1 / 53

Campbell’s Chapter 22

Campbell’s Chapter 22. Evaluation and Nonsurgical Management of Erectile Dysfunction and Premature Ejaculation. Brent Zamzow DO January 14, 2008. ED - Historical. Before 1970 – Psychotherapy 1970’s - Penile prosthesis & psychotherapy, sleep lab

ikia
Download Presentation

Campbell’s Chapter 22

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Campbell’s Chapter 22 Evaluation and Nonsurgical Management of Erectile Dysfunction and Premature Ejaculation Brent Zamzow DO January 14, 2008

  2. ED - Historical • Before 1970 – Psychotherapy • 1970’s - Penile prosthesis & psychotherapy, sleep lab • 1980’s - Yohimbine, intracavernous & transurethral therapy, vacuum device, testosterone, ultrasound • 1990’s to present - oral PDE-5 inhibitors • ED treatment • Psychologist → Urologist → Primary Care

  3. ED - Historical • 1999 - 1st International Consultation on Sexual Medicine (ICSM) • ED redefined as consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual performance • ED is a symptom of many medical problems • requires physician involvement • internet prescribing condemned • Goal-directed approach

  4. ED - Historical • 2nd ICSM - 2004 • Patient-centered & evidence-based • See illness through patient’s eyes • Holistic approach - biologic, psychologic & social aspects • Flexible & individualized approach • Let patient choose his best therapy • 3rd ICSM - July 10-13, 2009

  5. Self-Administered Questionnaires • International Index of Erectile Function (IIEF) • most common questionnaire • addresses erectile function, orgasmic function, desire, intercourse satisfaction, overall satisfaction • Male Sexual Function Scale • 2nd ICSM • Doesn’t take into account partner

  6. History Taking • Medical • atherosclerosis, DM, depression • organic vs. psychogenic • medications, pelvic surgery?, trauma? • Sexual • severity, onset, duration • Psychosocial • social, occupational, family, financial • Don’t assume everyone’s involved in monogamous, heterosexual relationship

  7. Exam & Labs • Physical Exam • General screening for risk factors • body habitus, cardiovascular, neurologic, genital • Labs • Fasting glucose, lipids, hormonal profile, thyroid function • Findings • Educate patient on modifiable risk factors • stress, marital conflict, smoking, EtOH, obesity, bicycle riding, prescription drugs

  8. ED Treatment Options

  9. Vascular Evaluation • Goal - diagnose & quantify arterial & veno-occlusive dysfunction • Options: • Combined intracavernous injection & stimulation (CIS) • Duplex ultrasound • Dynamic infusion cavernosometry & cavernosography (DICC) • Selective penile angiography

  10. Evaluation of Penile Blood Flow 1stline • Combined Intracavernous Injection & Stimulation (CIS) • Inject vasodilator, stimulate, assess • Most commonly performed diagnostic procedure for ED • Bypasses neurologic & hormonal influences to evaluate vascular status • Use: • alprostodil 10-20ug • papaverine & phentolamine (Bimix 0.3 mL) • Trimix 0.3 mL • 27 or 29g needle, compress for 5 min after injection

  11. 1st line - CIS • Normal results = normal venous occlusion • False negative up to 20% w/ borderline arterial flow

  12. Evaluation of Penile Blood Flow 2nd Line • Duplex Ultrasonography • Penile blood flow study (CIS & blood flow measurement by US) is most reliable & least invasive evidence based assessment of ED • Red = towards probe • Blue = away from probe • Can visualize dorsal & cavernous arteries in real time • Can diagnose high flow priapism

  13. 2nd line - Ultrasound • Technique • Measure flow velocities 5-10 min after injection • Rate erectile quality • Look at both cavernous arteries & diameters • Asymmetric cavernous arterial flow >10cm/s or reversal of flow across a collateral may mean atherosclerotic lesion

  14. 2nd line - Ultrasound • Doppler Waveform

  15. 2nd line - Ultrasound • Peak Systolic Velocity (PSV) • PSV < 25 correlates with abnormal pudendal arteriography • Severe unilateral arterial insufficiency >10 cm/s asymmetry • Severe vascular ED, diameter increase is <75%, diameter rarely exceeds 0.7 mm • Be aware of variant vessel anatomy

  16. 2nd line - Ultrasound • Veno-occlusive Dysfuntion • Need to trap blood & limit venous outflow • Venogenic impotence • High systolic flow (>25 cm/s) • Persistent end-diastolic flow (EDV) (>5 cm/s) • Resistive Index (RI) • RI = PSV – EDV/PSV • Measure 20 min after injection & stimulation • RI > 0.9 normal • RI < 0.75 venous leakage

  17. ISCM Recommendations on US • Intracavernosal injection with color duplex Doppler ultrasound • Most informative diagnostic test • Least invasive for vascular ED, high vs. low flow priapism, Peyronie’s plaque • Useful measurements • PSV, cavernous artery diameter, EDV, RI • PSV <25 = severe cavernous artery insufficiency • PSV >35 = normal inflow • Negative relationship between age & PSV

  18. Evaluation of Penile Blood Flow3rd line • Cavernous arterial occlusion pressure • Basically penile blood pressure measurement – 1989 • Technique • Inject vasodilator • infuse saline into corpora to get pressure > systolic BP • apply Doppler to penile base • Pressure when cavernous arterial flow becomes detectable is cavernous artery systolic occlusion pressure (CASOP) • Gradient between cavernous & brachial artery pressure <35 & equal pressure on L & R is normal

  19. 3rd line – Penile Blood Flow • Pharmacologic Arteriography • Technique • Inject vasodilator • Cannulate internal pudendal artery • Inject contrast • Look at anatomy of iliac, internal pudendal, penile arteries • Aberrant anatomy in 50% of normal volunteers • Useful for anatomy, not function • Indication: • Young pt w/ ED due to traumatic arterial disruption or perineal compression injury. Essential for planning reconstruction

  20. 3rd line – Penile Blood Flow • Pharmacologic Cavernosometry & Cavernosography • Cavernosometry • Saline infusion while monitoring intracavernous pressure • Assesses penile outflow • Cavernosography • Infusion of contrast into corpora after vasodilator induced erection • Good for young men who may be candidates for penile vascular operations

  21. Historical & Investigational • Penile Brachial Pressure Index • Inaccurate • Penile Plethysmography • Penile pulse volume recording • Infrared Spectrophotometry • Radioisotopic Penography • MRA • Cavernous Smooth Muscle Content

  22. Nocturnal Penile Tumescence (NPT) • 80% NPT during REM sleep • Total tumescence time • 20% of night at puberty • Adults – 27 minutes/night • RigiScan - 1985 • Monitors radial rigidity, tumescence, number, duration of erectile events • Portable – can use at home • Can record 3 different nights up to 10 hrs each • Results • Radial rigidity >70% = good erection • <40% = flaccid penis • Normal = 3-6 erections/night, 10-15 minutes per episode

  23. NPT • NEVA device • Uses electrobioimpedance to assess volumetric changes in penis during nocturnal erections • Undetectable alternating current from glans to hip electrodes • Penile base electrode measures impedance & changes in penile length • Mean volume change in controls = 213% increase (14.4 mL)

  24. NPT Summary • Freedom from psychological influences & its ability to detect sleep-related abnormalities • Full erection = neurovascular axis is functionally intact & cause is likely psychogenic • Disadvantages • Age dependent • Costly • Not recommended as routine test for ED • Indications: • Suspected sleep disorder • Obscure cause • Nonresponse to therapy • Planned surgical treatment • Legally sensitive case • Measurement of drug effects in placebo-controlled drug trials • Suspected psychogenic cause

  25. Psychological Evaluation • ED associated with: • Anxiety • Depressive symptoms • Low self-esteem • Negative outlook on life • Emotional stress • History of sexual coercion • General vs. Situational? • Primary vs. Acquired • Substance abuse, psychiatric illness • Noncoital erections • ?Masturbatory, nocturnal, morning

  26. Hormonal Evaluation • Hypogonadism increases with age • Decrease or absence of hormonal secretion from the gonads in men • Draw testosterone between 8-11am • For screening – total testosterone • If testosterone low or low-normal • Confirm with 2nd draw + LH + prolactin

  27. Testosterone • Men produce 4-8 mg/day in pulsatile manner • Peaks in morning, nadir in evening • Converts to DHT by 5α-reductase in skin, liver, prostate • Metabolized to estradiol by aromatase in brain, fat, liver, testes • 2% unbound – free testosterone • 30% bound to SHBG • Rest bound to albumin & other serum proteins • Bioavailable testosterone = free + albumin bound • SHBG made by liver – downregulated by androgens, upregulated by estrogens • Estrogens, thyroid hormone, aging increase serum SHBG & decrease bioavailable testosterone • Exogenous androgens, growth hormone, obesity depresses SHBG & increases free testosterone

  28. Lifestyle Change & ED • Obesity • Decreased BMI = improvement in ED • Physical Activity • Sedentary = highest risk • Cigarette Smoking • Statin to lower cholesterol may improve ED • Long distance bicycle riding • No Effect • Education level • Marital status • Urban vs. Rural • Coffee • EtOH

  29. Medications & ED • Nonspecific alpha-blockers have most severe effect on erectile function • Methyldopa & Reserpine • Thiazide diuretics • Spironolactone interferes with testosterone synthesis • SSRI’s – ED & ejaculation problems • Calcium channel blockers & ACE inhibitors don’t cause ED • Alpha-1 blocker is protective • Doxazosin reduces incidence of ED

  30. Herbal Supplements for ED • 25-50% placebo response • Acupuncture – psychogenic ED • Androstenedione – may benefit men w/ low testosterone, lowers HDL 10% • Ginko biloba – may have blood-thinning effect • Korean red ginseng – may benefit • L-Arginine – precursor to Nitric Oxide, may lower BP • Yohimbine – most supplements contain little or none, can have serious side effects • Zinc – good if low zinc, can be immunosuppressive

  31. Testosterone Therapy • Injectable (IM) • Least expensive • 200-250mg q2wks • Do not replicate normal circadian rhythm • Testosterone “rush” for 72 hrs, then low by 10-12 days • Transdermal • Can simulate normal circadian levels if applied in AM • Patch – 2.5-5 mg/day • Applied daily to arm, back, or upper butocks • Side effects – itching, chronic irritation, contact dermatitis • Gel – 50, 75, or 100 mg packs • Applied daily to arms, abdomen, or shoulders • Wash hands after application • Pellet – 75mg/pellet • 2-6 pellets implanted subQ q3-6months • Buccal – 30mg tablet BID • Oral – 200mg/d • Become metabolically inactive after 1st pass through liver • Large doses toxic to liver

  32. Hormonal Therapy • DHT • Cannot be aromatized to estradiol – pure androgen • Good for hypogonadal men w/ gynecomastia, boys w/ delayed puberty • Dehydroepiandrosterone (DHEA) • Controversial • End Points • General well-being, mood, sexual interest, sexual activity

  33. Adverse Effects of Testosterone Replacement • Infertility • Suppresses LH, FSH • Breast tenderness & gynecomastia • Erythrocytosis • Mean Hct increases from 42-47% after 3 months • Induce or worsen sleep apnea • May increase PSA • ? Exacerbates prostate cancer • Prostate or breast cancer = contraindication • Monitoring • DRE & PSA q6months • Periodic H&H, LFT’s, lipid profile • Efficacy of testosterone determined by clinical response • If hyperprolactinemia – testosterone does not improve sexual function

  34. Phosphodiesterase Type-5 Inhibitors • Sildenafil (Viagra) • FDA approved 1998 • Vardenafil (Levitra) • FDA approved 8/2003 • Tadalafil (Cialis) • FDA approved 11/2003

  35. Arousal Pathway • Sexual arousal stimulates NO release at penile nerve endings • NO diffuses into vascular & cavernous smooth muscle cells • Stimulation of guanylyl cyclase & elevation of cGMP • Hyperpolarization & lowers cytoplasmic calcium • Smooth muscle relaxation & erection • PDE-5 inhibitors potentiate NO’s effect • Do not increase NO levels • Need sexual stimulation for PDE-5 inhibitors to work

  36. PDE-5 Inhibitors • Sildenafil & Vardenafil cross-react slightly w/ PDE-6 • ? Reason for visual disturbances • Tadalafil minimally cross-reacts with PDE-11 • Consequences unknown • Other side effects: • Headache, flushing, low BP, dyspepsia due to PDE-5 inhibition in vascular or GI smooth muscle • Sildenafil 20mg TID FDA approved in 2005 for pulmonary HTN

  37. PDE-5 Inhibitors • Very effective at enhancing erectile function • Good for different patient subgroups, ED causes, outcomes measured • Difficult to Treat Patients • All effective in ED + DM • All improve ED following prostate cancer • Nerve sparing pts respond better • Daily PDE-5 inhibitor may be beneficial • Sildenafil + testosterone if ED & low testosterone • Cumulative probability of success increases w/ 1st 9-10 attempts • Tadalafil – less planning, longer half-life, more convenient for some

  38. PDE-5 Inhibitors • Side effects peak at first 2wks of use • Package Insert Warnings • MI within 90 days • Unstable angina, or angina w/ intercourse • NY Heart Association class II or greater heart failure in last 6 months • Uncontrolled arrhythmias, hypotension (<90/50), or HTN (>170/100) • Stroke in past 6 months • Known hereditary degenerative retinal disorders, including retinitis pigmentosa • Tendency to develop priapism (sickle cell, anemia, leukemia) • Impairs metabolic breakdown • Ketoconazole, itraconazole, protease inhibitors (ritonavir) – lower dose • Enhances breakdown • Rifampin – increase dose

  39. PDE-5 Inhibitors • Recommended starting dose • 50mg sildenafil • 10mg vardenafil & tadalafil • Cardiovascular safety • They do not worsen cardiac events • Vardenafil not recommended w/ type IA antiarrythmics (quinidine or procainamide) or type 3 (sotalol or amiodarone), or congenital prolonged QT syndrome • Use w/ caution in aortic stenosis, left ventricular outflow obstruction, hypotension, hypovolemia due to vasodilator effects • Nitrates – absolute contraindication • Use >2 wks ago, not contraindication • Don’t take nitrate for at least 24 hrs after (48hrs for tadalafil) • Alpha-blocker – use caution due to vasodilation & hypotension

  40. Intracavernous Injection • 1983 AUA meeting, Brindley personally demonstrated erection after injection of phenoxybenzamine • 1985 – papaverine & phentolamine injection use reported • Papaverine • Isolated from opium poppy • Inhibitory effect on PDE, increased cAMP & cGMP, blocks calcium channels • 1-2 hr half-life • Good • Low cost • Stable at room temp • Bad • Priapism (up to 35%) • Corporal fibrosis (1-33%) due to acidity • <55% effective • Not FDA approved

  41. Intracavernosal Injection • Phentolamine (alpha1 & alpha2-antagonist) (Regitine) • Side effects • Hypotension • Reflex tachycardia • Nasal congestion • GI upset • 30 min half-life • Increases corporal blood flow, but does not cause significant increase in intracavernous pressure

  42. Intracavernosal Injection • Alprostadil (Caverject & Edex 2-40mcg) - Prostaglandin E1 • Exogenous form of a naturally occurring fatty acid • Causes smooth muscle relaxation, vasodilation, inhibition of platelet aggregation by elevating cAMP • Metabolized by prostaglandin-15-hydroxydehydrogenase in corpora cavernosa • 96% locally metabolized after 60 min • Side effects • Pain at injection site or during erection • Hematoma • Priapism • Much lower incidence of fibrosis • Once reconstituted into liquid from powder, has shortened half-life if not refrigerated

  43. Intracavernosal Injection • Combinations • Papaverine + Phentolamine • Papaverine + Phentolamine + Alprostadil • Lower incidence of painful erection • As effective as alprostadil alone • Good for failed therapy or painful erection w/ PGE1 • Serious side effects • Priapism • Alprostadil 1.3% • Papaverine 10% • Papaverine/phentolamine 7% • Fibrosis • Alprostadil 1% • Papaverine 12% • Papaverine/phentolamine 9%

  44. Intracavernosal Injection • Contraindications • Sickle cell • Schizophrenia • Other severe psychiatric disorders • Severe systemic illness • If on anticoagulant, compress injection site for 7-10 min • Poor manual dexterity – have partner inject

  45. Intraurethral Therapy • Alprostadil (Muse) • Absorbed in spongiosum & transported to cavernosa through venous channels (circumflex & emissary veins) • 3mm x 1mm pellet • 500 mcg Muse = 10 mcg injected alprostadil • 2/3 respond • Side effects • Penile pain/dull ache in penis, scrotum, legs

  46. Central Acting Drugs • Yohimbine • Alpha2-antagonist from bark of yohim tree • Good for psychogenic ED • Side effects • GI upset, anxiety, HA, agitation, palpitations, HTN • AUA stance – no efficacy of yohimbine over placebo with organic ED • Trazadone • Apomorphine • Dopaminergic agonist

  47. Vacuum Constriction Device • Plastic cylinder connected to vacuum-generating source • Place constriction ring after engorgement • Remove ring within 30 min • Satisfaction rate 68-83%

  48. Premature Ejaculation (PE) • DSM-IV • Persistent or recurrent ejaculation with minimal stimulation before, on, or shortly after penetration and before the person wishes it • Short ejaculatory latency, lack of control, sexual dissatisfaction • Latency <2 min suggests possible PE • Excludes PE secondary to EtOH, substance abuse, medication

  49. Premature Ejaculation • Etiology • Penile Hypersensitivity • 5-Hydroxytryptamine-Receptor Sensitivity • Hyperarousability • Hyperexcitable ejaculatory reflex • Genetic predisposition • Psychogenic • Poor control techniques • Early sexual experience • Anxiety • Infrequent sex

More Related