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

therapies.

These observations were put into clinical context by

Shabsigh

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-

comes.

This would imply that normal variations

in testosterone, and perhaps even levels below the

lower limit of normal, might not compromise erectile

function.

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.

45,46

Sexual function assessment tools for

clinicians

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.

Further-

more, female sexual function has been reported to

improve in prospective studies in which men with

ED were treated.

48,49

Female partner age has even

been found to correlate inversely with the ability for

post-RP patients to achieve natural erections after

surgery.

One study has uncovered a potential

role for female sexual function as a predictor of

compliancewithanEPprogram.

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 (

P-

values

0.0001)

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.

54,55

Review and treatment protocol: erectile preservation for RP patients

DJ Moskovic

et al

187

International Journal of Impotence Research