Download Evaluation and Treatment of Erectile Dysfunction

( Lecture )
Andrology
[ Erectile dysfunction
]
Goals and Objectives
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Define erectile dysfunction (ED)
Discuss the most common causes of ED
Review a practical evaluation of men with ED
Review the treatment options
Provide suggestions for urologic referral
What is ED?
ED is the inability to achieve and maintain an
erection adequate for intercourse to the mutual
satisfaction of the man and his partner.
Remember, both partners in a relationship are
affected.
Incidence
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20-30 million American men suffer ED
Age dependent
2% men age <40 years
 25% men age 65
 75% men >75 years
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Not a necessary occurrence of the aging process
How Does an Erection Occur?
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The brain controls all sexual functions, from
perceiving arousal to initiating and controlling
the psychological, hormonal, nerve, and blood
flow changes that lead to an erection.
Hormones, including testosterone, control the
male sex drive
How Does an Erection Occur?
(cont.)
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Nerve impulses relay signals of arousal and
sensation to and from the penis
Arteries deliver extra blood to the penis that
causes it to stiffen.
Veins then drain the blood out of the penis after
intercourse.
Physical or
Psychological Stimuli Results
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Sacral parasympathetics (S2,3,4) stimulation to
the penile nerves
Dilation of the penile arteries
Relaxation of the smooth muscle in the corporal
bodies of the penis
Decrease venous outflow
An Erection Requires a Coordinated
Interaction of Multiple Organ Systems
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Psychological
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Endocrine
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Vascular
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Neurologic
Mechanism of
Smooth Muscle Relaxation
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Release of Neurotransmitters-nitric oxide
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Conversion of GTP to cGMP - erection
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Breakdown of cGMP by PDE type 5 detumesence
Cause of ED
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Psychogenic Causes:
Anxiety
 Depression
 Fatigue
 Guilt
 Stress
 Marital Discord
 Excessive alcohol consumption
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Causes of ED
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Organic Causes
Cardiovascular disease
 Diabetes mellitus
 Surgery on colon, bladder, prostate
 Neurologic causes (lumbar disc, MS, CVA)
 Priapism
 Hormonal deficiency
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Causes of ED
Risk Factors
Massachusetts Male Aging Study¹
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Treated heart disease
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Treated diabetes
28%
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Treated hypertension
15%
¹Feldman Ha, J Urol 1994; 151:54-61
39%
Causes of ED
Other risk Factors ²
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Diabetes
27% - 59%
Chronic renal failure
40%
Hepatic failure
25% - 70%
Multiple Sclerosis
71%
Severe depression
90%
Other (vascular disease, low HDL, high
cholesterol)
²Benet et al. Urol Clinic North Am. 1995; 151:54-61
Causes of ED
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Hormone Deficiency
End Organ Failure
Blockage of Blood Vessels
Venous Leak
Causes of ED
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Spinal cord injuries: 5% - 80%
Pelvic and urogenital surgery and radiation
Substance abuse
Alcohol: >600ml/wk
Smoking amplifies other risk factors
Medications may be responsible for ~25% of
cases of ED
Bicycle riding
Causes of ED
Medication:
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Most common cause of ED in men >50
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Many men are polymedicated
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Also have co-morbid conditions
Causes of ED
Medications (cont.)
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Anti-hypertensive drugs
All capable
 Common: thiazides and beta blockers
 Uncommon: calcium channel blockers, alphaadrenergic blockers, and ACE inhibitors
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Causes of ED
Medications (cont.)
 CNS drugs:
Antidepressants, tricyclics, SSRIs
 Tranquilizers
 Sedatives
 Analgesics
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H1 and H2 receptor blockers
Causes of ED
Medications (cont.)
 Anticholinergics
 LHRH agonists (Lupron, Zolladex)
 Alcohol
 Tobacco
 Drug abuse
 Estrogens, Ketoconazole
A Practical Evaluation of Men with ED
Basic evaluation
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Medical History
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Cardiovascular history
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Endocrine history
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Sexual history/questionnaire
A Practical Evaluation of Men with ED
Basic evaluation (cont.)
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Physical exam:
Focused neurovascular exam
 Size of testis
 DRE
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Lab tests
UA
 Testosterone, CMP, Lipid panel
 PSA in men >50 years
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A Practical Evaluation of Men with ED
Sexual History
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Premature ejaculation
Retarded ejaculation
Painful intercourse
Anorgasmia
Decreased Libido
Dissatisfaction with sex life
A Practical Evaluation of Men with ED
Sexual History (cont.)
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Do you have any problems with intimacy with your
partner?
Do you have early morning erections?
Do you have erections with self-stimulation?
Are you able to consistently obtain and maintain an
erection sufficient for sexual intimacy?
Does it hurt to have an erection or intercourse?
A Practical Evaluation of Men with ED
Sexual History (cont.)
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Do you ejaculation sooner than you would like?
Does it take too long to reach an orgasm?
Do you fail to reach an orgasm?
Did your erection problems start suddenly or
over time?
A Practical Evaluation of Men with ED
ED Questionaire³
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When you had erections with sexual stimulation,
how often were your erections hard enough for
penetration?
How do you rate your confidence that you could
get and keep an erection?
³The International Index of Erectile Function, Urol 1997;49:822-830
A Practical Evaluation of Men with ED
Questionaire (cont.)
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During sexual intercourse, how often were you
able to maintain your erection after you had
penetrated your partner?
During sexual intercourse, how difficult was it to
maintain your erection to completion of
intercourse?
When you attempted sexual intercourse, how
often was it satisfactory for you?
A Practical Evaluation of Men with ED
Differentiating Psychogenic from Organic ED
Psychogenic Impotence:
 Younger patient (<40)
 Preservation of morning erections and nocturnal
erections
 Achieve erection with masturbation
 May be partner-specific
 Often sudden onset
A Practical Evaluation of Men with ED
Differentiating Psychogenic from Organic ED
Organic ED:
 Gradual deterioration
 Decrease in morning erections and nocturnal
erections
 No erections with masturbation
 No loss of libido
 Presence of co-morbid conditions
A Practical Evaluation of Men with ED
Physical Examination
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Blood pressure
Examine penis (R/O Peyronie’s disease)
Determine size and consistency of testes
Digital rectal exam
Focused vascular exam/peripheral pulses
Focused neurologic exam
A Practical Evaluation of Men with ED
Laboratory Tests
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UA (glycosuria) – Fasting if elevated
PSA in men over 50
Testosterone (best to draw in A.M.)
Prolactin, Thyroid function, Lipid profile, Liver
function, Creatinine
A Practical Evaluation of Men with ED
Other Tests
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NPT – Nocturnal Penile Tumescence Test
Penile doppler
Injection of vasoactive drugs
NEVA (Nocturnal Electobioimpedance
Volumetric Assessment)
Treatment Options
Goal directed therapy
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4
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Find out what the patient wants
Try to tailor the treatment to the patients needs
and wants
Etiology rarely affects treatment choice for the
patient
Lue TF, World J. Urol 8:67,1990
Treatment Options
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Nonpharmacologic
Non-invasive
Minimally invasive
Invasive
Counseling and/or sex therapy
Treatment Options
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Oral medications - Viagra, Levitra, Cialis
Urethral suppositories (MUSE)
Injection therapy - Caverject, Trimix, Bimix
Vacuum constriction device
Surgery
Sex therapy
Counseling and/or Sex Therapy
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Rule out depression
Try oral medication in patient with psychogenic
impotence
Refer to sex therapist or psychiatrist for sever
psychopathology
Nonpharmacologic Treatment
Options
Lifestyle changes:
 Reduce fat and cholesterol in diet
 Decrease or limit alcohol consumption
 Eliminate tobacco use and substance abuse
 Weight loss if appropriate
 Regular exercise
Ideal Medication for Treatment of
ED
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Effective
Available on demand
Free of toxicity and side effects
Easy to administer
Inexpensive
Medication
(Viagra, Levitra, Cialis)
Mechanism of Action:
 PDE inhibitor and increases the cGMP that
promotes and sustains smooth muscle relaxation
Medication
(PDE Inhibitors)
Indications:
 Psychogenic ED
 Mild vasculogenic ED
 Neurogenic ED
 Side effects from medication(s) patient is already
taking
Medication
(PDE Inhibitors)
Side effects:
 Headache
 Flushing
 Dyspepsia
 Nasal congestion
 Visual disturbances
 Priapism
Medication
(PDE Inhibitors)
Contraindications:
 Organic Nitrites:
Oral
 Sublingual
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Severe cardiac disease
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Obtain stress testing
Medication
(Yohimbine, Yocon, Erex, Yohimex)
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Alpha 2 andrenoreceptor antagonist
Dose: 5.4 mg TID
Results: ~20% (same as placebo)
Side effects: increase blood pressure,
tachycardia, anxiety
Medication
Trazodone(Desyrel)
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Anti-depressant associated with priapism
Mechanism of action nor fully understood
Nor FDA approved for ED
Side effects: drowsiness, dry mouth, sedation,
priapism
Medication
Apomorphine (Spontane)
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Dopaminergic mechanism with hypothalamic
activity
Sublingual administration
64% to 67% response rate with ED
Side effects: nausea, sweating, hypotension,
yawning
Awaiting FDA approval
Medication
Phentolamine (Vasomax)
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Alpha-blocker
Relaxes smooth muscle tissue
40% efficacy in mild organic ED
Side effects: nasal congestion, tachycardia,
dizziness, hypotension
Awaiting FDA approval
Medication
Side effects
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Discontinue tobacco, alcohol, and abusive drugs
Alter dosage of drugs with ED side effects
Change to another class of drugs
Transurethral Therapy
Alprostadil - MUSE
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Mechanism of Action: vasodilator
Administration: 125, 250, 500. 1000ug
Insert in the urethra
Erection occurs 10-15 minutes later
Erection lasts 30-45 minutes
Results: 10-65%
Side effects: Pain, bleeding, priapism (<3%)
Penile Injection Therapy
Caverject, Edex, Tri/Bi-Mix
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Mechanism of action: smooth muscle
vasodilator
Administration: 10, 20, 40ug
Inject directly into corporeal bodies of the penis
Results: 70%-90%
Dropout rates: 25%-60%
Side effects: pain (36%), priapism (4%), fibrosis
Androgen Replacement Therapy
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Indications: hypogonadism (<285ng/dl)
Avoid oral estrogens-increase LFTs
Injectable – 200mg testosterone (cypionate,
enathate, propionate), q2-3 weeks
Transdermal
Patch
 gel
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Androgen Replacement Therapy
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Avoid in patients with prostate or breast cancer
Slight increase risk of BPH
Monitor all patients with annual DRE and PSA
Vacuum Constriction Device
Mechanism of Action:
 Penis placed in plastic tube
 Air evacuated from the tube
 Blood trapped in penis with constricting ring
Vacuum Constriction Device
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Erection limited to 30 minutes
Results: 80%-90%
Contraindications: bleeding disorders, sickle cell
disease, anticoagulation
Complications: coolness, petechiae, numbness,
pain with ejaculation
High drop out rate
Vacuum Constriction Device
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Was previously first-line treatment for ED
Seldom used now that oral therapy is available
Considered an alternative if patient fails oral
therapy and does not want to proceed with
surgery
Penile Prosthesis
Indications:
 Patients who have failed other therapies
 Peyronie’s disease
 Severe vasculogenic disease
Choosing a Penile Prosthesis
Considerations:
 Medical condition
 Lifestyle
 Cost
 Insurance coverage
 As with all prescription products, complications
are possible
Malleable Prosthesis
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Easy for patient and partner to use
Few mechanical parts
Same-day surgery usually possible
Least expensive type of prosthesis
Two-Piece Inflatable Prosthesis
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Small inflation pump provides comfort and ease
Fast and easy one-step deflation procedure
Better conceal ability when flaccid than with
malleable or self-contained devices
Three-Piece Inflatable Prosthesis
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Most closely approximates the feel of a natural erection
Cylinders expand in girth
Some cylinders have the potential to expand in length
When inflated, it feels more firm and more full than
other prosthetic erections
When deflated, it feels softer and more flaccid with
better conceal ability than with other prosthetic devices
Penile Prosthesis
Advantages:
 Low-morbidity
 Low-mortality surgery
 Low complication rates
 High success rates – 5% malfunction rate at 5
years
 High satisfaction rate – 87%
 High partner satisfaction rate
Penile Prosthesis
Advantages (cont.)
 Good rigidity
 Freedom from medications
 Outpatient/24HR surgery
 Resume sexual activity 4-6 weeks
 No loss of ability to ejaculate or achieve orgasm
Penile Prosthesis
Disadvantages:
 Surgery
 Expensive
 Possible mechanical failure
Penile Prosthesis
Insurance Reimbursement
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Covered by most companies, including Medicare
No co-payment for men with Medicare
supplemental insurance