Performance anxiety may always be present at some level in men with erectile dysfunction ( ED ). Anxiety over the failure to respond sexually may further aggravate impaired sexual responsiveness , and can lead to escalating anxiety after a succession of intercourse failures .

The loss of self-esteem can affect behaviour , causing a man to avoid intimacy , which can consequently affect his partner ’ s sexual quality of life and self-esteem .

Successful treatment of the functional aspects of ED is one of the key steps necessary to overcome performance anxiety and to improve men ’ s sexual experience and relationship quality .

SILDENAFIL DOSAGE Sildenafil citrate has proven efficacy in the treatment of ED . Sildenafil 50mg is the recommended starting dose for men with ED . However , most men are later titrated to sildenafil 100mg for improved efficacy .

To improve response , men are often titrated to a dose of 100mg sildenafil after beginning treatment at the 50mg dose , but whether the 100mg dose is an optimal starting dose for most men was an unanswered question . Improvements in relationship , treatment , and sexual satisfaction were observed in previous flexible dose trials in men who were titrated from 50-100mg .

A randomised , double-blind , placebo-controlled trial assessed the tolerability and efficacy of sildenafil initiated at the 100mg dose in men with ED . This trial compared the initiation of treatment with sildenafil 50mg and 100mg to more clearly assess the effect of a 100mg starting dose

on both functional and psychosocial parameters .

The main outcome measures were efficacy , tolerability , treatment satisfaction , and other end points were measured at baseline and / or the end of the double-blind and open-label phases and compared between placebo and sildenafil initiated at doses of 50 and 100mg .

100mg DOSE RESULTS Treatment at either sildenafil dose during the double-blind , placebocontrolled phase significantly improved scores on all patient-reported outcomes vs . placebo without increasing adverse events . Significant differences favoring the 100-mg dose during the double-blind , placebocontrolled phase were observed for measures assessing satisfaction with treatment and relationship factors . Improvements in functional ability after successful treatment of ED were previously associated with improvements in IIEF psychosocial domains .

Improvements in patient-reported outcomes from baseline were statistically significant for both sildenafil 50 and 100mg compared with placebo . At the end of treatment , 56 % of men on the 100mg dose felt no anxiety about the next intercourse attempt compared with 39 % in the 50mg group ( odds ratio 2.03 ; P = 0.0197 ).

Changes in functional scores from baseline were not statistically significant with the 100-mg dose compared with the 50mg dose . Measures of treatment satisfaction and sexual experience significantly favoured the 100mg dose compared with the

50mg dose . There was no increase in adverse events with the higher dose .

The 100mg dose significantly increased the number of men who experienced no feelings of anxiety about the next intercourse attempt compared with the 50mg group . One interpretation of the overall results is that small improvements in erectile function may lead to much larger improvements in psychosocial measures and a better sexual experience in men with ED .

In many men , initiating sildenafil at the 100mg dose may be beneficial , even if dose reductions to 50mg are possible later on . In clinical practice , the 50mg dose may not produce optimal erectile rigidity in some men compared with the 100mg dose , leading to initial disappointment and discouraging men from seeking additional help . This should be taken into consideration in clinical practice .

This result is illustrated by previous studies that followed men treated in the clinical setting who discontinued treatment because of the lack of efficacy . With proper instruction on the use of sildenafil and dose optimisation , many of these men were later successfully treated . ED affects selfesteem and quality of life . The adverse event profile of the 50- and 100mg doses is similar .

Consequently , it may be better to prescribe sildenafil 100mg to ensure immediate efficacy , rather than risk causing the patient further discouragement , and restore his confidence in his erectile ability sooner .

Men who enrolled in the study were motivated to treat their ED , and were willing to attempt intercourse at least twice weekly . Therefore ,

the concomitant improvement in psychosocial factors may be partly caused by patient selection . Additionally , the trial included men with little or no previous experience with PDE5 inhibitor treatment for their ED , and most men had mild to moderate ED . Therefore , the results may not completely extrapolate to men who have prior experience with PDE5 inhibitors or severe ED .

CONCLUSION Sildenafil at 50mg or 100mg significantly improved erection quality , treatment satisfaction , anxiety levels , and the sexual experience compared with placebo . Sildenafil 100mg improved the sexual experience and treatment satisfaction , and reduced feelings of anxiety compared with the 50mg dose .

Feelings of anxiety toward the next attempt at intercourse decreased in men treated with sildenafil 50mg or 100mg compared with baseline levels . Anxiety was graded as extreme , high , moderate , slight , or none at baseline and was reassessed at the end of double-blind treatment . No men reported being extremely anxious .

SAFETY Most adverse events were mild or moderate in severity , and occurred at similar frequencies in the sildenafil 50mg and sildenafil 100mg groups .

Reference Loran , Ströberg , Stecher et al . Sildenafil Citrate 100mg Starting Dose in Men with Erectile Dysfunction in an International , Double- Blind , Placebo-Controlled Study : Effect on the Sexual Experience and Reducing Feelings of Anxiety About the Next Intercourse Attempt . J Sex Med 2009 ; 6:2826-2835 .

22 MAY 2017 | MEDICAL CHRONICLE