Vein Patch Closure Using Below the Knee Greater Saphenous Vein for Femoral Endarterectomy Procedures is Not Always a Safe Choice.

BACKGROUND: The complication of vein patch rupture is well described after carotid patch angioplasty; however, there is a paucity of data about the safety of vein patch closure in the setting of femoral endarterectomy. METHODS/RESULTS: From May 2012 to May 2015, 115 femoral endarterectomies with patch closure were performed. A patch rupture occurred in three cases (2.6%) with a mortality rate of 66% (2/3). In all cases the greater saphenous vein below the knee was used as patch material. DISCUSSION/CONCLUSION: Vein patches, particularly from small calibre veins, should be excluded in femoral endarterectomy procedures as they pose a substantial risk of rupture.

[Sexual dysfunction associated with psychotropic drugs and treatment options]. / Psychopharmakaassoziierte sexuelle Funktionsstörungen und ihre Behandlung.

BACKGROUND: Sexual dysfunction associated with psychotropic drugs is a threat to patient quality of life and a major reason for non-compliance. Psychotropic agents can impair the sexual response in different ways due to their neurobiological mode of action. OBJECTIVE: Presentation of the frequencies of sexual functional disorders for selected psychopharmacological groups and the available treatment modalities. METHODS: Literature search, selection and review of relevant studies. RESULTS: The most relevant groups for impairments are antidepressants and antipsychotics due to the serotonin agonistic and anti-dopaminergic properties as well as the prolactin increasing characteristics. Agents with a favorable side effects profile are now available. All phases of the sexual response are affected. DISCUSSION: The treatment of psychiatric disorders should follow a comprehensive treatment plan that anticipates a likely sexual dysfunction at the initiation of treatment. The main aim is improvement of the underlying primary disorder. Some limited evidence-based treatment strategies are available.

Treatment expectations of men with ED and their female partners: an exploratory qualitative study based on grounded theory.

Erectile dysfunction (ED) can impair the quality of life and the relationship. An early treatment is necessary to avoid the development of comorbid complaints. To arise the help-seeking behavior and to improve the treatment of affected men, it is necessary to be aware of the treatment expectations. The objective of this study was to investigate the treatment expectations of men with ED and their female partners. This is an explorative qualitative study using semistructured telephone interviews with 12 men with ED and their female partners. Interviews were tape-recorded, transcribed and analyzed on the basis of the grounded theory. We could identify various treatment expectations, which could be differentiated into expectations according to the conditions (for example, low costs and an early access), the handling of the practitioner (for example, showing interest and taking the patient seriously or incorporate the female partner), the treatment itself (for example, clearing the causes and helpful medication) and the treatment outcome (for example, having no ED and more sexual desire). Considering the identified expectations could increase treatment motivation and compliance. We derive five theses from our data, how to implement our findings.

[Addiction counselling in the surgical emergency room. Implementation of a brief intervention for alcohol-intoxicated patients]. / Suchtberatung in der unfallchirurgischen Notaufnahme. Implementierung einer Kurzintervention bei alkoholintoxikierten Patienten.

INTRODUCTION: The primary care system, especially emergency rooms, seems to be an ideal location for the implementation of brief interventions for secondary prevention of alcohol use disorders. The present study examines whether a brief intervention can both lead to a reduction in alcohol quantity and consumption frequency as well as to an increased contact with alcohol counselling services. METHODS: The brief intervention for patients with alcohol consumption consisted of an interview about the alcohol drinking patterns and the delivery of a flyer from the local counselling services. One month later a follow-up interview was conducted. RESULTS: A total of 64 patients participated in the study; 37 patients gave their consent for follow-up. Patients with harmful/dependent alcohol use significantly reduced their alcohol amount (p<0,001) and consumption frequency (p<0,02). Patients who linked the injury to the consumed alcohol reduced their drinking frequency significantly more than those who did not (p=0,01). The intervention had no influence on the contact rate with counselling services. DISCUSSION: Promising evidence was found, which needs confirmation in the form of randomized controlled trials with focus on long-term effects.

Treatment motivation of men with ED: what motivates men with ED to seek professional help and how can women support their partners?

Although ED can impair sexual satisfaction as well as the quality of partnership and life, men affected often avoid seeking treatment. There is growing evidence that women have an influence on their partner's help-seeking behavior. This qualitative study examined men with ED and their female partners in order to detect motivational factors for men to seek treatment and motivational actions of the women to support their partners. Twelve couples took part in a semi-structured telephone interview, which was performed separately in men and women. Analysis was on the basis of the Grounded Theory. The identified motivational factors could be divided into extrinsic (for example, media, female partner) and intrinsic (for example, desire to clarify the cause of the ED, hope for improvement) factors. Women can support their partners in treatment-seeking through various motivational actions such as talking with each other, showing interest and dealing actively with the problem, appealing to the male self-esteem, supporting the doctor's visit, forcing the treatment, active cooperation and participation in the treatment or initiating sexual intercourse. On the basis of these findings, recommendations for women were developed to support their partners and increase the probability of help-seeking behavior.

Involvement of the atrial natriuretic peptide transcription factor GATA4 in alcohol dependence, relapse risk and treatment response to acamprosate.

In alcoholism, both relapse to alcohol drinking and treatment response are suggested to be genetically modulated. This study set out to determine whether the top 15 single nucleotide polymorphisms (SNPs) of a recent genome-wide association (GWA) and follow-up study of alcohol dependence are associated with relapse behavior and pharmacological treatment response in 374 alcohol-dependent subjects who underwent a randomized, double-blind, placebo-controlled trial with acamprosate, naltrexone or placebo. The single nucleotide polymorphism, rs13273672, an intronic SNP in the gene for GATA-binding protein 4 (GATA4), was associated with relapse within the 90-day medical treatment period (P<0.01). Subsequent pharmacogenetic analyses showed that this association was mainly based on patients treated with acamprosate (P<0.01). In line with the observation that natriuretic peptide promoters are modulated by GATA4, a significant gene dose effect on the variance of atrial natriuretic peptide (ANP) plasma concentration in the different GATA4 genotypes (P<0.01) was found. Hence, genetic variations in GATA4 might influence relapse and treatment response to acamprosate in alcohol-dependent patients via modulation of ANP plasma levels. These results could help to identify those alcohol-dependent patients who may be at an increased risk of relapse and who may better respond to treatment with acamprosate.

[Sexual dysfunction and its consequences in patients with cardiovascular diseases]. / Sexuelle Funktionsstörungen bei Herzkranken und die Folgen.

PURPOSE: Due to the high prevalence of sexual disorders in men and women with cardiovascular disease, the associations between sexual dysfunction, depression, anxiety, quality of life and partnership were investigated. Studies examining impairments to certain aspects of psychological health and interpersonal life in cardiac patients are still lacking. The SPARK (Sexuality of Patients in Rehabilitation of Cardiovascular Diseases) investigation is the first study which explores these relevant associations in German rehabilitation patients. METHODS: Five rehabilitation centers for cardiovascular diseases took part in our cross-sectional study. Associations between sexual dysfunction and depression, anxiety, quality of life and partnership were tested using z-tests (resulting parameter prevalence rate ratio, PRR) and via multiple binary logistic regressions controlling for age and severity of cardiovascular disease as possible confounders (resulting parameter odds ratio, OR). RESULTS: Sexual function could be assessed in 261 men and 75 women (sexual activity during the previous month; for detailed flow chart see Fig. 1). In total, 43.1% of female patients reported a sexual dysfunction, while 20.2% of male patients stated to have at least moderate erectile dysfunction (ED). The proportion of self-assessed sexual problems is shown in Fig. 2. Women with a sexual dysfunction were impaired to a significantly higher extent compared to women without sexual dysfunction with regard to their quality of partnership (PRR 13.0; p=0.019; OR 25.42, confidence interval, CI, 2.5-254.9), anxiety (PRR 3.2; p=0.053; OR 4.43, CI 1.2-16.4) and psychological quality of life (PRR 2.4; p=0.115; OR 6.08, CI 1.6-22.9). Men with ED reported significantly stronger depression (PRR 3.6; p=0.003; OR 3.63, CI 1.5-8.8) and anxiety (PRR 2.4; p=0.008; OR 2.88, CI 1.4-5.9) compared to men without ED. For detailed information see Tables 1 and 2. CONCLUSION: Due to the high proportion of men and women with cardiovascular disease reporting sexual disorders, depression and anxiety, screening for these disorders should be an integral part of comprehensive rehabilitation programs. In particular, the diagnosis and treatment of psychiatric comorbidity seem to be necessary from a tertiary preventive perspective.

[Patient safety indicators for obstetrics: a Delphi based study]. / Indicateurs sécurité en obstétrique : une étude Delphi.

OBJECTIVE: Clinical indicators are increasingly used to assess safety of patient care. In obstetrics, only a few indicators have been validated to date and none is used across specialties. The purpose of this study was to identify and assess for face and content validity a group of safety indicators that could be used by anaesthetists, obstetricians and neonatologists involved in labour and delivery units. MATERIALS AND METHODS: We first conducted a systematic review of the literature to identify potential measures. Indicators were then validated by a panel of 30 experts representing all specialties working in labour and delivery units. We used the Delphi method, an iterative questionnaire-based consensus seeking technique. Experts determined on a 7-point Likert scale (1=most representative/7=less representative) the soundness of each indicator as a measure of safety and their possible association with errors and complications caused by medical management. RESULTS: We identified 44 potential clinical indicators from the literature. Following the Delphi process, 13 indicators were considered as highly representative of safety during obstetrical care (mean score

[Testosterone and psyche]. / Testosteron und Psyche.

Testosterone, like other steroid hormones, crosses the blood-brain barrier, and the androgen receptor is present in most parts of the human brain. Therefore, testosterone has many effects on the psyche, mainly in men but also in women. Most often discussed is its influence on sexuality, especially on desire and sexual fantasies, spontaneous nighttime erections, sexual activity, and the number of orgasms and ejaculations. Mood and energy are also testosterone related. Testosterone deficiency in male patients can lead to depressive disorders. In the past, elevated testosterone levels were seen as responsible for strongly aggressive behaviour. Some cognitive functions (spatial and mathematical sense, verbal skills) are, at least to a certain point, testosterone related. Due to the extremely complex functioning of the human brain, a scientifically exact statement regarding the true relationship between testosterone and human behaviour is not possible. On the one hand, the cause is definitively multifactorial, but on the other, testosterone is metabolised in the brain, and the metabolites act by themselves. Furthermore, a bidirectional relationship exists between hormones and human behaviour: Human behaviour is influenced by hormones, and human behaviour also has a direct influence on the levels of many hormones in the human body. Finally, much data in this field are derived from animal studies; studies on humans cannot be conducted because of ethical reasons or scientific and technical problems.

Cluster-randomized controlled trial of dissemination strategies of an online quality improvement programme for alcohol-related disorders.

AIMS: This project investigated different dissemination strategies of an online quality improvement programme for alcohol-related disorders into routine care in South Baden and South Württemberg in Germany. METHODS: In a cluster-randomized controlled trial, 112 general practices were randomized into three groups. The first group (n = 43) received access to the online system and a training programme for the general practitioners (GPs). The second group (n = 42) additionally received education for the whole practice team. The third group (n = 27) acted as control and received only access to the online system. RESULTS: Two thousand six hundred and forty-seven practitioners were asked to take part in the study, and it was possible to randomize 112 (4%) practices. There were no significant differences concerning the use of the system between the groups: 41.9% of the GPs in the first group, 42.9% in the second group and 44.4% in the control group used the system. In terms of only the system users, 55.6% of the GPs in the first group, 33.3% in the second group and 8.3% in the control group used the system six times or more (P = 0.019). Diagnostic assessments made by the GPs in the groups differed substantially: 72.2% of diagnoses in the first group were correct, while this figure lay at 69.7% in the second group and 36.4% in the control group (P = 0.034). CONCLUSIONS: No effect of the additional training on the primary outcome (acceptance) was identified, but on two of the secondary outcomes. Further cost-effectiveness studies should investigate whether the effort involved in providing training additionally to the system is justifiable. The study is registered at ClinicalTrials.gov: NCT00314067. This article conforms to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement (Moher et al., 2001; Campbell et al., 2004).

[E-Learning--an important contribution to general medical training and continuing education?]. / E-Learning--eine wichtige Unterstützung in der medizinischen Aus-, Fort- und Weiterbildung?

There is increasing activity in the development of e-learning modules for general medical training and continuing education. One of the central advantages of e-learning is flexibility regarding time and place of its use. The quality of the available e-learning opportunities varies quite considerably. For users it is often not easy to assess the quality of e-learning modules or to find offers of high quality. This could be a reason for the fact that despite the huge number of e-learning modules still only few students and physicians are using them. This is although e-learning has proven to be as effective as and even more efficient than learning in the classroom or with paper-based materials. This article summarizes the different models of e-learning, how and where to find offers of high quality, advantages of using e-learning, and the effectiveness and efficiency of such offers. In addition problems of e-learning and possibilities to overcome these problems are shown.

Finding the ideal place for a psychotherapeutic intervention in a stepped care approach--a brief overview of the literature and preliminary results from the Project PREDICT.

AIMS: To provide an overview over empirical evidence regarding stepped care approaches that include psychotherapies. To present own preliminary study results in alcohol dependent patients. METHODS: Publications were searched in the databases Medline, PsycINFO and the internet search engine Google Scholar. Inclusion criteria were psychosocial treatment and psychiatric disorders. Our own study consists of two steps. In step 1 patients receive anti-craving medication or placebo and Medical Management (MM). After a relapse to heavy drinking patients can step up and after randomization they either continue with the same treatment or they receive additional alcoholism specific psychotherapy (ASP). RESULTS: Evidence suggests that stepped care might be efficacious in patients with obsessive-compulsive behavior and depression. There is no evidence for efficacy in problem drinkers. Results of our own study show that the completer rate in MM alone is higher than in ASP with MM, but there are no significant differences concerning age, sex and disease severity between completer and non-completer in both study arms. CONCLUSIONS: Further research with regard to stepped care in alcohol dependent patients is needed. An introduction of the psychotherapy at earlier stages might be sensible.

A typology of men's sexual attitudes, erectile dysfunction treatment expectations and barriers.

In total, 1122 men completed non-validated structured interviews on sexual attitudes and on erectile dysfunction treatment expectations and barriers. Dimensions of sexual attitudes and treatment expectations and barriers were extracted by factor analysis and subjects were grouped into types by cluster analysis. Five types emerged: the sensation seeker, the sensuous, the anxious, the confident and the abstinent. The majority of men agreed on the importance of sex for the partnership. For the majority of anxious, sensuous and sensation-seeking men, sex was important for self-esteem. Expecting quality of life, enjoyment, self-esteem and hard reliable erections from treatment with phosphodiesterase-5 inhibitors, anxieties for side effects and loss of control, sexual abstinence and desire for an intensive sex life had the strongest impact on the likelihood of use. Men's sexual attitudes vary considerably and impact reactions to erection difficulties. A typology of five groups was developed, which will contribute to research on and understanding of men's sexual and treatment-seeking behaviors.

[Diagnostic and treatment of alcohol-related disorders. Results of a representative survey in counseling centers]. / Diagnostik und Behandlung alkoholbezogener Störungen - Ergebnisse einer repräsentativen Umfrage in Suchtberatungsstellen.

BACKGROUND: Due to the high prevalence of alcohol related disorders (dependent, harmful and at risk drinking) the improvement of the outpatient treatment situation in this area is of major importance. The aim of this study was to examine the treatment structure and modalities of patients with alcohol related disorders in counseling centers for substance abusers based on the questioning of the counselors. METHODS: A 3-page questionnaire to characterize the institution and six standardized 10-page questionnaires (for the counselors) were sent to all counseling centers (n = 123) in Baden-Württemberg. The counselors were asked about diagnostic and therapeutic procedures they had employed in the last patient seen. Further questions regarded patient related and structural problems. RESULTS: The results are related to a representative sample of 262 counselors of 73 counseling centers (59.5 %). Further 28 counseling centers (22.6 %) were not able to take part in the survey because they do not care for people with alcohol related disorders. The sample complies with respect of relevant dimensions (sponsoring institution, profession of the counselors, age distribution of patients, accomplished interventions) with the population of counseling centers in Baden-Württemberg. The reported patients were predominantly male (80.5 %) and nearly all patients were addicted to alcohol (95.8 %). They had a mean age of 41,9 +/- 10 years, high acceptance of diagnosis (79.2 %) and treatment (80.3 %) and only 6.4 % used multiple substances. The results with respect of the diagnostic procedure refer to a structured, broad and professional procedure. 63.4 % of the counsellors are geared to formal diagnostic criteria when making a diagnosis. All relevant history elements are observed. But the study pointed towards some deficits in recognising suicidal tendencies. The own responsibility related to the supply of people with alcohol problems is predominantly seen in educational advertising and counselling, but also in numerous other areas the own responsibility is judged very high. Further training is particularly seen regarding relapse prevention and suicidality. The co-operation with several institutions, e. g. general practitioners, is judged to be relatively low. DISCUSSION: The majority of patients described by the counselors were dependent drinkers. This indicates that harmful and at risk drinkers are hardly reached by counseling centers. So there is clear space for optimizing the care for people with alcohol-related disorders.

Can written information material help to increase treatment motivation in patients with erectile dysfunction? A survey of 1188 men.

Although erectile dysfunction (ED) prevalence is high, patients and physicians often have problems discussing this issue. This study examines whether written information material increases motivation to seek treatment in patients with ED. For the study, persons were able to order information material about sexual problems within the context of a public campaign. From a total of 70,000 responders, 8000 persons were asked to fill out an epidemiological questionnaire. The response rate yielded 18.4%, the data of 1188 men with ED were analyzed. As a result of the information material, 28.3% of the untreated men intended to seek treatment and 38.5% of the men who had not spoken with their physician about their problem, planned to do so now. Nearly all responders were satisfied with the information material. These data reflect the usefulness of written information for men with ED. It not only serves as an informational source for patients but may also encourage them to seek treatment.

[Diagnostics and treatment of alcohol-related disorders: results of a representative study in psychiatric and psychotherapeutic practices]. / Diagnostik und behandlung alkoholbezogener störungen - ergebnisse einer repräsentativen umfrage in psychiatrischen und psychotherapeutischen praxen.

BACKGROUND: Alcohol use disorders (AUD) are of high prevalence in the community. The aim of the present study is to examine the diagnostic and therapeutic strategies of psychiatrists and psychotherapists in patients with AUDs. METHODS: A standardized questionnaire was sent to all psychiatrists and psychologists in the South Badenia region (n = 745). It consisted of general questions and those regarding diagnostic and therapeutic procedures in the last patient seen with an AUD. A total of 224 questionnaires sent back by 160 psychotherapists [PT] and 64 psychiatrists [P] could be included in the analysis. RESULTS: The mean stated prevalence of AUDs was 5 %. The mean age of the reported patient was 44 +/- 10 years, 60 % were men. The initial reason for consultation in psychotherapy was in 61.9 % depression in comparison to 40.7 % psychiatry (p < or = 0,01). The majority of patients seen by psychiatrists (44.1 %) were referred by their general practitioners. Standardised screening instruments were rarely used. The concordance of the diagnostic judgement and formal ICD 10-criteria was 74.5 % [P] vs. 45.5 % [PT] (p

Management of sexual dysfunction due to antipsychotic drug therapy.

BACKGROUND: Psychotropic drugs are associated with sexual dysfunction. Symptoms may concern penile erection, lubrication, orgasm, libido, sexual arousal or overall sexual satisfaction. OBJECTIVES: To determine the effects of different strategies (e.g. dose reduction, drug holidays, adjunctive medication, switching to another drug) for treatment of sexual dysfunction due to antipsychotic therapy. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group's Register (June 2006), the Cochrane Library (Issue 2, 2005), MEDLINE (1966-8/2005), PsycLIT (1974-8/2005), EMBASE (1980-8/2005) and references of all identified studies for further trials. We contacted relevant pharmaceutical companies and authors of trials. SELECTION CRITERIA: We included all relevant randomised controlled trials involving people with schizophrenia and sexual dysfunction. DATA COLLECTION AND ANALYSIS: Working independently, we extracted data. For dichotomous data we calculated random effects odds ratios (OR) with 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data we calculated weighted mean differences on the basis of a random effects model. We analysed crossover trials under consideration of correlation of paired measures. MAIN RESULTS: Currently this review includes two pioneering crossover studies (total n=42 men, duration 2-3 weeks). They reported significantly more erections sufficient for penetration when receiving sildenafil compared with when receiving placebo (n=32, WMD 3.20 CI 1.83 to 4.57), a greater mean duration of erections (n=32, WMD 1.18 CI 0.52 to 1.84) and frequency of satisfactory intercourse (n=32, WMD 2.84 CI 1.61 to 4.07). The second trial found no evidence for selegiline as symptomatic treatment for antipsychotic-induced sexual dysfunction compared with placebo (n=10, WMD change on Aizenberg's sexual functioning scale -0.40 CI -3.95 to 3.15). AUTHORS' CONCLUSIONS: We are not confident that crossover studies are appropriate for this participant group. Sildenafil may be a useful option in the treatment of antipsychotic-induced sexual dysfunction in men with schizophrenia, but this conclusion is based only on one small short trial. Further well designed, conducted and reported trials are urgently needed.

A meta-regression analysis of treatment effect modifiers in trials with flexible-dose oral sildenafil for erectile dysfunction in broad-spectrum populations.

Several trials and reviews provide evidence for the efficacy of phosphodiesterase-5 inhibitors in the treatment of erectile dysfunction (ED). However, little is known about the impact of treatment effect modifiers other than concomitant diseases. Our objective was to identify patient and trial characteristics as well as methodological and publication-related issues that are associated with the treatment effect measured in flexible-dose randomized controlled trials of oral sildenafil for ED. The MEDLINE and the Cochrane Central databases were searched for efficacy trials of sildenafil. Thirteen trials fulfilled all inclusion criteria. A series of meta-regression and graphical analyses were performed to test the impact of possible effect modifiers. Treatment effect was influenced by mean baseline disease severity and mean duration of the disease. These associations were at least partly mediated by placebo response. Trial duration, age of patients and etiology of ED in patients did not have any significant influence on the treatment effect. The year of publication of primary trials was also related to trial findings. Our analysis adds important data to enable the control of confounding variables in future trials and meta-analyses. It might also help the individual to assess the unbiased efficacy and true innovative potential of available and forthcoming pharmacological agents.

[Diagnostic and treatment approaches to alcohol-related disorders]. / Diagnostik und Behandlung alkoholbezogener Störungen -- Ergebnisse einer Umfrage in hausärztlichen Praxen.

BACKGROUND: Due to their high prevalence alcohol related disorders (dependent, harmful and at risk drinking) are of major importance for the general practitioner (GP). The aim of this study was to examine the diagnostic and treatment strategies employed by the general practitioners. METHODS: A standardized 10-page questionnaire was mailed to a representative sample (n = 1232) of the general practitioners in south-west Germany. They were asked about diagnostic and therapeutic procedures they had employed in the last patient seen. Further questions regarded patient-related and structural problems. The response rate was 24.3 %. RESULTS: The reported patients had a mean age of 49 +/- 10.3 years. 70.6 % were of male sex. The mean duration of the last patient contact was 18.7 minutes. The diagnosis originated more in clinical impression than in use of screening instruments (0.7 % of patients) or formal diagnostic criteria. 76.7 % fulfilled ICD-10 criteria for dependent drinking, 65.0 % were judged dependent drinkers by the GP's. In most cases the patient had been referred to inpatient services. The main intervention (97.3 % of cases) was disease related counseling. 69.4 % were judged to be quite ill and severely ill. In most cases an inpatient referral had taken place. Pharmacotherapeutic measures were relatively rarely employed (11.3 %). As the major impediments of treatment patient related factors were stated (lack of acceptance of diagnosis, resistance to treatment). DISCUSSION: The majority of patients described by the GP's were dependent drinkers. This indicates that many at risk drinkers might perhaps not be correctly identified. Concerning therapeutic competency patient-related factors are considered as the major impediments for the delivery of effective care. This reflects a view of GP's that patients with alcohol problems are being difficult and time consuming. This should be carefully addressed by future GP-education programs.

Efficacy of PDE-5-inhibitors for erectile dysfunction. A comparative meta-analysis of fixed-dose regimen randomized controlled trials administering the International Index of Erectile Function in broad-spectrum populations.

This meta-analytic study aims to estimate the likely improvements of erectile dysfunction (ED) measured by the International Index of Erectile Function (IIEF) at the highest fixed dosages of the three available PDE-5-inhibitors: sildenafil, tadalafil, and vardenafil. MEDLINE and the Cochrane Library were searched electronically for efficacy trials of PDE-5-inhibitors for treating ED. In addition drug manufacturers were contacted to provide unpublished or unrecorded congress proceedings. Randomized, double-blind, placebo-controlled, parallel-group, maximum fixed-dose, broad-spectrum efficacy trials using IIEF were included in the analysis. Data were independently extracted by two reviewers. The results were pooled using weighted mean differences. A formal indirect comparison (including Bonferroni-correction) was conducted to estimate the differences between agents. A total of 14 trials were included in the meta-analysis (three with 100 mg sildenafil, eight with 20-25 mg tadalafil, and three with 20 mg vardenafil). All trials were of good methodological quality. Overall heterogeneity was moderate: I(2)=33.2%, chi(2)=19.47, P=0.11. The funnel plot suggested moderate likelihood of publication bias. Pooled results of IIEF-improvement were for sildenafil 9.65 (95% CI: 8.50, 10.79) points, tadalafil 8.52 (7.61, 9.42) points, and vardenafil 7.50 (6.50, 8.50) points, respectively. Sildenafil proved to be significantly more effective than vardenafil (d=2.15, P=0.006), other pairwise comparisons showed no difference in efficacy. All PDE-5-inhibitors are highly effective in the treatment of ED. At maximum dosage they improve erectile function 7-10 points on the IIEF compared to placebo-treatment. There is evidence that sildenafil might be more efficacious than vardenafil, although this is to be interpreted with caution. To prove higher efficacy truly independent comparative trials are needed.