Erectile Dysfunction

John Ewan Sandyford Glasgow

Overview

Epidemiology Anatomy and Physiology History Examination Investigations Treatment

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

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

Anatomy and Physiology of erection

Reproduced from Carson C, Holmes S, Kirby R. Fast Facts- Erectile Dysfunction. Oxford: Health Press Limited; 2002: 8

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.

Veno-occlusive Mechanism

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

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

Clues differentiating psychogenic from organic causes

Psychogenic

Organic

Sudden onset Situational Normal waking and nocturnal erections Normal erection with masturbation Relationship problems Life event Anxiety, fear, depression

Gradual onset All situations Reduced or absent waking and nocturnal erections No erection with masturbation Penile pain

Relationship issues

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

History

Medical Surgical Psychiatric Medication Smoking Alcohol Recreational drug use

Arteriogenic Cause of ED

Hypertension Smoking Diabetes Hyperlipidaemia Peripheral vascular disease Blunt perineal or pelvic trauma Pelvic irradiation

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

Psychogenic and Psychiatric causes

Anxiety Loss of attraction to partner Relationship difficulties Stress Depression

Psychogenic ED

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

Endocrine causes of ED

Hypogonadism

Low testosterone Raised SHBG Raised Prolactin

Thyroid disease

Drugs associated with ED

Antihypertensives

Antipsychotics

Thiazides B blockers Centrally acting drugs Tricyclics MAO inhibitors SSRI Atropine

Phenothiazines

Anxiolytics

Benzodiazepines
Alcohol Opiates Amphetamines Cocaine

Antidepressants

Psychotropic drugs

Anticholinergics

Examination

Blood pressure Peripheral pulses, palpate for AAA Testes size and consistency Secondary sexual characteristics Penis for Peyronies plaques, phimosis

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

Investigations

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

Specialised Investigations

Vascular studies

Young patients with primary ED History of trauma e.g. penile fracture Patients unresponsive to medical therapies

Treatment of ED General Measures

Smoking cessation Reduce alcohol Weight loss Exercise

Endocrine Disorders

Hypogonadism Hyperthyroidism Hyperprolactinaemia Endocrinology referral

Psychosexual therapy

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

Drugs for ED

Oral agents

Centrally acting dopamine-receptor agonist Apomorphine (discontinued in UK) Phosphodiesterase type 5 inhibitors Prostaglandin E1 Alprostadil Alprostadil

Intra-cavernosal

Intra-urethral

PDE5 inhibitors

Sildenafil (Viagra) 25mg, 50mg, 100mg

1 hour before sexual activity 4-6 hour window Absorption delayed by fatty meal 30 minutes before sexual activity 36 hour window Absorption not affected by food daily 30-60 minutes before sexual activity 4-6 hour window Absorption delayed by fatty meal

Tadalafil (Cialis) 10mg, 20mg

Tadalafil (Cialis) 5mg

Vardenafil (Levitra) 5mg, 10mg, 20mg

PDE5 Physiology

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

PDE5 Inhibitors Side Effects

Facial flushing Headache Nasal congestion Dizziness Dyspepsia Visual disturbance (blue halo) Priapism Non-arteritic anterior ischaemic optic neuropathy

PDE5 Contraindications

Recent cardiovascular event Nitrates Hypotension Anatomical deformity

Angulation, cavernosal fibrosis, Peyronies

Predisposition to prolonged erection

Sickle cell disease Multiple myeloma Leukaemia

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) Protease inhibitors especially Ritonavir use very small dose Cimetidine, Ketoconazole, Erythromycin

Cytochrome P450 inhibitors

Alpha blockers

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

Intracavernosal Injections

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

Intraurethral

Alprostadil (Muse) 125mg, 250mg, 500mg,1g

Pellet inserted with applicator Massage penis to aid absorption Side effects: Penile pain, dizziness, priapism rare

Intraurethral Alprostadil

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

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

Vacuum devices

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

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

Penile Prosthesis

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

NHS Prescription for ED

Diabetes Multiple sclerosis Parkinsons 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

Private Prescription

Pharmacy costs vary Sildenafil 100mgX4 25-40 Pharmacy2U 25

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 dont ask your patient may be too embarrassed to tell you