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Erectile Dysfunction
that both treatments were well tolerated with minor treatment- the IIEF-5 questionnaire, with administration of vardenafil. Erectile
emergent adverse events. function did not respond to CPAP treatment in five men with low
testosterone, but the response rate was 100% when vardenafil
In an open-label, randomised, prospective study of similar design, and testosterone were added. Of 19 hypogonadal men receiving no
40 men with OSA and ED who were naïve to phosphodiesterase CPAP for their OSA, the response rate to vardenafil was 41%. The
(PDE)-5 inhibitors received either sildenafil 100mg on demand at authors concluded that the addition of testosterone to PDE-5
least one hour prior to anticipated intercourse or CPAP for a period inhibitor treatment in hypogonadal men with OSA and ED gives
of 12 weeks.
31
Erectile function was reassessed at an end-of- promising results and warrants further investigation.
treatment visit using the IIEF-EF domain score, the SEP and the first
question of the Erectile Dysfunction Inventory of Treatment Treatment of Erectile Dysfunction in Patients
with Undiagnosed Obstructive Sleep Apnoea
Given the frequent co-existence of OSA and ED, a number of
patients presenting with ED may have undiagnosed OSA. PDE-5
A significant percentage of patients
inhibitors, a first-line oral ED treatment, could, at least theoretically,
exacerbate sleep apnoea by interfering with pharyngeal muscle
whose erectile dysfunction did not
tone, nasal patency and gas exchange in the lung through
respond or who were not satisfied with
vasodilatory and smooth-muscle relaxation effects in these organs.
37
A double-blind, placebo-controlled, cross-over study to assess the
conventional management responded to
effects of a single 50mg oral dose of sildenafil at bedtime on the
on-demand sildenafil.
results of polysomnography in patients with severe OSA without
pulmonary hypertension has been published.
37
Men 40–65 years of
age with a BMI of less than 30, an AHI of more than 30 events per
Satisfaction (EDITS). Treatment with sildenafil resulted in a hour of total sleep time and an oxygen desaturation (4%) index of
significant increase in IIEF-EF domain score (14.3 versus 7.8 at 10 or more episodes per total sleep time, as evidenced by recent
baseline; p<0.001) and 51% successful intercourse attempts. Fifty polysomnography, were screened. Patients with respiratory or
per cent of 20 men receiving sildenafil were satisfied with cardiac disease or systemic or pulmonary hypertension were
their treatment. Sildenafil was significantly more effective than excluded. Fourteen patients with a mean age of 53.1 years and
CPAP treatment, which confirmed the results of our previous study. mean BMI of 26.7 entered the study. They underwent
polysomnography for the duration of the entire night after receiving
In another trial we tested the hypothesis that combining CPAP and sildenafil 50mg or placebo at bedtime.
sildenafil offers superior results for OSA patients compared with
each treatment alone.
34
Forty men with OSA and ED were treated Statistically significant increases were observed in the number of
with CPAP for a four-week run-in period and were then randomised arterial oxygen desaturations (decrease higher than 4%) per total
to receive either sildenafil 100mg on demand or no additional sleep time, the percentage of total sleep time with saturated oxygen
treatment for a period of six weeks. After a one-week washout they of less than 90%, the maximal duration of a desaturation event, the
were crossed over. All patients received six weeks of sildenafil and AHI owing to an increase in obstructive events with no significant
six weeks of no treatment additional to CPAP in a random order. The changes in mixed and central events and the percentage of total
success rate of intercourse attempts was 24.8% when men were sleep time elapsed in apnoea or hypopnoea. Sleep structure was also
given CPAP alone, compared with 61.1% when sildenafil and CPAP modified by the use of sildenafil, with an increase in stage 2 of non-
were combined. The addition of sildenafil resulted in 70% of men rapid-eye-movement sleep in comparison with placebo and a
being satisfied with their treatment. decrease in slow-wave sleep in comparison with baseline and
placebo. There were no significant differences in the percentage of
Forty-eight men with OSA and chronic obstructive pulmonary time spent in the supine position and the number of arousal events
disease (overlap syndrome) diagnosed with ED were treated per hour of total sleep. Headache, flushing and nasal congestion were
conventionally with CPAP and bronchodilators for six months.
35
ED more common in sildenafil patients. The authors concluded that in
intensity score was significantly improved in the entire study patients with severe OSA, a single 50mg dose of sildenafil at bedtime
population. When the clinical improvement criterion of an at least worsens respiratory and desaturation events. These findings may be a
five-point increase in ED intensity score was used, only 12 patients concern regarding the use of sildenafil by subjects with severe OSA.
(25%) responded. A significant percentage of patients whose ED did
not respond or who were not satisfied with conventional To our knowledge this is the first and only study to address the
management responded to on-demand sildenafil. We therefore issue of the safety of PDE-5 inhibitors in OAS with a systematic
concluded that adding sildenafil to conventional treatment is approach. Nevertheless, there are some drawbacks to this study. A
superior to conventional treatment alone in patients with OSA and small sample of 14 patients with severe OSA, indicated by more
chronic obstructive pulmonary disease. than 30 respiratory episodes per hour of sleep, is probably not
representative of the average male with ED and sleep-disordered
In a pilot study of 32 men with OSA and ED, testosterone levels breathing. Patients with such severe OSA would definitely receive
were measured, and the effects of testosterone administration on CPAP in everyday practice, and combining CPAP with sildenafil
sexual functions were assessed.
36
Of eight men with normal could minimise possible sildenafil deleterious effects on sleep
testosterone levels receiving conventional CPAP treatment for their apnoea. In addition, in real life patients are usually advised to take
OSA, six had improvements in their erectile function, assessed by their ED pill at least one hour before attempted intercourse. Given
62 EUROPEAN UROLOGICAL REVIEW
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