Therapies such as penile injections, vacuum devices, or intraurethral medication have extremely high dropout rates, and of men who seek help at clinics for erectile dysfunction, only about one-third feel long-term satisfaction, despite trying a mean of two different treatment modalities.[29,30,31][Level of evidence: II] For men who have a suboptimal response to oral therapies after radical retropubic prostatectomy, the use of combined intracorporal injection (ICI) and a PDE-5 inhibitor has been shown to improve erectile function. One retrospective study found that among men who experienced erectile dysfunction after nerve-sparing retropubic prostatectomy, 68% who combined ICI with either sildenafil or vardenafil reported improved erectile function. On follow-up, 36% of these patients used ICI therapy only intermittently, as they reportedly felt that this was adequate for good results.[Level of evidence: III]
Rates of long-term satisfaction are superior for penile prosthesis surgery,[34,35,36] but with less invasive and permanent treatments available, fewer men choose this treatment modality, particularly after undergoing intensive cancer therapy. The role of the man's partner in prompting him to try a treatment or to keep on using it is also poorly understood. When erectile functioning is impaired, counseling should initially focus on obtaining sexual pleasure and satisfaction without erections or intercourse. For men with postsurgical erectile dysfunction, there is the possibility for improved function over time as nerves may potentially regenerate for up to 2.5 years after surgery. Providers should educate patients that opting to use no medical intervention to restore erections is also a valid choice. Comprehensive reviews of the current management of erectile dysfunction are available.[38,39,40,41,42] Also, several authors [39,43,44] provide further discussion on the management of inhibited sexual desire and other male sexual dysfunctions.
When women experience changes in arousal, most notably vaginal dryness and irritation, vaginal moisturizers (e.g., Replens) and water-based lubricants (e.g., Astroglide and K-Y Liquid) should be suggested, especially in women who cannot use estrogen replacement. The approval of the estradiol-releasing vaginal ring (Estring), containing a slow-release preparation, 2 mg of micronized 17-beta-estradiol, may also provide a less risky alternative to systemic estrogen replacement for women with postmenopausal vaginal atrophy.[Level of evidence: I] Estring has demonstrated a decreased recurrence of urinary tract infections in postmenopausal women and a significant maturing effect on vaginal and urethral mucosal cells, decreasing the urogenital symptoms of postmenopausal women.[Level of evidence: I] Another alternative to local estrogen replacement is the first-available 25-?g 17-beta-estradiol vaginal tablet (Vagifem). A study comparing Vagifem tablets with 1.25-mg conjugated equine estrogen vaginal cream (Premarin) found both to be equivalent in relieving symptoms of atrophic vaginitis, with patients who received Vagifem experiencing less endometrial proliferation or hyperplasia. This study also found that women rated vaginal tablets more favorably than vaginal cream.[Level of evidence: I] The long-term safety of the use of vaginal estrogens by women who should avoid estrogens has not been determined.