Evaluation and Treatment of Erectile Dysfunction

1. Evaluation and Treatmentof Erectile Dysfunction Michael P. Finkelstein, M.D.

3. Goals and Objectives Define erectile dysfunction (ED) Discuss the most common causes of ED Review a practical evaluation of men with ED Review the treatment options Provide suggestions for urologic referral

4. What is ED? ED is the inability to achieve and maintain an erection adequate for intercourse to the mutual satisfaction of the man and his partner. Remember, both partners in a relationship are affected.

5. Incidence 20-30 million American men suffer ED Age dependent 2% men age <40 years 25% men age 65 75% men >75 years Not a necessary occurrence of the aging process

6. How Does an Erection Occur? The brain controls all sexual functions, from perceiving arousal to initiating and controlling the psychological, hormonal, nerve, and blood flow changes that lead to an erection. Hormones, including testosterone, control the male sex drive

7. How Does an Erection Occur?(cont.) Nerve impulses relay signals of arousal and sensation to and from the penis Arteries deliver extra blood to the penis that causes it to stiffen. Veins then drain the blood out of the penis after intercourse.

8. Physical orPsychological Stimuli Results Sacral parasympathetics (S2,3,4) stimulation to the penile nerves Dilation of the penile arteries Relaxation of the smooth muscle in the corporal bodies of the penis Decrease venous outflow

9. An Erection Requires a Coordinated Interaction of Multiple Organ Systems Psychological Endocrine Vascular Neurologic

10. Mechanism ofSmooth Muscle Relaxation Release of Neurotransmitters-nitric oxide Conversion of GTP to cGMP - erection Breakdown of cGMP by PDE type 5 - detumesence

11. Cause of ED Psychogenic Causes: Anxiety Depression Fatigue Guilt Stress Marital Discord Excessive alcohol consumption

12. Causes of ED Organic Causes Cardiovascular disease Diabetes mellitus Surgery on colon, bladder, prostate Neurologic causes (lumbar disc, MS, CVA) Priapism Hormonal deficiency

13. Causes of EDRisk FactorsMassachusetts Male Aging Study¹ Treated heart disease 39% Treated diabetes 28% Treated hypertension 15% ¹Feldman Ha, J Urol 1994; 151:54-61

14. Causes of EDOther risk Factors ² Diabetes 27% - 59% Chronic renal failure 40% Hepatic failure 25% - 70% Multiple Sclerosis 71% Severe depression 90% Other (vascular disease, low HDL, high cholesterol) ²Benet et al. Urol Clinic North Am. 1995; 151:54-61

15. Causes of ED Hormone Deficiency End Organ Failure Blockage of Blood Vessels Venous Leak

16. Causes of ED Spinal cord injuries: 5% - 80% Pelvic and urogenital surgery and radiation Substance abuse Alcohol: >600ml/wk Smoking amplifies other risk factors Medications may be responsible for ~25% of cases of ED Bicycle riding

17. Causes of ED Medication: Most common cause of ED in men >50 Many men are polymedicated Also have co-morbid conditions

18. Causes of ED Medications (cont.) Anti-hypertensive drugs All capable Common: thiazides and beta blockers Uncommon: calcium channel blockers, alpha-adrenergic blockers, and ACE inhibitors

19. Causes of ED Medications (cont.) CNS drugs: Antidepressants, tricyclics, SSRIs Tranquilizers Sedatives Analgesics H1 and H2 receptor blockers

20. Causes of ED Medications (cont.) Anticholinergics LHRH agonists (Lupron, Zolladex) Alcohol Tobacco Drug abuse Estrogens, Ketoconazole

21. A Practical Evaluation of Men with EDBasic evaluation Medical History Cardiovascular history Endocrine history Sexual history/questionnaire

22. A Practical Evaluation of Men with EDBasic evaluation (cont.) Physical exam: Focused neurovascular exam Size of testis DRE Lab tests UA Testosterone, CMP, Lipid panel PSA in men >50 years

23. A Practical Evaluation of Men with EDSexual History Premature ejaculation Retarded ejaculation Painful intercourse Anorgasmia Decreased Libido Dissatisfaction with sex life

24. A Practical Evaluation of Men with EDSexual History (cont.) Do you have any problems with intimacy with your partner? Do you have early morning erections? Do you have erections with self-stimulation? Are you able to consistently obtain and maintain an erection sufficient for sexual intimacy? Does it hurt to have an erection or intercourse?

25. A Practical Evaluation of Men with EDSexual History (cont.) Do you ejaculation sooner than you would like? Does it take too long to reach an orgasm? Do you fail to reach an orgasm? Did your erection problems start suddenly or over time?

26. A Practical Evaluation of Men with EDED Questionaire³ When you had erections with sexual stimulation, how often were your erections hard enough for penetration? How do you rate your confidence that you could get and keep an erection? ³The International Index of Erectile Function, Urol 1997;49:822-830

27. A Practical Evaluation of Men with EDQuestionaire (cont.) During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? When you attempted sexual intercourse, how often was it satisfactory for you?

28. A Practical Evaluation of Men with EDDifferentiating Psychogenic from Organic ED Psychogenic Impotence: Younger patient (<40) Preservation of morning erections and nocturnal erections Achieve erection with masturbation May be partner-specific Often sudden onset

29. A Practical Evaluation of Men with EDDifferentiating Psychogenic from Organic ED Organic ED: Gradual deterioration Decrease in morning erections and nocturnal erections No erections with masturbation No loss of libido Presence of co-morbid conditions

30. A Practical Evaluation of Men with EDPhysical Examination Blood pressure Examine penis (R/O Peyronie’s disease) Determine size and consistency of testes Digital rectal exam Focused vascular exam/peripheral pulses Focused neurologic exam

31. A Practical Evaluation of Men with EDLaboratory Tests UA (glycosuria) – Fasting if elevated PSA in men over 50 Testosterone (best to draw in A.M.) Prolactin, Thyroid function, Lipid profile, Liver function, Creatinine

32. A Practical Evaluation of Men with EDOther Tests NPT – Nocturnal Penile Tumescence Test Penile doppler Injection of vasoactive drugs NEVA (Nocturnal Electobioimpedance Volumetric Assessment)

33. Treatment OptionsGoal directed therapy4 Find out what the patient wants Try to tailor the treatment to the patients needs and wants Etiology rarely affects treatment choice for the patient 4 Lue TF, World J. Urol 8:67,1990

34. Treatment Options Nonpharmacologic Non-invasive Minimally invasive Invasive Counseling and/or sex therapy

35. Treatment Options Oral medications - Viagra, Levitra, Cialis Urethral suppositories (MUSE) Injection therapy - Caverject, Trimix, Bimix Vacuum constriction device Surgery Sex therapy

36. Counseling and/or Sex Therapy Rule out depression Try oral medication in patient with psychogenic impotence Refer to sex therapist or psychiatrist for sever psychopathology

37. Nonpharmacologic Treatment Options Lifestyle changes: Reduce fat and cholesterol in diet Decrease or limit alcohol consumption Eliminate tobacco use and substance abuse Weight loss if appropriate Regular exercise

38. Ideal Medication for Treatment of ED Effective Available on demand Free of toxicity and side effects Easy to administer Inexpensive

39. Medication(Viagra, Levitra, Cialis) Mechanism of Action: PDE inhibitor and increases the cGMP that promotes and sustains smooth muscle relaxation

40. Medication(PDE Inhibitors) Indications: Psychogenic ED Mild vasculogenic ED Neurogenic ED Side effects from medication(s) patient is already taking

41. Medication (PDE Inhibitors) Side effects: Headache Flushing Dyspepsia Nasal congestion Visual disturbances Priapism

42. Medication (PDE Inhibitors) Contraindications: Organic Nitrites: Oral Sublingual Severe cardiac disease Obtain stress testing

43. Medication(Yohimbine, Yocon, Erex, Yohimex) Alpha 2 andrenoreceptor antagonist Dose: 5.4 mg TID Results: ~20% (same as placebo) Side effects: increase blood pressure, tachycardia, anxiety

44. MedicationTrazodone(Desyrel) Anti-depressant associated with priapism Mechanism of action nor fully understood Nor FDA approved for ED Side effects: drowsiness, dry mouth, sedation, priapism

45. MedicationApomorphine (Spontane) Dopaminergic mechanism with hypothalamic activity Sublingual administration 64% to 67% response rate with ED Side effects: nausea, sweating, hypotension, yawning Awaiting FDA approval

46. MedicationPhentolamine (Vasomax) Alpha-blocker Relaxes smooth muscle tissue 40% efficacy in mild organic ED Side effects: nasal congestion, tachycardia, dizziness, hypotension Awaiting FDA approval

47. MedicationSide effects Discontinue tobacco, alcohol, and abusive drugs Alter dosage of drugs with ED side effects Change to another class of drugs

48. Transurethral TherapyAlprostadil - MUSE Mechanism of Action: vasodilator Administration: 125, 250, 500. 1000ug Insert in the urethra Erection occurs 10-15 minutes later Erection lasts 30-45 minutes Results: 10-65% Side effects: Pain, bleeding, priapism (<3%)

49. Penile Injection TherapyCaverject, Edex, Tri/Bi-Mix Mechanism of action: smooth muscle vasodilator Administration: 10, 20, 40ug Inject directly into corporeal bodies of the penis Results: 70%-90% Dropout rates: 25%-60% Side effects: pain (36%), priapism (4%), fibrosis

50. Androgen Replacement Therapy Indications: hypogonadism (<285ng/dl) Avoid oral estrogens-increase LFTs Injectable – 200mg testosterone (cypionate, enathate, propionate), q2-3 weeks Transdermal Patch gel

51. Androgen Replacement Therapy Avoid in patients with prostate or breast cancer Slight increase risk of BPH Monitor all patients with annual DRE and PSA

52. Vacuum Constriction Device Mechanism of Action: Penis placed in plastic tube Air evacuated from the tube Blood trapped in penis with constricting ring

53. Vacuum Constriction Device Erection limited to 30 minutes Results: 80%-90% Contraindications: bleeding disorders, sickle cell disease, anticoagulation Complications: coolness, petechiae, numbness, pain with ejaculation High drop out rate

54. Vacuum Constriction Device Was previously first-line treatment for ED Seldom used now that oral therapy is available Considered an alternative if patient fails oral therapy and does not want to proceed with surgery

55. Penile Prosthesis Indications: Patients who have failed other therapies Peyronie’s disease Severe vasculogenic disease

56. Choosing a Penile Prosthesis Considerations: Medical condition Lifestyle Cost Insurance coverage As with all prescription products, complications are possible

57. Malleable Prosthesis Easy for patient and partner to use Few mechanical parts Same-day surgery usually possible Least expensive type of prosthesis

58. Two-Piece Inflatable Prosthesis Small inflation pump provides comfort and ease Fast and easy one-step deflation procedure Better conceal ability when flaccid than with malleable or self-contained devices

59. Three-Piece Inflatable Prosthesis Most closely approximates the feel of a natural erection Cylinders expand in girth Some cylinders have the potential to expand in length When inflated, it feels more firm and more full than other prosthetic erections When deflated, it feels softer and more flaccid with better conceal ability than with other prosthetic devices

60. Penile Prosthesis Advantages: Low-morbidity Low-mortality surgery Low complication rates High success rates – 5% malfunction rate at 5 years High satisfaction rate – 87% High partner satisfaction rate

61. Penile Prosthesis Advantages (cont.) Good rigidity Freedom from medications Outpatient/24HR surgery Resume sexual activity 4-6 weeks No loss of ability to ejaculate or achieve orgasm

62. Penile Prosthesis Disadvantages: Surgery Expensive Possible mechanical failure

63. Penile ProsthesisInsurance Reimbursement Covered by most companies, including Medicare No co-payment for men with Medicare supplemental insurance

64. When to Refer to a Urologist

65. Refer Patients to a Urologist Patients who fail medical management Patients with Peyronie’s disease Patients with severe vasculogenic ED Patients on NTG who are not candidates for oral medications Patients requesting an implant

66. Why Refer to a Urologist? Only specialty that is trained in andrology and/or management of ED Urologists offer a range of treatment options ED represents a significant aspect of many urologic practices Urology support staff is comfortable treating men and their partners who suffer from ED

67. Summary ED is a common problem that affects millions of American men ED can be easily evaluated by the PCP ED can be treated with oral medications by the PCP Patients that do not respond to medical therapy should be referred to a Urologist Penile prosthesis is an effective means of treating ED

68. Remember Primary care physician should consider early referral to Urologist if initial treatment is not successful No one needs to suffer the “tragedy of the bedroom”

69. Any Questions?