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Erectile Dysfunction

Erectile Dysfunction. John Ewan Sandyford Glasgow. Overview. Epidemiology Anatomy and Physiology History Examination Investigations Treatment. Definition of ED. DSM-IV (American Psychiatric Association, 2000)

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Erectile Dysfunction

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  1. Erectile Dysfunction John Ewan Sandyford Glasgow

  2. Overview • Epidemiology • Anatomy and Physiology • History • Examination • Investigations • Treatment

  3. Definition of ED DSM-IV (American Psychiatric Association, 2000) • Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection • The disturbance causes marked distress or interpersonal difficulty • The erectile dysfunction is not better accounted for by another Axis I disorder (other than a sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition

  4. Epidemiology Massachusetts Male Aging Study, Feldman et al. J Urol 1994; 150:54-61 Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 7

  5. Anatomy and Physiology of erection Reproduced from Carson C, Holmes S, Kirby R. Fast Facts- Erectile Dysfunction. Oxford: Health Press Limited; 2002: 8

  6. Anatomy and Physiology of erection • Parasympathetic nerves S2-4 mediate erection • Sympathetic nerves T11-L2 control ejaculation and detumescence • Smooth muscle relaxation • Nitric oxide diffuses into cavernosal smooth muscle cells, activates Guanylate cyclase converts guanosine triphosphate to cGMP resulting in smooth muscle relaxation. Effect of cGMP stopped by Phosphodiesterase type 5 which exists primarily in corpora cavernosa.

  7. Veno-occlusive Mechanism Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 :12

  8. History • Detailed description of problem, is it ED? • Causative factors • Sexual desire/libido • Ejaculatory disorders • Impact on quality of life and on relationship • Expectations of treatment

  9. Psychogenic Sudden onset Situational Normal waking and nocturnal erections Normal erection with masturbation Relationship problems Life event Anxiety, fear, depression Organic Gradual onset All situations Reduced or absent waking and nocturnal erections No erection with masturbation Penile pain Clues differentiating psychogenic from organic causes

  10. Relationship issues • Current relationship status • Length of relationship • Previous sexual partners and relationships • Partner issues e.g. menopause/pain/cancer

  11. History • Medical • Surgical • Psychiatric • Medication • Smoking • Alcohol • Recreational drug use

  12. Arteriogenic Cause of ED • Hypertension • Smoking • Diabetes • Hyperlipidaemia • Peripheral vascular disease • Blunt perineal or pelvic trauma • Pelvic irradiation

  13. Neurogenic causes of ED • Lesions of medial preoptic nucleus, paraventicular nucleus, hippocampus • Spinal trauma • Myelodisplasia (spina bifida) • Pelvic surgery/radiotherapy • Multiple sclerosis • Intervertebral disc lesion • Peripheral neuropathies • Alcohol • Diabetes • HIV

  14. Psychogenic and Psychiatric causes • Anxiety • Loss of attraction to partner • Relationship difficulties • Stress • Depression

  15. Psychogenic ED Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 33

  16. Endocrine causes of ED • Hypogonadism • Low testosterone • Raised SHBG • Raised Prolactin • Thyroid disease

  17. Antihypertensives Thiazides B blockers Centrally acting drugs Antidepressants Tricyclics MAO inhibitors SSRI Anticholinergics Atropine Antipsychotics Phenothiazines Anxiolytics Benzodiazepines Psychotropic drugs Alcohol Opiates Amphetamines Cocaine Drugs associated with ED

  18. Examination • Blood pressure • Peripheral pulses, palpate for AAA • Testes size and consistency • Secondary sexual characteristics • Penis for Peyronie’s plaques, phimosis

  19. ED and Coronary Artery Disease • Generalised atherosclerosis • Penile arteries smaller than coronary arteries • ED pre-dates coronary artery disease • Man with ED and no cardiac symptoms is a cardiac patient until proven otherwise

  20. Investigations • Fasting glucose and lipids • Morning testosterone and SHBG • If testosterone is low or borderline repeat with Prolactin, FSH and LH • Thyroid function • PSA

  21. Specialised Investigations • Vascular studies • Young patients with primary ED • History of trauma e.g. penile fracture • Patients unresponsive to medical therapies

  22. Treatment of ED General Measures • Smoking cessation • Reduce alcohol • Weight loss • Exercise

  23. Endocrine Disorders • Hypogonadism • Hyperthyroidism • Hyperprolactinaemia • Endocrinology referral

  24. Psychosexual therapy • Even if cause of ED is physical the patient will develop psychosexual issues • Performance anxiety • Sensate focus exercises • Relationship counselling

  25. Drugs for ED • Oral agents • Centrally acting dopamine-receptor agonist Apomorphine (discontinued in UK) • Phosphodiesterase type 5 inhibitors • Intra-cavernosal • Prostaglandin E1 Alprostadil • Intra-urethral • Alprostadil

  26. PDE5 inhibitors • Sildenafil (Viagra) 25mg, 50mg, 100mg • 1 hour before sexual activity • 4-6 hour window • Absorption delayed by fatty meal • Tadalafil (Cialis) 10mg, 20mg • 30 minutes before sexual activity • 36 hour window • Absorption not affected by food • Tadalafil (Cialis) 5mg • daily • Vardenafil (Levitra) 5mg, 10mg, 20mg • 30-60 minutes before sexual activity • 4-6 hour window • Absorption delayed by fatty meal

  27. PDE5 Physiology Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 40

  28. PDE5 Inhibitors Side Effects • Facial flushing • Headache • Nasal congestion • Dizziness • Dyspepsia • Visual disturbance (blue halo) • Priapism • Non-arteritic anterior ischaemic optic neuropathy

  29. PDE5 Contraindications • Recent cardiovascular event • Nitrates • Hypotension • Anatomical deformity • Angulation, cavernosal fibrosis, Peyronie’s • Predisposition to prolonged erection • Sickle cell disease • Multiple myeloma • Leukaemia

  30. PDE5 Drug Interactions • Nitrates • Glyceryl trinitrate, isosorbide mono or dinitrate • Chest pain after taking Sildenafil/Vardenafil no nitrates 24 hours, Tadalafil no nitrates 48 hours • Recreational amyl nitrate (Poppers) • Cytochrome P450 inhibitors • Protease inhibitors especially Ritonavir use very small dose • Cimetidine, Ketoconazole, Erythromycin • Alpha blockers

  31. Intracavernosal Injections • Alprostadil (Caverject, Viridal) 5-40 mcg • Independent of intact nervous system • Manual dexterity, adequate vision, training • Contraindicated: bleeding disorders, sickle cell anaemia, multiple myeloma, leukaemia • Side effects: penoscrotal pain, haematoma, fibrosis at injection sites, priapism • Papaverine, Phentolamine, Aviptadil (vaso-intestinal peptide) been used sole or with Alprostadil

  32. Intracavernosal Injections Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 53

  33. Intraurethral • Alprostadil (Muse) 125mg, 250mg, 500mg,1g • Pellet inserted with applicator • Massage penis to aid absorption • Side effects: Penile pain, dizziness, priapism rare

  34. Intraurethral Alprostadil Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 55

  35. Vacuum Devices • Blood trapped in intracorporal and extracorporal compartments of penis • Constricting ring at base of penis • Cyanosis, oedema, cold • Pivots at base below ring • Maximum time 30 minutes

  36. Vacuum devices Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 61

  37. Penile Prostheses • Semi-rigid rods • 2 piece inflatable prosthesis • 3 piece inflatable prosthesis with abdominal reservoir • Risks • Infection • Destroys corpora cavernosa • Erosion and extrusion • Mechanical failure

  38. Penile Prosthesis Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 66

  39. Diabetes Multiple sclerosis Parkinson’s Disease Poliomyelitis Prostate cancer Prostatectomy incl TRP Radical pelvic surgery Severe pelvic injury Renal failure On dialysis Transplant Single gene neurological disease Spinal cord injury Spina bifida Receiving NHS Rx 14/9/1998 Severe distress NHS Prescription for ED

  40. Private Prescription • Pharmacy costs vary • Sildenafil 100mgX4 £25-£40 • Pharmacy2U £25

  41. Conclusions • ED is a common problem • Impact on patient and partner/s • Overlap of psychological and physical • May be initial presentation of diabetes or coronary artery disease • Good range of safe and effective therapies • If YOU don’t ask your patient may be too embarrassed to tell you

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