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Erectile Dysfunction. HDR Peer Presentation Pennine Training Scheme Dr Lorna Clark, GPST. What is Erectile Dysfunction. Synonym: Impotence Inability to attain and maintain an erection sufficient for satisfactory sexual performance Benign Significant impact on quality of life.

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Erectile dysfunction l.jpg

Erectile Dysfunction

HDR Peer Presentation

Pennine Training Scheme

Dr Lorna Clark, GPST

What is erectile dysfunction l.jpg
What is Erectile Dysfunction

  • Synonym: Impotence

  • Inability to attain and maintain an erection sufficient for satisfactory sexual performance

  • Benign

  • Significant impact on quality of life

Epidemiology l.jpg

  • Incidence and prevalence is high worldwide

  • Effects up to 52% of men (40-70yrs)

  • Steep age-related increase. Complete impotence from 5% of 40yr olds to 15% of 70yr olds

  • Only 10-20% solely psychogenic

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Risk factors

Note shared risk factors with CVD:

  • Sedentary lifestyle

  • Obesity

  • Smoking

  • Hypercholesterolaemia

  • Metabolic syndrome

  • Diabetes mellitus

Aetiology l.jpg

  • Organic

  • Hormonal

  • Anatomical

  • Drugs

  • Psychogenic

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Organic causes

  • Vascular factors (CVD, atherosclerosis, hypertension, diabetes, hyperlipidemia, smoking, trauma)

  • Central causes (Parkinson’s, stroke, MS, tumours, spinal disease/injury)

  • Peripheral causes (poly-/peripheral neuropathy, diabetes, alcoholism, uraemia, pelvic surgery

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Hormonal causes

  • Hypogonadism

  • Hyperprolactinaemia

  • Thyroid disease

  • Cushing’s disease

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Anatomical causes

  • Peyronie’s disease

  • Micropenis

  • Penile anomalies (hypospadias etc)

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  • Antihypertensives (beta blockers, diuretics)

  • Antidepressants (tricyclic and SSRIs)

  • Antipsychotics (phenothiazines, risperidone)

  • Anticonvulsants (phenytoin, carbamazepine)

  • Antihistamines

  • H2 antagonists (cimetidine, ranitidine)

  • Recreational drugs (inc tobacco and alcohol)

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Psychogenic Causes

  • General (disorders of intamacy, lack of arousability)

  • Situational (partner, performance, stress)

  • Psychiatric illness (Anxiety states, depression, psychosis, alcoholism)

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Taking a history

  • Take an understanding approach

  • Sexual history – International Index of Erectile Function questionnaire (IIEF)

  • Current and Past sexual partners

  • Current emotional state

  • Erectile symptoms (onset and duration)

  • Previous problems, advice and treatments

  • Quality of erections (erotic and morning)

  • Arousal, ejaculation and orgasm difficulties

  • General medical/past medical history and medications

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History suggesting organic cause

  • Gradual onset

  • Normal ejaculation

  • Normal libido

  • Medical risk factor

  • Trauma/surgery/radiotherapy to pelvis

  • Current medication

  • Lifestyle

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History suggesting psychogenic cause

  • Sudden onset

  • Early collapse of erection

  • Self stimulated or waking erections

  • Premature ejaculation or inability to ejaculate

  • Problems/change in relationship

  • Major life event

  • Psychological problems

Examination l.jpg

  • Genitourinary examination (anatomical abnormalities, size of testes)

  • Pulses (femoral), BP

  • Rectal examination (over 50yrs)

Investigation l.jpg

  • Bloods: Fasting glucose, lipids, U&Es, LFTs, TSH, Early morning serum testosterone (plus FSH and LH if testosterone low)

  • Haemoglobinopathy screen (sickle cell) in afro-caribbean patients

  • Dipstick urinalysis

  • Vascular studies (duplex ultrasound cavernous arteries, arteriography, intracavenous vasoactive drug injection)

  • Neurological studies

  • Specialist psychodiagnostic evaluation

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Indications for referral

  • Endocrine abnormality

  • Young patients with trauma

  • Penile disorder/abnormality

  • Complex cases

  • Patient/partner request for specialist tests/treatment

Management l.jpg

  • Main goal: diagnose and treat underlying cause

  • Modify reversible causes (lifestyle, drugs). Men who initiated physical exercise and weightloss have upto 70% improvement (note: cycling more than 3 hours per week may cause dysfunction)

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  • Hormonal: testosterone failure – give testosterone

  • Post-traumatic arteriogenic: surgery

  • Psychogenic: underlying problem, sex therapy/counselling, phosphodiesterase type-5 inhibitors (sildenafil, tadalafil, vardenafil)

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First-line treatment – oral therapy

  • PDE-5 inhibitors improve relaxation of smooth muscle. Contraindicated in patients receiving nitrates, recent stroke/MI, unstable angina

  • Sildenafil: well tolerated, efficacy reduced after fatty food, 50mg starting dose

  • Tadalafil: longer half-life, start at 10mg

  • Vardenafil: more potent (but not clinically more effective), useful in difficult to treat subgroups, effect reduced by fatty food.

  • Apomorphine hydrochloride: dopamine agonist, quick action, sublingual, not effected by foods

Treatment vacuum devices l.jpg
Treatment: Vacuum devices

  • External cylinder, pumping air out around penis and causing engorgement

  • Clinical success rate of 90%

  • Work best: motivation, supportive partner

  • Adverse effects: pain, petechiae, bruising, numbness

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Second line treatments

  • Intraurethral alprostadil (prostaglandin E1): insert pellet urethral meatus, barrier contraception if partner pregnant, less effective than intracavernous injections, may cause penile pain

  • Intracavernosal alprostadil: injected, may cause pain and priapism (refer urgently to hospital for blood to be drained)

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Third-line treatment

  • Penile prosthesis: semi-rigid, malleable or inflatable. Considered if impotence has organic cause and fail to respond to medical management

  • Topical agents: some vasoactive drugs come in topical gel form, may suffer local reaction and side-effects to partner if absorbed from vagina.

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Prescription advice

  • Medications only to be prescribed on NHS if: diabetes, MS, Parkinson’s, poliomyelitis, prostate cancer, severe pelvic injury, spina bifida, spinal cord injury, receiving dialysis, history of radical pelvic surgery/prostatectomy/renal transplant, or receiving treatment before September 1998

  • Should also be available if dysfunction causing severe distress (significant disruption to normal social activities, interpersonal relationships and effecting mood, behaviour etc)