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