Erectile dysfunction (ED) is a public health problem with well-determined risk factors and manifestations that compromise the well-being and overall quality of life of affected individuals.[1] The prevalence of ED and its development are mostly related to restrictive or obstructive alterations in blood flow.[2] The clinical picture can worsen when a man feels vulnerable and embarrassed to seek treatment, often depending on a support network to access healthcare services.[2] Therefore, it is necessary to create procedures and protocols to facilitate men's access to healthcare services and to improve treatment adherence. Our service has a partnership with public management to improve service provision for men with ED. The aim of this study is to describe the management of a public health service focused on men with erectile dysfunction.

This is a longitudinal observational study involving men of any age complaining of ED. The evaluation was conducted by a multidisciplinary team consisting of a pelvic physiotherapist, nurse, ultrasound physician, urologist, and psychologist. The patient data presented are from evaluations conducted between November 2021 and January 2024. All men were referred to the service from other public services or actively sought out assistance, and all of them scheduled for screening. Screening was performed by a nurse or physiotherapist who compiled all patient information, after which the patients were referred for evaluation with an ultrasound physician. During penile doppler ultrasound, the physician, accompanied by a physiotherapist and psychologist, explained all procedures, and patients were instructed to lie in a supine position with the exposed penis. An intracavernous injection inducing erection (provided by Flukka Laboratory) was administered at the base of the penis. At this point, Peak Systolic Velocity (PSV), Final Diastolic Velocity (FDV), and cavernous artery diameter data were collected using the MindRay DC-40 model equipment. Following evaluation, all men underwent 12 sessions of physiotherapy consisting of pelvic floor muscle training, low-intensity shock wave therapy, and non-ablative radiofrequency therapy. Throughout the follow-up, men who demonstrated psychological distress due to ED were suggested consultations with psychologists from our service. After the 12th session, men were reassessed.

Of the total of 189 men with a mean age of 63.3 years (±9.9), 60 (31.7%) were diabetic, 105 (55.6%) were hypertensive, 139 (73.9%) had a history of prostatectomy, 141 (74.6%) complained of urinary incontinence, 22 underwent radiotherapy sessions (11.6%), 3 (1.6%) underwent chemotherapy, and 5 (2.6%) underwent hormone therapy. These data are presented in table 1. Regarding the data collected from penile doppler ultrasound upon their arrival at our service, the following values were found: for PSV, 28.8 cm/s (±16.0) on the left side and 28.9 cm/s (±16.6) on the right side. For FDV, 4.2 cm/s (±3.8) on the left side and 4.0 cm/s (±3.4) on the right side; and for the diameter of the cavernous artery before intracavernous injection, 0.55 mm (±0.16) on the right side and 0.51 mm (±0.15) on the left side. The diameter of the same artery under the effect of intracavernous injection was 0.69 mm (±0.16) on the right side and 0.69 mm (±0.16) on the left side. After the first 12 sessions, the following values of 115 men were collected for PSV: 24.87cm/s (±13.1) on the left side and 26.21cm/s (±14.5) on the right side. Regarding FDV, 2.9 (±2.1) on the left side and 2.77 (±2.8) on the right side. As for the diameter of the cavernous artery before intracavernous injection, it was found to be 0.5mm (±0.15) on the right side and 0.51mm (±0.15) on the left side, and the diameter of the same artery under the effect of injection was 0.66mm (±0.15) on the left side and 0.65 (±0.14) on the right side. See these data in table 2.

The data presented are from a protocol for men with complaints of ED in our service. We observed that most of them have a history of prostatectomy surgery, are hypertensive, and a considerable number of them have diabetes. This leads to the realization of chronic and long-standing conditions that would require more than 12 sessions for more adequate monitoring. Another characteristic of this patient group is their average age; these are patients who are showing the first signs of androgenic dysfunction, which requires a systemic approach due to reduced testosterone levels in the blood.[2] The history of oncological treatment in this sample shows that a small fraction of the men followed in our service requires additional treatment to resolve prostate cancer, indicating the severity of the cancer. Regarding hemodynamic findings, we can affirm that the majority of men have erectile dysfunction due to arterial insufficiency (PSV<30cm/s), which is the difficulty of blood flow to the penis at the time of erection. This finding is consistent when considering the profile of the sample composed of men with a history of conditions resulting in poor circulation in the penis and who would require guidance regarding the effects of diabetes and arterial hypertension on blood flow to the penis.[1,3] When comparing the hemodynamic values from the initial evaluation and reassessment, we observed no improvement, suggesting that more physiotherapy sessions are needed in patients with chronic conditions to allow time for vascular improvement and for patients to make lifestyle adjustments. Another striking finding is the loss of 64 patients (33.9%) who did not undergo reassessment, indicating a pattern of low adherence to seeking and maintaining treatment, possibly due to a culture of machismo that makes men uncomfortable showing sexual vulnerabilities even in safe environments such as healthcare services.

In our service, we have a sample of men with chronic conditions that lead to the development of ED due to arterial insufficiency and who showed no improvement after 12 physiotherapy sessions. To mitigate the low adherence of men with erectile dysfunction, it is necessary for healthcare services to develop health education strategies to raise awareness among this population.

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