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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

Erectile Dysfunction

HDR Peer Presentation

Pennine Training Scheme

Dr Lorna Clark, GPST

what is erectile dysfunction
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
  • 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
risk factors
Risk factors

Note shared risk factors with CVD:

  • Sedentary lifestyle
  • Obesity
  • Smoking
  • Hypercholesterolaemia
  • Metabolic syndrome
  • Diabetes mellitus
  • Organic
  • Hormonal
  • Anatomical
  • Drugs
  • Psychogenic
organic causes
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
hormonal causes
Hormonal causes
  • Hypogonadism
  • Hyperprolactinaemia
  • Thyroid disease
  • Cushing’s disease
anatomical causes
Anatomical causes
  • Peyronie’s disease
  • Micropenis
  • Penile anomalies (hypospadias etc)
  • 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)
psychogenic causes
Psychogenic Causes
  • General (disorders of intamacy, lack of arousability)
  • Situational (partner, performance, stress)
  • Psychiatric illness (Anxiety states, depression, psychosis, alcoholism)
taking a history
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
history suggesting organic cause
History suggesting organic cause
  • Gradual onset
  • Normal ejaculation
  • Normal libido
  • Medical risk factor
  • Trauma/surgery/radiotherapy to pelvis
  • Current medication
  • Lifestyle
history suggesting psychogenic cause
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
  • Genitourinary examination (anatomical abnormalities, size of testes)
  • Pulses (femoral), BP
  • Rectal examination (over 50yrs)
  • 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
indications for referral
Indications for referral
  • Endocrine abnormality
  • Young patients with trauma
  • Penile disorder/abnormality
  • Complex cases
  • Patient/partner request for specialist tests/treatment
  • 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)
  • Hormonal: testosterone failure – give testosterone
  • Post-traumatic arteriogenic: surgery
  • Psychogenic: underlying problem, sex therapy/counselling, phosphodiesterase type-5 inhibitors (sildenafil, tadalafil, vardenafil)
first line treatment oral therapy
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
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
second line treatments
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)
third line treatment
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.
prescription advice
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)