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Erectile Dysfunction
 

Erectile Dysfunction

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    Erectile Dysfunction Erectile Dysfunction Presentation Transcript

    • Erectile dysfunction – a growing problem Dr Thomas Fox Endocrine SpR Royal Cornwall Hospital, Truro
    • Erectile Dysfunction (ED)
      • Definition
      • Epidemiology
      • Aetiology
      • Clinical features
        • History
        • Examination
      • Investigation
      • Treatment
    • Definition
      • The consistent inability to obtain and maintain penile erection sufficient to complete satisfactory sexual performance
    • Epidemiology
      • Estimated to affect 152m men worldwide
      • Non-diabetic men 0.1-18.4% prevalence
      • In a study of 541 diabetic males
        • 35% in diabetic men
        • 5.7% in 20-24 year olds
        • 52.4% in 55-59 years olds
      • ED is a growing problem
        • Massachusetts Male Aging Study estimate an 11% world increase by 2015
    • Aetiology
      • Vascular
      • Neurological
      • Endocrine
      • Psychological
      • Pharmacological
      • Penile tissue abnormalities
      • Others
    • Vascular
      • Arterial insufficiency
        • Endothelial dysfunction (up to 95%)
        • Discrete lesions
      • Venous leakage
        • Failure of venule constriction
    • Neurological
      • Damage to autonomic nervous system
        • Predominant parasympathetic damage
    • Endocrine
      • Hypogonadism
        • Most commonly primary testosterone deficiency
        • Secondary hypogonadism
      • Hypothyroidism
      • Hyperprolactinaemia
    • Other causes of ED
      • Penile
        • Balinitis
        • Phymosis
        • Penile finrosis
        • Tumours
        • Trauma
      • Pharmacoloical
    • Clinical features
      • History
      • Examination
    • History
      • Patient’s description of the problem
      • Patient’s and partners expectations
      • Duration
      • Speed of onset
      • Intermittent/progressive?
      • History of sexual partners
      • Nocturnal erections?
      • Libido
      • PMH
        • Glycaemic control
        • Vascular/neurological disease
        • Urological
        • PSH and trauma
      • DH
        • Anti-hypertensives
        • Androgen antagonists
        • Sedatives
        • Drugs that cause hyperprolactinaemia (phenolthiazides)
        • Alcohol
      • Psychological assessment
    • Examination
      • General
      • Vascular
      • Neurological
      • Genitalia
      • DRE
    • Investigation
      • Diabetic/vascular
      • Endocrine
        • 9am Testosterone
        • Thyroid function tests
        • Pituitary hormones (LH,FSH,PRL)
      • Imaging
    • Management
      • Multidisciplinary approach
      • Involvement of partner
      • Couples expectations and desires
    • Oral therapies
      • Phosphodiesterase V inhibitors
        • Sildenafl ( Viagra) 4hr
        • Tadalafil ( Cialis) 17hrs
        • Vardenafil (Levita) 4 hrs
      • Side effects
        • flushing, headache and GI disturbance
      • Contraindications - nitrates
    •  
    • Efficacy of PDE-V inhibitors
      • Hundreds of studies internauinally
      • Improved erections and increased successful episodes of sexual intercourse vs placebo (15 RCTs)
    • Levinson et al 1998
      • 254 males over 18 with clinical diagnosis of ED for >6 months
      • Randomised double blind placebo controlled trial
      • Primary end-point Index of Erectile Function (IEF)
      • Variable dose 25mg-100mg adjusted by the patients
    • IEF Q3 ability to obtain erection IEF Q4 ability to maintain erection p<0.0001 IEF7 satisfaction with therapy
    •  
    • Improved erections at 12 weeks p<0.0001 % successful sexual attempts in last 4 weeks p<0.0001
    • PDE V inhibitor prescribing
      • Following conditions
        • DM
        • PD, MS, polyiomyelitis
        • Pinal cord injuries, spina bifida
        • Radical prostatectomy
      • Trial of 8 doses with dose titration before classifying as failure of treatment
      • Once correct dose achieved then can prescribe 1 tablet per week
    • Vacuum devices
      • Can improve erection
      • Messy and user dependent
      • Satisfaction varies 35-80%
    • Intracavernosal injections
      • Intracavernosal injections with prostaglandins
        • Alprostadil (prostaglandin E1)
      • One large RCT found increased rate of satisfactory erections when alprostadil injected compared to placebo
      • Side effects – pain, priapism
    • Testosterone replacement
      • Improves erectile function and libido
      • Preparations
        • Topical (testim gel)
        • Im testosterone
        • Long-acting depots
    • Testosterone replacement improving diabetes?
      • Kapoor et al 2006
      • Small double-blind placebo controlled crossover trial (n=24)
      • T II DM with testosterone deficiency (10 on insulin therapy)
      • 3 months treatment with testosterone (200mg im 2-weekly)replacement and 3 months with placebo (1 month washout)
      • Endpoints – fasting glucose, HbA1C and HOMA in non-insulin treated subjects (homeostatic model index)
      • Secondary endpoints waist circumference, BP and lipids
      • Results
        • HbA1C reduced by 0.37% (p=0.03)
        • Fasting glucose reduced by 1.58mmol/L(p=0.03)
        • HOMA index reduced 1.73 (p=0.02)
        • Waist circumference reduced 1.73cm (p=0.03)
        • Total cholesterol reduced 0.4mmol/L (p=0.03)
        • No effect on BP
      • Conclusions
        • Testosterone replacement can improve T II diabetic control
    • Intraurethral alprostadil
      • Effective but requires sufficient training required
    • Penile implant
      • Inflatable
      • Malleable
    • Psychosexual counselling
      • Talking therapies for men and couples
    • Summary
      • ED
        • Common
        • Marker for other forms of neurovascular complications in diabetes
        • Psychologically damaging
        • Treatable
        • Treat associated hormonal deficiencies
    • References
      • Efficacy and safety of sildenafil citrate (Viagra ® ) for the treatment of erectile dysfunction in men in Egypt and South Africa International
      • Journal of Impotence Research (2003) 15, Suppl 1, S25–S29.Levinson et al
      • Testosterone replacement therapy improves insulin resistance, glycaemic control, visceral adiposity and hypercholesterolaemia in hypogonadal men with Type II Diabetes
      • Kapoor et al European Journal of Endocrinology 2006
      • Diabetes Chronic conplication
      • Wiley press, Shaw et al
      • The role of testosterone in erectile dysfunction
      • Gooren et al
    •  
    •  
    •