Erectile Dysfunction

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 – – – – – – –

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



Organic – – –

– –

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 – – –



Antidepressants – – –



Thiazides B blockers Centrally acting drugs Tricyclics MAO inhibitors SSRI

Anticholinergics –

Atropine



Antipsychotics –



Anxiolytics –



Phenothiazines Benzodiazepines

Psychotropic drugs – – – –

Alcohol Opiates Amphetamines Cocaine

Examination  Blood

pressure  Peripheral pulses, palpate for AAA  Testes size and consistency  Secondary sexual characteristics  Penis for Peyronie’s 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  If

testosterone and SHBG

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

 Intra-cavernosal –

Prostaglandin E1 Alprostadil

 Intra-urethral –

Alprostadil

PDE5 inhibitors 

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



Tadalafil (Cialis) 10mg, 20mg – – –



30 minutes before sexual activity 36 hour window Absorption not affected by food

Tadalafil (Cialis) 5mg –



1 hour before sexual activity 4-6 hour window Absorption delayed by fatty meal

daily

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

30-60 minutes before sexual activity 4-6 hour window Absorption delayed by fatty meal

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, Peyronie’s

Predisposition to prolonged erection – – –

Sickle cell disease Multiple myeloma Leukaemia

PDE5 Drug Interactions 

Nitrates – – –



Cytochrome P450 inhibitors – –



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

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 Parkinson’s 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 don’t ask your patient may be too embarrassed to tell you