Erectile Dysfunction

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Erectile Dysfunction

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

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