Your SlideShare is downloading. ×
0
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Erectile Dysfunction Causes and Treatment: 2014 Presentation
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Erectile Dysfunction Causes and Treatment: 2014 Presentation

3,729

Published on

Erectile Dysfunction in 2014: Causes and Treatment Options discusses common causes of ED, treatment options including penile prosthesis, Viagra, Cialis.

Erectile Dysfunction in 2014: Causes and Treatment Options discusses common causes of ED, treatment options including penile prosthesis, Viagra, Cialis.

3 Comments
1 Like
Statistics
Notes
No Downloads
Views
Total Views
3,729
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
182
Comments
3
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Treatment of Erectile Dysfunction Alex Shteynshlyuger MD Board Certified Urologist Director of Urology New York Urology Specialists 2014 www.NewYorkUrologySpecialists.com
  • 2. Erectile Dysfunction (ED) (Impotence)  Definition of Erectile Dysfunction:  Persistent (3 months or longer) or recurrent inability to attain or maintain penile erection sufficient for sexual performance.”  Diagnosis based on history/complaints/patient perception of a problem  Can be self-diagnosed by a patient  IIEF (International Index of Erectile Function) Questionnaire is easy to self-administer  Classification of Erections  Nocturnal  Psychogenic/erotic  Reflexogenic
  • 3. Organic vs Non-Organic  Organic traditionally refers to vascular or neurogenic (nerve damage) causes  Non-Organic traditionally refers to “Psychogenic”  Classification is Based on Outdated understanding of human physiology: Psychogenic problems are organic in origin, due to imbalances in neurotransmitter activity (as in depression) and treatable with medical management. Patients respond to the same treatment approaches regardless of the cause: PDE5 inhibitors are the staple of therapy – help with “confidence”, overcome ‘situational’ ED. Psychotherapy may be beneficial for all patients as there are always components of “psychogenic” in all cases of ED, whether primary or secondary.
  • 4. Classification of Erectile Dysfunction  Psychogenic  Neurogenic  Vascular  Mixed (Psychogenic and Organic components)  Iatrogenic  Medications  Surgical trauma
  • 5. Treatment of ED  History  Pre 1970’s Psychosexual therapy; ED treated by psychiatrists  1970’s  Pre-1998 (pre-Viagra)  Penile implants (prosthesis) - the gold standard of treatment  Topical; Vacuum Pump  1980’s intraurethral and intracavernous injections  Post 1998->  Viagra = 1st line of therapy  Cialis / Levitra, etc…
  • 6. Evaluation of a patient with ED History Onset; duration; IIEF, history of trauma Medications (TCAs, spironolactone, etc) Nocturnal Penile Tumescence test  Poor correlation with ED.  Not recommended  Cigarette Smoking and vascular risk factors are better predictors of organic ED than NPTT Audiovisual Sexual Stimulation (AVSS)  useful in distinguishing psychogenic causes  But does not change management
  • 7. Non-surgical Treatment of ED  1st line of therapy: invariably PDE5 inhibitor (sildenafil citrate/Viagra, Cialis, Levitra)  Inhibits breakdown of cGMP, which produced from cGTP by nitric oxide  PDE 5 isoenzyme is enriched in the penis  Metabolized by P450  Contraindicated in patients taking nitrates (Potentiates the hypotensive effects of nitrates.)  Relative contraindication in patients with ischemic coronary disease, heart failure patients  Effective in patients with organic, psychogenic and mixed ED.  Effective in 70-80% of patients after sufficient trial
  • 8. Sildenafil citrate (cont)  Improves erections in  70 % of pts with HTN  56 % of diabetics  42 % of RRPR patients  80 % of patients with spinal injury.  60 % of patients with TURP  70-80 % of patients with SSRI induced arousal disorder
  • 9. Non-surgical management of ED  Lifestyle modification  Regular exercise  Healthy diet  *SMOKING CESSATION  Alcohol  Bicycling  Syndrome of general anesthesia and ED  ED 2x as frequent in long distance bikers  Ergonomic saddles
  • 10. Meds implicated in ED  Antihypertensives  Methyldopa, reserpine b/c of central action  Thiazide diuretics, spironolactone  alpha-1 adrenergic antagonists  Doxazosin – reduced incidence of ED compared to placebo (Guthrie 1997).  TCAs, SSRIs
  • 11. Meds implicated in ED  Inhibit Testosterone Production  Spironolactone  Ketoconazole  Metronidazole  Flutamide  Cimetidine  Cyproterone  Inhibit GnRH  Progesterone  Estrogen  GnRH agonists (leuprolide, goserelin)  Prolactinoma  Estrogen  Phenothiazines  TCAs  Reserpine  Cocaine/opioids
  • 12. Treatment of Medication Induced ED  Change medication  Decrease the dose (start low go high)  Drug holidays  Only under medical supervision
  • 13. Hormonal Therapy  Testosterone  Reasonable to use in patient with documented hypogonadism  Prostate CA or Breast CA are contraindications for androgen supplementation (but this is evolving):  Bx to R/O prostate Bx based on clinical risk stratification  No increased risk for developing prostate cancer  May be safe in select men with history of treated prostate cancer  DRE and PSA every 6 months  Only DHEA and DHEAS are effective  Improves libido; ED improvement.  Side Effects:  Suppress LH/FSH -> infertility  Breast tenderness/gynecomastia  Erythrocytosis  risk of stroke. Monitor Hematocrit; LFTs
  • 14. Androgen replacement (cont)  Parenteral preparations  Depo preparations do not resemble the circadian rhythm  Testosterone enanthate and cypionate IM q2-4 weeks 200-400 mg  Transdermal preparations – often best option  Can resemble circadian rhythms (importance not known).  Oral preparations  Poor bioavailability due to first-pass metabolism  Toxic to the liver (hepatitis, hepatoma, liver cysts, hepatocellular Ca.  Injectable Depot or implants  Convenient; work well
  • 15. Hyperprolactenemia  Testosterone supplementation of no benefit  Eliminate the offending drugs  Estrogens, morphine, sedatives, neuroleptics  Treatment:  Medical: bromocriptine  Surgical: Excision
  • 16. Yohimbine & Trazodone  Centrally acting alpha-2 antagonist  No benefit to patients with organic ED vs placebo (Morales, 1997)  Better than placebo in patients with psychogenic ED (62% vs 16%). Often prescribed with Trazodone.  TRAZODONE  Mild antidepressant with rare incidence of priapism  SSRI
  • 17. Apomorphine for ED  Not an opiate  Dopaminergic agonists acts on the paraventricular nucleus in the brain, the sexual drive center in humans.  Stimulates pro-erectile signaling  Requires sexual arousal to work  Rapid onset of action, 12 min to erection;  More effective than placebo (Uprima Pharm).  Not in clinical use
  • 18. L-arginine  No better than placebo for treatment of ED
  • 19. Intraurethral Therapy  Alprostadil, PGE1 (Prostaglandin E1)  Via intracavernous or intra-urethral routes  Urethral route (MUSE)  Stimulates adenyl cyclase, which raises cAMP that leads to lower Ca++ and relaxation of smooth muscle  Penile pain is a major side effect with incidence of 10-30%  Hypotension and syncope with MUSE – 1st administration in the office.
  • 20. Transdermal Therapies  Nitroglycerin (no longer used)  Smooth muscle relaxant  More effective than placebo for ED (Heaton 1990).  Minoxidil vs Placebo Vs Nitroglycerin: Double blinded studyMinoxidil more effective than Placebo or Nitro in ED.
  • 21. Intracavernous Injections  Papaverine  Very effective in psychogenic or neurogenic ED  Erection sufficient for penetration in 98% of tetra/quadra-plegic patients  Priapism (0-35%)  Corporal Fibrosis (1-33%)  As monotherapy 55% effective
  • 22. Intracavernous Injections (cont)  Alprostodil (Caverject, Prostin VR)  Smooth muscle relaxation, vasodilation, inhibition of platelet aggregation  96% locally metabolized  Full erections in 70-80% patients  Lower incidence of fibrosis and priapism than with papaverine but higher incidence of painful erections  Triple therapy Trimix (papaverine, phentolamine, alprostadil) mixture for ICI of alprostadil failure or for pain with alprostadil; as effective as alprostadil alone
  • 23. Efficacy of Intracavernous Injections  ICI 80-100% successful in treatment of ED in patients with non-vascular disease  In vascular disease, higher dosage and more trials required  Contraindicated in patients with:  Sickle cell disease  Psychiatric illness  Severe systemic disease
  • 24. Herbal Supplements for ED  Many herbal supplements have been tried  No randomized trials ever to show benefit  Billions in Profits  Successful supplements: Recalled by FDA because they had Viagra/Cialis mixed in.
  • 25. Vacuum Erection Devices  Effective, safe treatment of ED  Penis is engorged by negative pressure, a ring is applied at the base.  Can be used with failed penile prosthesis  35% use the device long term  10% incidence of hematoma
  • 26. Treatment of Erectile Dysfunction: SUMMARY  Initial Treatment:  PDE5 inhibitor: Viagra / Cialis / Levitra / Staxyn  If fail repeated high dose Viagra (100 mg)  Alprostadil (PGE1) intracavernous injection or intraurethrally  Vacuum Pump  If failed alprostadil,  Triple therapy Trimix (papaverine, phentolamine, alprostadil)  Penile Implant Surgery for medical failure
  • 27. Treatment of ED in NYC Contact us to schedule an appointment: ED Treatment Center at the New York Urology Specialists http://www.newyorkurologyspecialists.com

×