes were noted in any of the 5 objectively measured nocturnal penile tumescence parameters. CONCLUSIONS: Long-term prostaglandin E1 based intracavernous injection may provide subjective improvement in erectile function in some men. However, as measured by nocturnal penile tumescence testing, no objective improvement in spontaneous erectile function occurs.     

Association between International Index of Erectile Function and axial penile rigidity in patients with erectile dysfunction

We investigated the association between the International Index of Erectile Function (IIEF) and axial penile rigidity parameters in patients with erectile dysfunction (ED). A total of 516 male patients (491 patients with ED and 25 patients without ED) were assessed using IIEF. Patients were assessed for axial penile rigidity (APR) using a digital inflection rigidometer. Mean age+/-s.d. was 52.4+/-9.9 y. ED was mild in 11.4% of the patients, moderate in 40.1%, and severe in 48.5%. Regarding APR, the following was found: (1) no significant difference between patients who had a mild degree of ED and patients who had no ED (P>0.05); (2) a significant difference between patients with different degrees of ED (P<0.05 for each); (3) a significant association between overall presence of ED and low APR (P<0.05). IIEF score is associated with APR and can differentiate between patients with and without ED.